Monthly Archives: February 2019

Over 40% of GPs intend to quit within five years: new survey

A new survey by Warwick University foretells the end of easy access to a qualified diagnostic practitioner. The “Independent medical practitioner” is a thing of the past, and yet this is what “registration” implies.

The reasons are multiple, but not easily corrected in a short timespan. Recruitment from overseas could help short term, but these doctors will be recruited to the less desirable and popular areas of the UK, and perpetuate the health divide by having poorer communication skills and cultural awareness. In addition, they will block our own doctors from the jobs they are hurriedly recruited to, and if we train enough the excess will have to go elsewhere or change career. This is the end game following disastrous manpower planning, over many dispensations. Rationing of medical school places has led to the post code lottery, and with 80% of undergraduates women (because they perform better at 18) the problem is only going to get worse. 

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Owen K, Hopkins T, Shortland T, et al. : Over 40% of GPs intend to quit within five years: new survey – 

  • University of Warwick researchers describe a ‘worsening crisis’ in GP retention as workload increases
  • New survey identifies an increase in GP intentions to leave or cut hours since 2014; almost half of GPs are bringing forward their plans to retire
  • GPs report that they have felt little effect from recent NHS initiatives to relieve pressures on their workload; most GPs reported that they were working more hours and that morale had worsened compared to 2 years earlier
  • NHS Long Term Plan announced in January may help stem the tide of low morale and early retirement, but some policy initiatives, such as video consulting, are viewed negatively

A new survey of GPs has revealed that over 40% intend to leave general practice within the next five years, an increase of nearly a third since 2014.

The survey of 929 GPs conducted by the University of Warwick has revealed that recent national NHS initiatives are failing to address unmanageable workloads for GPs and left them unconvinced that the NHS can respond to the increasing challenges facing general practice.

The survey conducted in the Wessex region follows up a similar survey in the same region in 2014, allowing the researchers to identify changes in attitude over time.

Published today (28 February) in the journal BMJ Open, it reveals that 42.1% of GPs intend to leave or retire from NHS general practice within the next five years compared to 31.8% of those surveyed in the same region in 2014, an increase of almost a third.

Workload was identified as the most significant issue with 51% of GPs reporting that they were working longer hours than in 2014. This has been linked to the size of the GP workforce not keeping pace with the growing healthcare needs associated with the changing age profile of the UK population, with more people living with complex long-term conditions such as diabetes, hypertension and stroke. In addition, as community and social care services are being cut back or stretched, more pressure is put on general practice as patients have fewer options to turn to.

The researchers argue that the survey paints a picture of GPs feeling increasingly demoralised and looking towards either reducing their hours or retiring altogether.

Lead author Professor Jeremy Dale, from Warwick Medical School, said: “GP morale and job satisfaction has been deteriorating for many years, and we have known that this leading to earlier burnout with GPs retiring or leaving the profession early. What this survey indicates is that this is continuing and growing despite a number of NHS measure and initiatives that had been put in place to address this over the last few years. Many GPs clearly feel that this is ‘too little, too late’ and have failed to experience any benefit from these initiatives and are unable to sustain working in NHS general practice.

“Intensity of workload, and volume of workload were the two issues that were most closely linked to intentions to leave general practice, followed by too much time being spent on unimportant bureaucratic and administrative tasks.

“There’s a worsening crisis in general practice. The situation is bad, it is getting worse and GPs are feeling increasingly overworked and increasingly negative about the future.”

Their paper highlights a number of national policy initiatives that since 2014 have sought to relieve pressures on general practice through targets such as recruiting large numbers of doctors from overseas, changes to governance such as the Quality and Outcomes Framework, an expanded role for allied health professionals and the streamlining of services through measures such as sustainability and transformation plans (STPs).

The NHS also launched its Long Term Plan in January 2019, with increased investment and support for primary care, a reduction in bureaucracy, and 22,000 proposed new allied health professionals and support staff working in general practice.

Professor Dale said: “Views from our survey would suggest that many of the changes in the Long Term Plan, such as greater funding for general practice, increasing the GP workforce, and increasing clinical and support staff in general practice, are desperately needed. But in the context of low and worsening morale and job satisfaction, the question is can these be introduced quickly enough now to stem the flow of GPs who are bringing forward their plans to leave the NHS.

