Author Archives: Roger Burns - retired GP

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

End-of-life care is a postcode lottery, say experts

Commissioners get away with rationing care to the dying because the patients are not with us for long enough to vote. Cradle to grave NHS!!!

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In The Express 9th June avid Williamson reports: End of life care is a postcode lottery. 

END-of-life patients face a postcode lottery when it comes to palliative care, experts will say this week. They will call for a change in the law so more than 100,000 adults and children every year do not miss out on vital pain relief and support..

…Baroness Finlay argues it would be “totally unacceptable not to provide maternity services” but the country has “people dying with complex needs with no specialist service available in their area”….

And Care UK on 10th June reports the same: 

BMJ 1st March 2017: Concerns over inconsistent palliative care provision | BMJ

The Cecily Saunders web site : Palliative care postcode lottery and wide variations in budget per patient

Cancer Nursing Practice suggests: Palliative care services vary widely across England and the government should introduce national guidelines to ensure services are commissioned more appropriately, researchers have warn

NHSreality notes the omission of the 3 other dispensations. So much for comparatives, and so much for a “National” standard in care of the dying.

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Richard Smith: Chair of NHS England wants a £50 billion NHS bond, culture change, a good relationship with the private sector, and innovation

Things are getting desperate. When you cannot raise the money from the treasury, you try to raise it from the citizens in a “bond”. I and most others would rather pay for private health care than trust the government too use my bond money any better than they have used money in the past. It is the system and the fundamental assumptions which need to change. ? Everything for everyone for ever ?

Richard Smith: Chair of NHS England wants a £50 billion NHS bond, culture change, a good relationship with the private sector, and innovation June 6th BMJ Opinion

Lord Prior, the chair of NHS England, is tall and thin, has a playful smile most of the time, and answers questions with a directness unusual in the higher echelons of the NHS. A barrister, he has worked in finance and industry, been a member of parliament, and chaired multiple NHS bodies. He spoke earlier this week at a meeting of the Cambridge Health Network, which brings together people from the NHS, private sector, charities, and academia. Usually its meetings are held according to the Chatham House Rule, meaning that people can be quoted only with consent, but Prior’s meeting was open.

Prior began by emphasising the deep significance of the NHS to the British. He’d been listening on the radio to the American ambassador discussing access for American companies to the NHS and had realised that the ambassador just didn’t understand the cultural importance of the NHS……

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….In short, the NHS is, said Prior, “capital starved.” More investment is needed, particularly in information technology. Government, he pointed out, can borrow money at around 2% interest, whereas trusts are paying 10-12% of private finance initiatives, totalling almost £1.5 billion annually. The case for a government bond for the NHS, concluded Prior is “almost unarguable.”

Several people asked whether the NHS was becoming more anti-private sector. Prior said that it would be “very sad” if that was the case as new ways of doing things often come from the private sector. He said that as far as he was concerned the private sector is “part of the system” not outside the system.

Somebody in the audience said that selling innovative technology into the NHS was difficult because NHS organisations had no money, had a risk-averse culture, and needed to see an immediate financial return. Prior said that he hoped that the creation of NHSX [the new joint organisation for digital, data and technology] would lead to a “gear change.” “You,” he said to the questioner, “are crucial.” Innovation is good for the NHS and for the British economy. Asked at the end what one thing he would like to see if he had a magic wand Prior concluded “innovation.”

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The firm: does it hold the answers to teamworking and morale?

The BMJ The firm: does it hold the answers to teamworking and morale? (BMJ 2019;365:l4105 )

Rotations and shift patterns mean that junior doctors often struggle to feel part of a team. Some want to bring back the “firm” way of working. But is this feasible, and was the firm really part of a golden age for trainees, asks Abi Rimmer

In the discontinued “firm” system—a model of medical apprenticeship—groups of doctors worked together to provide patient care.

