Monthly Archives: October 2019

Health Services might be designed wrongly: In praise of dissenters.. Currently there is little ability to speak out, “without fear of sanction”.

The Different health services in the UK are not open to the suggestion that they might be designed wrongly. They are failing more quickly than anyone imagined (other than those in the profession, and NHSreality). An interview with Helen Stokes-Lampard (RCGP chair) In “You and Yours” on Radio 4 17th October 2019 tells it straight: its going to take at least 12 years to remedy the failure in forward and manpower planning. (The interview is at the end of the recording) The culture of fear means that opportunities to learn constructively are being lost, educational standard are falling, and engagement with the politics of health is minimal. One route to honesty is the exit interview, and these collated together could give messages that lead to the changes needed. Meanwhile……  “Winter is coming”. We will all be hearing how they will listen (See Jill Patterson in Walesonline below), but NHSreality can tell you that even if they hear, they don’t have the human resources to act. 

In Bartleby in The Economist 12th October 2019 “In praise of dissenters – It pays companies to encourage a variety of opinions “

The ability to speak up within an organisation, without fear of sanction, is known as “psychological safety” and was described by Amy Edmondson of the Harvard Business School in a book on the issue. Mr Syed cites a study of teams at Google, which found that self-reported psychological safety was by far the most important factor behind successful teamwork at the technology giant. ….“In praise of dissenters

As many practices disintegrate, I give a link to a local practice in the news.

Eleanor Philpotts in Pulse 12th October 2019 reports on Ferryside practice.: Practice set to close after 3 years without a GP

In Walesonline Sandra Hembury on 14th October reports: The GP surgery that hasn’t had a GP for over 3 years..

A doctors’ surgery hasn’t had a GP working there for three years and is now being threatened with closure.

The Mariners Surgery in Ferryside has only had nurse sessions since 2016, because there were no GPs available to operate from it.

Now plans have been unveiled to close the surgery and relocate services to other practices, forcing patients to have to travel for miles to receive treatment.

A public drop-in session is being held to consult with patients at the Three Rivers Hotel in Ferryside between 2pm and 7pm tomorrow (Tuesday, October 15).

But there are fears those less mobile patients will struggle to get to the next nearest surgeries in the Meddygfa Minafon practice – in Kidwelly or Trimsaran.

Cllr Mair Stephens is ward councillor for St Ishmael and deputy leader of Carmarthenshire County Council.

She said the Carmarthen Road practice had been there for a number of years.

“There’s traditionally been a dispensing surgery, which is exactly what we do need,” she said.

“The majority of people who live in the area are older, and the surgery has been on the decline in recent years, but it still has such things as foot clinics and heart clinics.

“They are now going to close it, which is out of all proportion.”

She said the nearest surgery in the group was Minafon in Kidwelly, which was about four miles away. But it was difficult to get to if patients needed public transport. The nearest bus route to the Kidwelly surgery dropped passengers off at least 10 minutes away from the practice, which wasn’t suitable for the less mobile, she added.

She suggested the practice could set up a bus route taking passengers without suitable transport from the Ferryside surgery to Kidwelly.

Cllr Stephens added: “This is about moving services from their locality.

“What older people want to do is to see a GP. They don’t necessarily want to see a nurse.

“Once they have seen the doctor they are quite happy to meet a nurse or practitioner. That’s where the whole system seems to be falling down.”

She felt the consultation was not being spread out enough to the wider community, including nearby Llandyfaelog.

A petition has been set up to maintain the surgery in Ferryside.

Started by Ute Eden, it says: “We feel very strongly that it is essential to maintain a surgery in Ferryside.

“We need a doctor, a nurse and a dispensary to provide the vital services required by a village where most residents are over the age of 50.

“It is an integral part of Calon y Fferi Community Centre, which is very accessible.”

The petition, which has been signed by 44 people, said it would be a backward step to oblige all residents to leave the village for treatment.

Jill Paterson, director of primary care at Hywel Dda University Health Board, said: “As a health board we are committed to listening to and engaging with local populations around our proposals to relocate our primary care services from Mariners Surgery to neighbouring surgeries.

“We would therefore like to invite residents to come along and get involved in the conversation.