“Recent NHS schemes to recruit more GPs haven’t paid dividends and the consequence is that GPs are still saying that their workload is getting more intense and increasingly difficult to cope with. It’s not perceived that the NHS has taken seriously the crisis facing general practice, and that some policy-led changes in themselves are actually making the workload within general practice less sustainable.

“The point that came through repeatedly in the survey was that GPs felt that we’ve gone a long way down the road of insufficient investment and insufficient reward. Turning this around will be a mammoth task. The initiatives that were thought most likely to bring benefit included greater investment in practice nursing, closer working with and support from hospital specialists, investment in technology, expansion of the GP workforce, and streamlining CQC practices.”

The survey received responses from 929 GPs working in in the Wessex area and is broadly representative of the demographic of GPs working in the NHS, with a slightly larger proportion of responses from older GPs.

Professor Dale added: “A number of recent surveys have shown similar issues to be prevalent across the whole country. Even in an area like Wessex, which in the past would have been considered an attractive place for GPs to work, we can see the effects of chronic under-investment in general practice, and how this is driving GPs to want to retire or reduce their hours of work.”

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: “GPs are under intense strain – our workload has escalated in recent years, both in terms of volume and complexity, but we have fewer GPs than we did two years ago.

“There is some great work ongoing to increase recruitment into general practice, and we now have more GPs in training than ever before – but when more family doctors are leaving the profession than entering it we are fighting a losing battle.

“The NHS long-term plan has aspirations that will be good for patients – but we will need the workforce to deliver it. The forthcoming NHS workforce strategy for England must contain measures to help retain GPs in the workforce for longer – steps to reduce workload to make working in general practice more sustainable and removing incentives to retire early for GPs who might not necessarily want to would both be sensible places to start.”

An increase in prescription charges encourages autonomy, but only in England. It also encourages movement between different systems… In Wales we already know we are second class citizens.

The recent announcement of an increase in prescription charges is “good news” for the English, because they will have more services of a higher cost and lower volume: the very services that Aneurin Bevan wanted to be available equally to miners and bankers. Unfortunately, with 4 / 5 health services, we are going to see more differences rather than les, in life expectancy (measurable) and in many services (unmeasurable) in the future. Wales and Scotland seem unable to discuss the subject of prescription charges without the emotion involved in a regressive rather than a progressive system. The short termism of this discussion, avoiding the “hard truths” and longer term financial issues means there will be more movement between different dispensations in future… But even this may become more within England, as different commissioners reduce the choices available to their patients. In Wales these choices have been severely limited for a decade, but then we know we are second class citizens.

There are already co=payments in eyes and dental services. Why not the drugs and appliances? We have to bring reality into the Health Services, and we need to challenge and “accuse” our governments of failing us with devolution.

In the current financial year in England:

If you will have to pay for four or more prescription items in three months, or more than 14 items in 12 months, you may find it cheaper to buy a PPC. The charge for a single prescription item is £8.80 (from 1st April 2018), whereas a three month PPC will cost you £29.10 and a 12 month PPC £104.00. They are free for many groups: children, retired, disabled etc. Why not charge according to means?

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The Pharmaceutical Journal 25th Feb 2019: Prescription fees set to increase to £9 from April 2019

Money Saving Expert 21st Feb 2019: NHS prescription charge to rise to £9 Feb 2019: Fury as NHS plans to raise prescription cost to £9

The cost of a surgical bra will rise from £28.85 to £29.50. And the charge for a full bespoke wig made of human hair will increase by £6, to £282.
NHSreality May 27th 2013: Prescription Charges and philosophy
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Bullying – we have to reduce it.

There is a grand collusion in politics and public services that bullying is uncontrollable, and therefore nothing is done. Large organisations have exit interviews, but the 4 UK Health services and the Irish have the same problem. The health services are chaotic, dysfunctional and one of the worst cultures to work in – and bullying is endemic everywhere. The recent article in the Times (Not available on line) indicates a soaring number of reports, is reproduced below. This illustrates the difference between prevalence (the total amount) and incidence (What comes to our attention). It may well be good news that more bullying is reported…. How about exit interviews then? No wonder GPs, who are self employed, resist being salaried and bought into the state culture!