Firms generally had at least one permanent member, a consultant, who led the firm and after whom it was named. Some four of five trainees of varying seniority weren’t permanent members of this firm, but they belonged to it, and for many it was a consistent source of professional and emotional support.1 The quality of education and training that trainees received, however, varied.2

The firm’s demise came after 2005 when trainees began rotating more frequently under the Modernising Medical Careers programme. From 2009 European working time regulations shortened doctors’ working hours. Junior doctors spent less time on the wards and their involvement in teams became far more transitory.

But many doctors would like to see the firm reinstated, seeing it as an answer to today’s problems of disenfranchisement and low morale among junior staff.

The cause of all the mayhem

When the firm functioned well, says the Royal College of Physicians (RCP), it provided “a structured development process, role modelling of professional behaviour, mentoring, and a good balance of challenge and support.”2

Harold Ellis, a retired professor of surgery who qualified in 1948, describes his firm as being like a family. In a firm, Ellis tells The BMJ, there would be one or two consultants known as “the chiefs,” a senior trainee known as “the registrar,” a junior trainee known as the “house physician” or “house surgeon” who lived in the hospital, and medical students……

Re: The firm: does it hold the answers to teamworking and morale? Reply 13th June 2019

Firms would wither in this age of individualism.

Firms that thrived in past had a wise head leading it; collective responsibility was cherished and self sacrifice was applauded not derided.

In firms, good and bad decisions had ownership and learning from mistakes is encouraged without a sword hanging over the head.

But the firms of the past would not survive the current “age of individualism”. Now individual rights reign supreme without even a symbolic nod to group responsibility. Good firms place patient needs first and hence is incompatible with a clock watching culture.

Today:

Re: Consequences of losing firm: true or false ?

Having had surgical training between mid – 80s and early 90s in traditional firms led by a consultant and supported by senior registrar, registrar and house surgeons (senior and junior) and following completion of the training , worked as a consultant till date, has given me an opportunity to appreciate the gains and losses incurred under both schemes. In all honesty, both systems have their inherent advantages and disadvantages, and both are not perfect. When one speaks to trainees of current system, they favour the present system of training with shift system as this is thought to be more humane and safe in comparison to the past system which included long hours of on calls (24 hours on week days and 72 hours on the weekends) with potential risks to the patients and doctors from lack of rest and exhaustion. Lack of continuity of patients care and incomplete connection with the patients and team are the major barriers to comprehensive training in the current system. However, eight years of structured current surgical training programme (core and specialist training) with well described curriculum and objective examinations (MRCS and FRCS) on completion of stipulated training, is at par with surgical training schemes internationally, including USA and Australia, as far as I am aware. It must be acknowledged that NHS in UK is under financial constraints and its repercussion as reflected by the reduced number of staffs (doctors and nurses) has significant implications on the workload of doctors, particularly the consultants, and the quality of training. It is important to assess issues surrounding the current training scheme and address them commensurate with the rapidly advancing science and technology in medicine.

New and higher taxes will never solve the problems of health and social care…

and migration limits on doctors have been lifted.

Matt Hancock pledges to lift immigration limits on NHS medics

Older people should receive free help to eat, wash and get dressed in a move which would improve their health but need to be funded by a 2p tax rise, a thinktank has said.

The proposal, by the left-of-centre Institute for Public Policy Research (IPPR), highlights the growing political consensus that personal care should become free for over-65s. If implemented, it would bring England into line with Scotland, where such care has been free since 2002.

The IPPR argues that the key principle underlying access to the NHS – free care at the point of need – should be extended to this element of social care services in England.

'When a patient is clearly in need of personal care it's imperative that you call a care assistant urgently!'Image result for personal care cartoon

 

 

As rationing bites harder- survival may become a popularity contest

Some parts of the UK will be more prone to crowdfunding. Wales will be the area with most need as the waits are so bad. Ideally funding should go preferably to those with most life years ahead of them…. Nick Triggle reports on The best and the rest – what we’ve learned from the NHS Tracker (BBC news 15th June 2019)

“Things are getting worse” says Nick Triggle (WHat has NHSreality been saying for 7 years?)