“Following a review of how services are used by patients at the surgery, it is becoming clear that these services are limited and not fully utilised and could be relocated to Minafon and Trimsaran Surgeries.”

A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas

Don’t wait until you are ill, or your next of kin needs emergency care. Try and think ahead to what options you have in your post code. In reality most of us will have no choice, but there may be a choice in the bigger cities. Certainly NHSreality expects market forces to mean private services expand. As A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas. And its going to get worse…

It is all very well having long waits for access to GP and cold hospital care, but it is quite another when one of the holes in the safety net gets so large that the net has been removed. I can attest to the fall in standards from personal experience with a recent Right hand compartment syndrome that was ignored at first, and then operation was delayed, for a total of 18 hours. The recovery will be longer, and more painful than it might have been, but thank goodness I have kept my hand.

The failure in manpower and forward planning in general, the over supply of doctors who wish to work part time, and under supply of those who wish to work full time, rationing of medical school places, and lack of increased reward for working a shift pattern career are all part of the problem. There is no valuing of what are seen as temporary staff, and it has to get worse…

The Care Quality Commission

Henry Bodkin in the Telegraph 15th October: More than half A&E services failing

More than half of A&Es are now failing because patients who should be treated at home or in clinics are flooding through emergency departments’ “ever-open doors”, inspectors have warned.

The Care Quality Commission said breakdowns in provision for dementia and mental health patients are fueling the deterioration of standards….

ITV News: A&E under tremendous pressure as more departments need improvement (Standards fall)

Shaun Lintern in Health Service Journal: Regulator warns of ‘extraordinary’ winter for A&Es

  • Chief inspector warns of “extraordinary circumstances” for emergency departments this winter
  • Care model failure leaves hospitals overloaded
  • Watchdog warns of deterioration on mental health, learning disability and autism wards

A failure to provide the right models of care is forcing thousands more people to attend emergency departments each day, the Care Quality Commission has said, while warning of a “perfect storm” for the health service this winter……

Dennis Campbell in the Guardian: More than half of A&Es provide substandard care, says watchdog – Hospitals struggling to cope with rising numbers of patients who cannot get help elsewhere

Kaya Burgess in the Times: More than half of A&Es not up to job, says care watchdog

The health watchdog has warned that A&E departments are under “tremendous pressure”, with more than half now deemed inadequate or in need of improvement.

The Care Quality Commission’s annual State of Care ( England only) report also warned of a “perfect storm” across health and social care where people cannot access the services they need or where care is provided too late.

The regulator found that A&E standards had slipped over the past year and that emergency departments were the most likely part of a hospital to be ranked as inadequate.

In 2018-19, 44 per cent of urgent and emergency services were rated as requiring improvement — up from 41 per cent the year before — with a further 8 per cent deemed inadequate, up from 7 per cent the year before.

Inspectors said that A&E departments had not had their usual “breathing space” over the summer months to prepare for the perennial winter pressures.

He said: “We know that it’s a combination of increased demand and challenges around workforce [that] are creating something of a perfect storm and if that perfect storm is allowed to continue we will have a number of problems.”

He said that the 18-week waiting list for planned hospital treatment had grown from about 3 million people to 4.4 million over the past five years.

The CQC also warned of a “serious deterioration” in the quality of inpatient services for people with mental health problems, autism or learning disabilities. About 7 per cent of child and adolescent mental health services were rated inadequate last year, up from 3 per cent the year before.

Mr Trenholm said: “We also know that adult social care remains fragile. We know that the failure to agree a long-term funding solution is driving instability in the sector.”

Sally Warren, director of policy at the King’s Fund health charity, said: “The CQC’s report provides further evidence that staffing is the make-or-break issue across the NHS and social care. Staff are working under enormous strain as services struggle to recruit, train and retain enough staff with the necessary skills.”

Nick Scriven from the Society for Acute Medicine said: “At some point in the near future all these sustained and repeated problems with increasing demand, inadequate workforce that is haemorrhaging senior cover, the pension tax crisis, crumbling estates, insufficient community medical care and community social care in general totally under-provisioned, we will reach a vital tipping point and care will be compromised despite all the heroic efforts by the human side of this, the staff in post.”