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The Times in Ireland 28th Feb 2018: Beat Bullying

Public representatives should respond to claims of abuse and harassment in politics by leading the way to stamp out such behaviour in any workplace

Kieran Andres in Scotland 27th December 2018: Patients ‘losing out amid culture of bullying in NHS’ and even if you want to see him: The Minister is too busy to see you! (Jan 8th 2019)

Bullying costs the NHS more than £2 BILLION a year due to harassed staff quitting, making mistakes and resigningDaily Mail26 Oct 2018

and 8th November 2018:The number of NHS staff in Hull who say they’re being bullied

Health Service Journal 16th November 2018 by Laurence Dunhill: Full details: New NHS England and Improvement structure

Health service is chaotic and dysfunctional, says NHS chief Lord Prior of Brampton

The Times reports 25th Feb 2019 (Jonathan Ames) and not on line: Bullying and harassment claims in NHS soar by 40%.

Bullying and sexual harassment allegations in the NHS have risen by nearly 40% over the past 5 years, but only a fraction of claims result in disciplinary action.

Figures released yesterday showed that there were 585 reports of bullying and harassment9n the health service (presumably England only), up from 420 in 2013-14.

It was also revealed that two hospital trusts had imposed gagging orders on employees after settling claims.

Staff shortages and other work pressures were blamed for the rising number of reports, which include various forms of harassment including racism.

The figures emerged from a freedom of information act request submitted by the Guardian. A London surgeon, who asked not to be named, told the newspaper: “There are times when I have been operating and racist comments were used – this was when I was more junior, and it happens less now i am more senior.”……

Findings show sheer scale of issue, with only a fraction of cases leading to disciplinary action

Dr Anthea Mowat, British Medical Association representative body chair, said: “This is further evidence of the scale of bullying taking place in the NHS and it is essential that solutions are put in place immediately to eradicate unacceptable behaviour.”

This was too serious for another cartoon!







The Market for health

In a letter to the Times 25th Feb 2019 a consultant exposes the weaknesses of the Internal Market:

Sir, The abolition of competition among NHS hospitals is long overdue (News, Feb 22). The “internal market” introduced within the NHS in 1991 was intended to drive down costs and increase choice, among other things. In fact it was inefficient, costly, resulted in a proliferation of managers and was potentially harmful to patients, as well as many other problems.

Smaller hospitals wanted to introduce money-raising procedures for which they had neither the staff nor equipment, procedures usually performed by larger, more experienced tertiary centres. This resulted in duplication of expensive equipment, inexperienced staff doing procedures for which they did not have enough training and ultimately a risk of patient harm. A few years ago I recall a local colleague telling me that his hospital needed to start a cardiology procedure “to balance the books”.

Fortunately, it has been realised that collaboration is highly preferable to competition. At last the damage started by the internal market is being undone. Patients can be directed to centres that are best at the task in hand, not the cheapest.
Dr David E Ward

Consultant cardiologist (ret’d)
London SE22

NHS plan ‘ends public right to choose hospital’ – A form of rationing well known to Wales

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NHS plan ‘ends public right to choose hospital’ – A form of rationing well known to Wales

The Welsh did not complain about lack of choice when it was begun a decade ago, and the weak BMA in Wales made comment, but no hue and cry resulted in this “lowest common denominator” medicine. Choice is a fundamental plank of a liberal society, and its loss is justified in war, famine, civil war and national emergencies. But rarely has choice been threatened in an advanced democracy/ Standards really are falling, and the right to choice may only be available to those who can afford it. A two tier society once again, and exactly what Aneurin Bevan wanted to avoid when he started the original health service. The Welsh health service has excluded choice because the money moves with the patient. The English will be less accepting of this form of rationing…… Losing choice does work for commissioners in saving money; but it does not work in saving lives. In rural and poorer areas where there are under resourced and under staffed hospitals it may actually do harm. 

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Oliver Wright reports in the Times 22nd Feb 2019: NHS plan ‘ends public right to choose hospital’

Patients’ right to choose where they are treated is being threatened by radical plans to scrap competition in the NHS, ministers have been warned in leaked documents.