The three hospital measures the BBC has focused on are the most high-profile targets in the NHS.

The way they are measured in each UK nation varies, particularly for cancer and routine operations.

But in each case, they were set to stretch the health service and encourage it to provide care quickly to patients who needed it.

As a result, the targets have never been achieved all the time.

But for the first time since they were introduced more than a decade ago, we have had a whole 12-month period where no part of the UK met any of the targets.

That milestone was passed last year.

Graph

And the situation has continued every month since…….

When survival is a popularity contest: the heartbreak of crowd funding healthcare – Sirin Kale in the Guardian 20th May 2019

A growing number of Britons are turning to online fundraising for essential treatment in a desperate, ‘Dickensian’ attempt to get around NHS shortfalls. But does it work?……….

….” it’s normalising the idea, at least in the US, that, in order to get essential health services, you need to compete with all these other people to be the most deserving, the most needy, the most compelling.”

Tere is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

GP list sizes in England can be found here. 

Standards are falling in most areas because of the pressure of work both in Hospital and General Practice. Occasional well respected and popular training practices are the least under pressure. In social care standards are also falling, and one inspector (Greg Hurst reports in the Times 13th June 2019) has quit citing a toxic culture in the Care Quality Commission. He should be listened to, as there is a toxic culture, and disengagement everywhere in Health and Social Care. Of course there will always be examples of individuals who break the mould, but in general NHSreality says it as it is. The Times report is below..

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Mary MacCarthy in Pulse December 2018: Cappling GP lists would make GPs and patients safer: 

Nick Bostock in GPonline 12th December 2018 reports that since 2004, there has been a 50% increase in GP list sizes.

and earlier that year, he reported with Teni Oluwunmi  that the number of GP practices had declined by 263!!

and last year, according to the Mail by 138

Emma Bower for GPonline 5th June 2019 also suggests that Scotland needs a new target for the GP workforce. With increasingly elderly population with multiple pathologies and complexity, 15 minute appointments are also needed. (BBC News)

Anal Carcinoma needs prevention with HPV vaccine? A nurse comments on her own illness…in Healthonline

Research in the US has discovered what the drug manufacturers should have found: drugs for shrinking enlarged prostates cause delay in the diagnosis if the prostate goes malignant. Another case of Big Pharma and overtreatment.

Barry Stanley-Wilkinson gives his exit interview from the CQC. (Greg Hurst reports in the Times 13th June 2019) has quit citing a toxic culture in the Care Quality Commission.

Waiting lists are getting longer, even for cancer diagnosis and treatment. Nick MacDermott in the Sun12th June 2019 so keep up the private insurance payments as long as you can, especially if you live in Wales.

An inspector whose report highlighting failings at a scandal-hit hospital was never published resigned from the regulator, protesting that some of its staff were too close to the private company that ran the hospital.

Barry Stanley-Wilkinson also complained of a “toxic” culture at the Care Quality Commission and said many of its inspectors felt that they worked in a “bullying, hostile environment”.

Mr Stanley-Wilkinson resigned six months after he led an inspection in 2015 of Whorlton Hall, a private hospital in Co Durham for adults with learning disabilities or autism. Police arrested ten carers at the hospital last month after Panorama on the BBC broadcast footage of staff appearing to mock and intimidate patients.

The inspector reported in 2015 that some patients had accused staff of bullying and inappropriate behaviour. He said patients did not know how to protect themselves from abuse and recommended that the hospital should be given a rating of “requires improvement”.

His report was never published and a new CQC team that inspected Whorlton Hall in 2016 gave it a “good” rating. Mr Stanley-Wilkinson’s resignation email, sent to the CQC in January 2016, was published yesterday by parliament’s joint committee on human rights, which took evidence from two CQC executives. He expressed frustration that his report on Whorlton Hall had not been published “despite significant findings that compromised the safety, care and welfare of patients”.