An NHS spokesman welcomed the watchdog’s finding that quality standards had remained stable when taken as a whole and said: “While the NHS Long Term Plan set out an extra £4.5 billion to ramp up GP and community care, the CQC rightly highlights the need for a long-term solution to adult social care so that older and vulnerable people get the right care when they need it.”

March 2015 NHSreality: From bad to worse: “NHS medical accidents investigation unit ‘needed’”

Jan 2016 NHSreality: Accident and Emergency – departments understaffed – report suppressed

Doctors let dying patients waste their last days in Accident and Emergency

The Care Quality commission has different standards and reports in different jurisdictions

 

The best and worst places to have your hip operation (In England. No global comparisons)

All hail the honesty of the Health Services Journal. Unfortunately they are not allowed to advocate rationing and freedom of speech is limited. But the stories they expose and the issues they address are relevant to  us all. There are many problems, which include poor staff hygiene, poor hospital cleaning, inadequate training, and above all, the failure to separate cold orthopaedics from “dirty” hospital cases where infected wounds and guts are operated on in the same building. The old fashioned DGH has served its time for hips and knees. But why are there no comparable figures for the Scottish, Welsh and Irish Hospitals? Because there is no “National” health service, I as a taxpaying citizen in Wales cannot find out how my service performs compared to England. Indeed, I would like to know comparisons with other countries, and with the private sector. Only with such data can patients be properly advised, and of course they also need to be “led” ask the right questions! Rationing by lack of choice, restriction to a local DGH, and long waiting lists, can only lead to more infections and complications (increased obesity and heart attacks from immobility). Should your GP air these issues when you choose to be referred? Of course he should even if it means telling the truth about your local services.

In the Times Monday 14th October a short report ( not in the on line edition) reads:

Repeat Offenders

The hospitals with the worst records for having to repeat knee and hip surgery on patients are revealed in a report in the Health Services Journal. The sick/ Six NHS hospitals are Southampton General, Milton Keynes, Chichester, Wansbeck, (Northumbria), Weston General, Somerset, and Ormskirk DGH Lancashire. Overweight patients, high infection levels and shortcomings in supervising trainees are blamed for poor performance.

In the Telegraph they report: “Revealed: the best and the worst places to have your hip operation”.

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites

 

Mislabelled samples: should we all be tattooed with blood type?

I have personal experience of incorrectly labelled specimen bottles. It is too easy to make a mistake, especially in S Wales where so many people have the same name and initials, and often even same or similar dates of birth. It was one of the last “complaints” I has, and the outcome was harmless, but the patient complained and was given redress. In financial terms the redress was 10 times the legal fees!! Computerised records will help, especially if the patient has to give an ID card or a password for access. But the 4 health services are way off, and indeed the end game is fast approaching as standards fall further. When I was a rock climber I had my blood type painted on my helmet…

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Andrew Gregory in the Sunday Times reports 13th October 2019: Blood test mix-ups hit record high – Mislabelled samples are putting hundreds of NHS patients at risk of death or harm, with midwives the worst offenders

Pregnant women, newborn babies and other patients are being put at risk of death or serious harm because NHS staff are frequently mixing up blood samples, an alarming report has found.

Last year there were almost 800 serious incidents in which patients narrowly avoided a “catastrophic outcome” after blood-transfusion test results were either labelled or collected incorrectly, according to an investigation by Britain’s patient safety body. The number of potentially lethal blunders is now at a record high, having more than doubled since 2010.

The report by the Healthcare Safety Investigation Branch (HSIB), a government agency that conducts independent inquiries into patient safety issues, warned: “WBIT incidents are still frequent in the NHS despite a recognition of the risk.”

WBIT errors mean that vital blood samples have been either taken from the wrong patient or from the correct one but then labelled with someone else’s details.

The Serious Hazards of Transfusion Office (Shot) at NHS Blood and Transplant, the body that oversees blood services, last year recorded 792 WBIT near misses. In 2010, there were 386.

Dr Paula Bolton-Maggs, a consultant haematologist and former medical director of the Shot haemovigilance scheme, said: “Correct patient identification is crucial. Biological samples and their results, if attributed to the wrong patient, can lead to disastrous outcomes including fatal incompatible transfusions or other serious treatment errors.”