Plans to abolish the health service’s internal market are being resisted by Whitehall officials who have told Matt Hancock, the health secretary, that they would quietly reverse 30 years of policy, according to a Department of Health briefing seen by The Times.

Mr Hancock is understood to be ruling out any changes that would prevent patients selecting the NHS hospital or private provider where they are sent for treatment. But he has been told that if he blocks new laws the NHS could blame the government for the failure of a £20 billion reform plan that was expected to save 80,000 lives a year.

The confidential briefing reveals for the first time the scale of changes proposed by health chiefs, which officials believe amount to another major reorganisation of the NHS.

Last month Simon Stevens, the chief executive of NHS England, asked Theresa May to reverse market-based reforms introduced in 2012 by Andrew Lansley, then the health secretary. Mr Stevens wants to make hospitals, GPs and local services work together.

His proposals were presented as a tidying-up exercise, but a briefing for Mr Hancock privately warned that NHS England’s unpublished plans went much further and would undo the internal market introduced by Kenneth Clarke when he was health secretary in 1991. Since then NHS managers have bought services from self-governing hospitals and companies, which were encouraged to compete for business.

The briefing warns Mr Hancock that he must be comfortable with this before signing off, adding: “Removing the internal market will entail undoing some 30 or so years’ worth of policy and legislation in the English NHS, including some of the checks and balances that a market-type approach allows and could have broader implications, for example, how choice works in the NHS.”

Mr Hancock has backed ending enforced competition but he supports patient choice and has little appetite for a Commons battle to reform the NHS.

The briefing warns that Mr Stevens’s position “implies that primary legislation is essential” to implementing the long-term plan, published last month. “This presents a future risk that, in the event that the long-term plan is not delivered, the NHS blames the government if there is no bill. We don’t think you should accept this shift in emphasis.”

Department of Health sources played down a split with NHS England, suggesting a compromise would be found that made clear that legislation was not essential, and which minimised upheaval and protected choice.

NHS England said Mr Stevens did not want to remove patients’ choice on where they are treated. A spokesman said new laws would not be needed. But, he said, as requested by the Commons health and social care committee and the prime minister, “carefully targeted” legislative changes had been drawn up that would provide better services.

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Heath and Safety Executive news 22nd Feb 2019: Patients’ 30-year right to choose where they are treated under threat as part of NHS England reshuffle

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Health service is chaotic and dysfunctional, says NHS chief Lord Prior of Brampton

Yes, targets used in professional health care are not constructive. The gain in Hospitals has been negated by their continuance, and managers responsible moving in such short times that they are never accountable. The gain from “performance related pay” in General Practice has halted (QOF – the Quality and Outcomes Framework is a silhouette, a shadow of its former self) , and at the expense of a disillusioned and disengaged workforce. In the Telegraph .NHS targets ‘have had their day’ says health service chief as he claims they encourage ‘gaming’.  

The good Lord describes staff in the NHS as “disempowered” and having a mindset of “learned helplessness”. All we disagree with him is that there is no NHS any longer.

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Chris Smyth reports in the Times 15th Feb 2019: Health service is chaotic and dysfunctional, says NHS chief Lord Prior of Brampton, Chairman of NHS England

NHS staff suffer from “learned helplessness” in a dysfunctional system, the chairman of NHS England has said in an attack on 25 years of flawed health policies.

As accident and emergency units reported their worst waiting times on record, Lord Prior of Brampton gave a scathing assessment of the system over which he presides. He said that such targets had “had their day” and that they contributed to the erosion of the vocational culture of the NHS.

He said that targets, competition and reliance on inspectors had all led to a disjointed system and demoralised staff.

A series of NHS reforms that have broken up the health service into autonomous hospitals “makes driving an integrated strategy across the NHS almost impossible”, he added. “You could not have designed something that had at its heart more dysfunction. It’s truly remarkable.”

Lord Prior, whose role is guiding the health service’s strategy, said that the main aim of a ten-year plan was to overcome organisational divides that had “riven the NHS over the last 25 years”. He said that chaotic organisation and overuse of targets “led to a disempowered culture, a learned helplessness culture, a top-down looking-upwards culture, a very hierarchical culture”.