Despite a relentless drive by ministers to digitise the NHS, investigators found labels on blood samples were still being written by hand, which meant they were “open to error”. Some staff were using window ledges or chairs as a hard surface to write on, because of a lack of bedside furniture. Faulty printers were producing old label requests, while staff shortages, fatigue and “chaotic” work environments were also blamed.

More than 260 of the victims last year were pregnant women. The most blunders occurred on general wards. The next worst were obstetrics and A&E.

Midwives were found to have made more of the mistakes than staff from any other specialty, according to Shot data. They overtook doctors as the largest staff group responsible for WBIT mistakes.

The vast majority of potentially deadly errors were discovered by lab staff.

The national investigation by HSIB was sparked when the alarm was raised over mistakes at an unnamed maternity unit. It recorded 16 WBIT incidents in 2017. It retrained every member of staff, but there were another four mistakes in 2018.

The HSIB found that a midwife who put two patients at risk by mixing up their samples was working a 12½-hour shift, caring for up to 30 patients on her own.

She also “routinely” walked more than seven miles during the course of a shift.

Mervi Jokinen of the Royal College of Midwives said: “It is a concern when mistakes happen, and we need to be looking at why they happen and taking steps to prevent them.” Staffing shortages often left midwives dealing with multiple patients in emergency situations, “leading to samples being labelled retrospectively away from the patient”, she added.

Dr Stephen Drage, the HSIB’s director of investigations, said most blood tests “happen without incident, but when it does go wrong it could represent a catastrophic outcome”. He said it was “paramount” to understand how the reality of life in the NHS might differ from how it is perceived by policymakers.

The 40-page report says NHSX, the body in charge of digitising the health service, should “take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling”.

The “end game” for the UKs 4 health services? The ethical issues involved in the politics of training doctors

If government does not address properly and long term the issue of recruitment and retention we are fast entering the “end game”, as repair will be too difficult. The Queens speech was an opportunity to bribe the public with short term promises, but the longer term issues were ignored. When I am dying I will appreciate continuity of care, and care from someone who understands me and where I come from in my beliefs and experience. This is not going to happen within 15 years, and my life expectancy is just that..

There are complicated and pragmatic decisions to be made by politicians, especially those involving the training of doctors and nurses. In India over 80% 0f doctors are trained privately. This means a “caste” of medical families dominates, who can afford to send their children through Med School. Do we want this to happen in the UK? A letter in The Times suggests that Doctors funded by the state should be “tied” to working for the state. (or buy their way out as in India?) This is contrary to the European Convention of Human Rights, but of course we will be abandoning this on Brexit.

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The Times letters December 21st 2018 prints:

TRAINING OF DOCTORS
Sir, Your leader (“Doctor, Doctor”, Dec 20) surely overlooks the most important point. The training of doctors is largely funded by taxpayers. These same taxpayers require the services of the doctors they have paid for. There is no shortage of very able applicants to study medicine; many of those rejected would be glad to serve the NHS as a career. Is it not now time to restrict taxpayer funding to those who will?
Kenneth Ross

Auchencairn, Dumfries and Galloway

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January 2015: First UK private medical school opens with £36,000 fees. A regressive development, which could increase inequalities further.

Medical Schools “moving admissions goalposts” & Private schools cry foul over medical courses

Exhausted GPs shun out-of-hours work. The long term result of rationing medical school places, of declining skill standards, and governments showing they “couldn’t care less” for years.

Could private top-up insurance fund the (failing) NHS? Jumping into the abyss of denial..

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

10% increase in vacancies. “Industrial scale” recruitment from overseas is a clear admission of recurrent cross party political failure.

Mandator NHS service plan for new doctors…..? Run, Doctors, Run! (While You Still Can)

The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

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Just a name on a rota? An adverse environment is holding back staff and affecting patients….

Update 26th October 2019: Shrewsbury Mum wants better care for doctors. Clare Gerada “”When they sign up to be a doctor in the first place they are signing up to give their working life to the care of others and we need to care for them.” The junior doctors don’t feel cared for.

From rags to Richer in the Economist October 3rd describes how one man, Mr Julian Richer, who is a fan of “In Search of Excellence”, a business bestseller by Tom Peters and Robert Waterman which came out in 1982, built his business and then sold over half to his staff. Bartleby describes this as A business success story built on treating people well”.  (There are few Health Service staff surveys which can be trusted, and exit interviews are rare …. Mr Richer does staff surveys every week.).

How does he keep staff loyal? One way is to survey morale every week.

The 4 Health Services of the UK need to treat their people well, but they don’t. Politicians and Trust Board members and managers should re-read Peters and Waterman, whose motto used to be the legend above my own local trust here in West Wales. I wonder what made them abandon it?

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In the BMJ 10th October 2019 Dr Chaand Nagpaul comments on an article written for Dr Tameem, a ST6 who has had experience in Australia where juniors feel much more valued. His account in ” More than just a name on a rota” in explicit and represents what is going on nationally, in all 4 dispensations. It is the culture of the organisation which is wrong. The rules of the game, decided by politicians, don’t allow people like Mr Richer to run the business….. Excellence has been written out of the script for most on call STs in DGHs. Surviving that shift, night or day, is the name of the game.

An adverse environment is holding back staff and affecting patients, says BMA council chair Chaand Nagpaul

People become doctors because this career embodies their values. It’s a long and arduous journey and it is a commitment that extends beyond working days.

Yet many doctors find themselves in a working environment that, instead or recognising this commitment, perversely works against them. Our own survey shows that nine out of 10 doctors feel they can’t provide safe, high-quality care because of the stress and strain placed on themselves, colleagues and the wider system.

To add insult to injury, if things do go wrong, more than half of doctors fear they will be blamed for errors caused by system and capacity issues and only half of doctors would feel confident to raise concerns.

Not only does this adverse environment prevent doctors from achieving their best but it is also denying patients the full potential skills and capability of care from our medical workforce.

Given this tough – and often unfair – working environment, one would expect employers to support frontline staff and offer them gratitude, understanding and support – rather than a culture many doctors inhabit of fear, blame and isolation.

As part of our Caring, supportive, collaborative project, the BMA will continue to campaign for an NHS that has adequate resources so that doctors can do their best for patients, underpinned by a culture rooted in learning and improvement rather than blame, and which values its workforce as its strongest asset.

Find out more about the BMA’s Caring, supportive, collaborative project

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the

Changing a culture of fear, bullying and gagging…… Start again with local pride….

CQC …

No need to comment on the “Culture of fear”

Despite the evidence, the health services culture crisis will be ignored by those with the power to act… It’s going to get worse..

The culture of the NHS has yet to catch up with the rhetoric as this speech from the GPC leader underlines.

Cleaning up the UK Health Services, changing the culture and importing honesty..

Welsh NHS ‘is a scandal’, says David Cameron. The philosophy of not aspiring to excellence, but rather to reducing inequalities

Clinical excellence may become impossible in state provided health care.

‘My local practice was a centre of excellence. Now we face a future of depersonalised, rationed healthcare’

All education is divisive – We must all aspire to excellence, and speak out.

Sir Bruce Keogh: “I am not interested in an NHS that aspires to mediocrity, the European average or whatever. We should set ourselves the achievable ambition of raising our cancer survival rates to match the very best in Europe.”

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Do you really know best Mr Gove? The Chief Medical Officer should not be ignored, and belittled…

Alistair Grant in the Herald 11th October 2019 reports: Michael Gove insists chief medical officer is wrong over Brexit threat to life

And on 6th October Martin Bagot in the Mirror reports: No-deal Brexit ‘could put thousands of people at risk as life ..

Lizzy Buchan in the Independent reports that “lives may well be at risk”.

Wales is an unsustainable state: another good reason not to leave the EU. Graphics in support…

What does the UK spend on health and social care?

All of us in the professions know that whatever the spend it will never be enough. That is why there are so many charities. These charities are primarily aimed at elderly people, as the 4 UK Health Services have not yet got to such a state that neonatal and maternity care is rationed… except in Cwm Taf Morgannwg. Private funding accounts for 22% of all spending on health and social care. The 78:22 split between public and private spend is similar to that in the Netherlands and France, somewhat greater than that in Germany Denmark and Sweden, (at about 15% private) and a bit below the OECD average of about 27% private spending.