He told a conference organised by Reform, the think tank: “How we address these cultural issues is fundamental, how we bring back that vocation. I remember talking to many junior doctors who say, ‘At the end of our day when we’re about to go, we’d always walk back to A&E to lend a hand if there was a problem. Now we go home’.

“The number of GPs who want to leave when their pension plan hits their maximum, who historically would have worked for another couple of years; the number of nurses you meet who say, ‘I’m 60, I’m going’, who might have worked for another couple of years in the past. If we just recapture that kind of engaged spirit, that vocational engaged spirit, then I think so many of our other issues would be taken care of.”

Official figures yesterday showed that only 84.4 per cent of A&E patients were dealt with in less than four hours, the worst since records began in 2010.

About 330,000 patients waited longer than four hours last month, beating the previous worst last March. A record 83,519 patients spent more than four hours on trolleys because beds were not available. The NHS Confederation of managers said that the system was “buckling under the strain” of rising patient numbers.

Criticising the “unnuanced” pressure on hospital bosses to hit targets, Lord Prior argued that they led to widespread “gaming” of the system.

A&Es “run around like headless chickens” trying to get people out at three hours and 55 minutes, only to stop caring once the target is missed, he said. “Targets have had their day. Of course they achieved

great things for a short period of time in the mid-2000s, when we had to get waiting times down, but they have had their day.”

Taj Hassan, president of the Royal College of Emergency Medicine, said that hospitals had become “normalised in crisis mode”. “Policymakers and governments that believe targets have ‘had their day’ will need to be held accountable for the impact on patient safety and the added risk of harm or avoidable death if they choose to scrap them,” he said.

 GP shortage threatens long term plan. Gareth Iacobucci in the BMJ

Show you value Health Service staff – please. Cultural change is possible in time..

It was the best job in the world – for me 1979-2012 – but now there are not enough of us to cover the country

Performance related pay is risky, and has been rightly reversed for GPs and Primary Care. Will it work for Trusts and Hospitals?

Leadership without accountability in all 4 health services.

Patients and the professions are ready to ration health care strategically, without devolution. It’s the politicians and the managers who won’t hear of it because the strategy might mention rationing.

Performance related pay schemes, such as QOF, are not suitable for professionals.

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Is tghere really a long term plan worth the name?

 GP shortage threatens long term plan. Gareth Iacobucci in the BMJ (BMJ 2019 ;364:1686)

Chronic staff shortages in key areas such as general practice are jeopardising the NHS’s long term plan to strengthen primary and community care in England, experts warn. New research by the Health Foundation has found “ongoing deterioration” in workforce numbers in primary and community care, nursing, and mental health services, with staff numbers failing to keep pace with demand. Shifting care out of hospitals and closer to people’s homes was identified as a priority in the long term plan, published in January. But Anita Charlesworth, a director at the Health Foundation, said, “If [the NHS] can’t recruit and retain more professionals in primary, mental health, and community care, this will continue to be an unrealised aspiration. There is no sign that the long term downward trend for key staff groups, most notably GPs, will be reversed.” The number of GPs in England fell by 1.6% (450 full time equivalent staff) in the year to September 2018, the report said, despite ministers’ pledge to recruit 5000 extra by 2020. The report also highlighted the continuing decline in numbers of community nurses and health visitors, falling by 1.2% (540 FTE staff) in the year to July 2018. It noted slow progress in
mental health recruitment. Psychiatrists saw the smallest percentage increase (0.6% or 50 FTE) among doctors, and numbers of mental health nurses rose by less than 0.5% (170 FTE) in the same period. The importance of international recruitment was being hampered by broader migration policies and Brexit uncertainties, the report said. Although the number of doctors from other EU countries had risen by 5.5% since 2016, recruitment of EU qualified nurses and midwives had fallen respectively by 8.5% and 3.1%. Charlesworth said, “So much now hinges on the workforce implementation plan. But to bring an end to chronic workforce shortages for good, action must address the underlying major fault lines in the current approach, particularly the lack of alignment between staffing and funding.” A Department of Health spokeswoman said some of the report’s figures were out of date. Latest statistics, from October 2018, showed 2564 more health visitors, 473 more mental health nurses, and 233 more psychiatrists than a year ago, she said, adding, “Last year a record number of doctors were recruited into GP training.”