UK health and social care spending. English NHS spending is set to increase in real terms by 11.6% between 2014–15 and 2020–21. This is more than is required to meet the government’s commitment to provide the £7 billion (2016–17 prices) requested by NHS England Chief Executive Simon Stevens in 2014.

Social Care Market Reports – Trends, Analysis & Statistics.

UK Health and Social Care spending: Institute of fiscal studies

What does the UK spend on health and social care? BMJ 2019;365:l1619 John Appleby at the Nuffield Trust

Rural and remote health services lose out on NHS funding …

Care is the second biggest sector of the UK economy, and new accounting practices tell us more about the £208bn is spent, finds John Appleby

The Organisation for Economic Co-operation and Development’s 2011 system of health accounts, revised in 2017, is a Herculean effort to try to impose some international order on the way member countries report their spending on health and care.1 Although it is impossible to obtain completely comparable data across countries, given differences in funding systems and organisation, the new accounts now drill down to reveal more information about what countries spend their money on.

The UK’s spending on health and social care (a grand total of nearly £208bn—including £5.3bn of capital spending) comes from two main sources, public (£157.6bn) and private (£44.9bn), and eventually flows through to various types of care: inpatient care, home based care, prevention, and medical goods, for example (fig 1).

Public and private spending on health and social care in the UK in 2016

These sorts of spending data alone cannot answer the sort of policy questions countries may grapple with: for example, are we spending too much or too little on secondary care versus preventive services? But as trends start to emerge from these new datasets, countries should be more able to supply data at more detailed levels of spending. And, importantly, as spending is linked to health outcomes, health and care services will be better able to assess the effectiveness of spending, given the allocative decisions they make.

Noteworthy – You can download and expand the figure above.

Total Funding £202.5 bn, Public Funding £157.6 bn, Healthcare £152.4 bn, of which curative care £109.5 bn. Long term care (Health) £35,5 bn, Long term care social £109 bn. Private funding £44.9 bn of which Private Insurance £7.2 bn, Non-profit £7.5 bn, and “Out of pocket cash” £30.3 bn

Further breakdown by downloading. Private funding accounts for 25% of all spending on health and social care.

 

 

Ambulances use unproven scoring system to ration their service…

As a recent sufferer from sepsis, and having had much pain as a result, and from a hand operation (for which I am most grateful) I am interested in this new form of rationing. Since ambulances are “free” and since many calls are for relatively trivial issues, triage has to occur. However, when a GP rings, rather like when a doctor appears in A&E, lights should alert the telephonist that this needs to be taken seriously. A&E, and Emergency, and Urgent Care centres, have sepsis warnings all over their walls…  It made little difference to my care..

The ambulance service regards being in a GP practice as a place of safety, with medical care to hand, although GPs are being systematically deskilled in emergency care. This reduces their “points” score and the perverse action of the GP whose surgery has been “arrested” by this, is to send the patient outside and ask them to ring the ambulance!

Yes, the ambulance service is underfunded, especially if it remains free for all. The Air Ambulance is a charity, and like many others it too has to prioritise its service. Waiting times for ambulance calls are generally getting worse, and it wont be long before private contractors compete. But in West Wales it would be very expensive as the journey to a competent hospital is 1.25 hours at Swansea, or 2 hours to Cardiff.

Hiba Mohamadi reports for Pulse 27th September 2019: GPs requesting ambulance will have to provide a score for level of emergency.

In the BMJ Elizabeth Mahase reports: GPs warn against use of scoring system.  BMJ 2019;367:l5814

…..The system is based on six physiological measures: respiratory rate, temperature, oxygen saturation, systolic blood pressure, pulse rate, and level of consciousness. Despite not being validated for primary care, NHS England has “encouraged” its use. Last year its was made mandatory in ambulance trusts. NHS England said the score should be used “for all pre-hospital patients who are ill or at risk of deteriorating” and to “support colleagues to identify deterioration early and prioritise resources in times of surge.”…..

Dr Rachel Marsden RCGP Clinical Support Fellow for Sepsis, is on the RGP website: The updated National Early Warning Score and its use with suspected Sepsis

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A new take on deserts based rationing. BMI threshold,,,,

In a new take on rationing Yorkshire CCG reduces BMI target before access to treatments is allowed. The perverse result could be that such excluded people are less active, and will gain more weight as activity reduces, thus increasing their weight and risk of heart disease and Diabetes. It all depends on the demographics of the population’s BMI… NHSreality feels it might also be regressive, in that the lowest social groups and poorest people are able to do less to change their lifestyle. However, it does have the benefit of being “overt”, and for that reason I support it if extended into other areas of deserts based rationing.. Obviously BMI > 35 did not save enough money. Will this?

CCG is criticised for “unfair” policy that delays surgery for patients with BMI over 30 BMJ 2019;366:l5757

A clinical commissioning group (CCG) in the north of England has been criticised for lowering the body mass index (BMI) threshold at which patients must join a weight management programme before they can have surgery.

From 1 October, East Riding of Yorkshire CCG will require patients with a BMI over 30 to be referred to the Get Fit for Your Operation programme before they join waiting lists for surgery. The previous threshold was a BMI over 35.

The CCG said that the new policy was based on evidence showing clear benefits for patients who had a lower BMI. After six months, patients would become eligible for surgery regardless of whether they had lost weight.

But local GPs and the Royal College of Surgeons (RCS) said that the new threshold was “unfair and ignored clinical guidance.” They warned that the policy could increase the risk of opioid dependence for patients waiting for pain relieving surgery.

In board papers1 the CCG said that it recognised that its new policy may be viewed as “a cost saving exercise which adds an additional barrier to people accessing secondary care.”

It added, “Surgery is not, however, being restricted and this risk is mitigated as the changes are based upon an over 30 BMI evidence base, as well as robust patient communications which outline the benefits of pre-surgical weight loss and smoking cessation, and the provision of a comprehensive programme of support for weight loss and smoking cessation.”

But Andrew Green, a local GP and former clinical and prescribing policy lead for the BMA’s GP committee, questioned the evidence base used to alter the threshold.

In a letter to local GPs seen by The BMJ, he wrote, “The analysis of this programme up to now with patients with BMIs less than 35 was lacking in scientific vigour (comprising simply of anecdotes), and did not demonstrate any significant improvement in their weights.”

He went on to express concern about the impact of patients taking opioids. Green—who represented the BMA in the landmark Public Health England review of prescribed medicine dependence and withdrawal2—wrote, “For patients awaiting pain relieving surgery who are on opioids, any possible benefit of this programme will be outweighed by the increased risk of opioid dependence, which they will incur as a result of the delay. As GPs, we have a duty to advise our patients of this.”

GP Anne Jeffreys, East Riding of Yorkshire CCG chair, acknowledged that the area has a higher than average rate of high dose prescription opioid use, but said that the CCG had commissioned a number of services to reduce this, such as two specialist addiction nurses to work alongside GPs.

“It has been shown that lifestyle changes can improve pain for many patients without the need for surgery or opioids. For many people, care is best suited in a community setting rather than within a hospital,” Jeffreys said.

GPs can also submit an individual funding request for clinical review in exceptional circumstances, she added.

However, Neil Mortensen, vice president of RCS England, said the move is “short sighted” as well as being unfair and ignoring clinical guidance.

“With a BMI threshold of 30, a good number of the players in the England rugby squad would have their surgery delayed, despite being at peak fitness. We strongly encourage this CCG to reverse their policy,” he said.

Mortensen added that such rationing policies have become “acceptable to CCGs,” despite the fact that they can “lead to the need for prolonged use of pain relief drugs, impact a patient’s quality of life and ability to work, and increase the likelihood of them needing social care support.”

He called on NHS England to make it clear to CCGs that these sorts of policies are “unacceptable.”

East Riding is not the first CCG to implement such a policy. In 2016, Vale of York CCG announced plans to delay all elective surgery for obese patients for a year until they lost 10% of their weight. The move was criticised, with David Shaw, a senior research fellow at the Institute for Biomedical Ethics, University of Basel, in Switzerland, writing in The BMJ that not only was BMI “notoriously unreliable,” but the delay could worsen the patient’s health and cause them unnecessary pain.3

BBC News 7th November 2019: Patients in East Yorkshire need to lose more weight before surgery