He referred to a complaint about his report by the hospital, which was then run by the healthcare company Danshell, and pointed out that it had previously been run by Castlebeck, which ran Winterbourne View, a care home where there had been an abuse scandal in 2011. Whorlton Hall was taken over by Cygnet Health Care this year.

“I am concerned about the relationship managers have had with the service,” Mr Stanley-Wilkinson wrote. “Discussions had taken place without my involvement despite me being the inspector.”

Paul Lelliott, deputy chief executive of the CQC, said the 2015 report had had inconsistencies and lacked evidence. Ian Trenholm, its chief executive, said the CQC planned to develop a new way to monitor institutions.

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The risks associated with not haveing a dentist and dental care…

There are large long term risks to the population, particularly the poorest and children of lowest social groups, in not having dental care. The prediction from some dentists is that the higher rate of caries from neglect will lead to an epidemic of Rheumatic Heart Disease in 20-30 years. But then, which party or politician will care about the votes of these people in 30 years’ time? The wait for a Dentist is only part of the problem: now we have longer waits for cancer treatments and that will hit voters! Unfortunately it wont hit MPs as they will go privately, and have access to all the central London facilities, and even if they stay in the EHS, they retain choice. We have rationed dental training, and now we are rationing dentists. In most overt rationing systems those at most need would get subsidised treatment, but most British trained dentists are working in the affluent areas, and privately.

Fiona McRae reports 12th June in the Times: Dentist closures leave thousands without access to NHS treatment

One of the country’s most densely populated cities does not have a single dentist able to take on NHS patients.

Up to 20,000 residents of Portsmouth will be without a dentist when a chain of practices closes its doors next month.

With no surgeries accepting new adult NHS patients, the nearest practices are in Gosport, which is a ferry-ride away, or Havant, a half-hour drive away, according to the NHS website.

The British Dental Association (BDA) said that “years of underfunding and failed contracts have taken their toll”, leaving practices struggling to recruit staff, and communities from Devon to Cumbria having difficulty getting access to dental care.

Research by the BDA highlighted 13 towns and cities where no dental practices were registering new adult patients, including Plymouth and Barrow-in-Furness.

It also calculated that more than a million new patients had tried and failed to find a surgery last year.

Colosseum Dental Group, which is owned by an investment company based in Switzerland, is closing three practices in Portsmouth next month. Estimates of the number of patients affected vary. Local sources have put the figure at 20,000 but NHS England suggested that it would be closer to 9,000.

Colosseum Dental blamed the closures on “longstanding and ongoing challenges in dentist recruitment”.

One Colosseum Dental patient, who did not wish to be named, said: “I received a letter saying that I would be provided with ongoing care at another surgery but when I contacted them I was told all they could do was put me on a waiting list. They said Colosseum had made a ‘business decision’ to shut the three surgeries and the staff had been made redundant.”

Stephen Morgan, Labour MP for Portsmouth South, said that poorer members of the community would be worst hit.

“The news that three dental practices in Portsmouth are set to close is deeply concerning,” he said. “How will poorer families pay for the additional transport costs? How will single parents get the time off work to travel the extra distance? What will the additional environmental cost be for our city, which is already plagued by air pollution? The government needs to answer these questions.”

He added that the situation raised questions over the use of private organisations to run public services.

Mick Armstrong, the BDA’s chairman, said: “We are seeing practices struggling to remain sustainable as vacancies go unfilled and over a million patients are unable to secure an appointment. NHS dentistry remains the Cinderella service and this is the latest evidence that its future can no longer be guaranteed.”

A spokesman for NHS England South East said: “There are more than 20 dental practices open in the Portsmouth area and patients at nine in ten dental surgeries will not be affected by these changes, while support is being offered for people to find alternative care where it is needed.”

Analysis

More than a million new patients were turned away by NHS dentists last year, on top of 700,000 who could not get an appointment with their usual surgery.

Some patients have spent years hunting for a dentist, others have given up and even pulled out their own teeth.

Changes to how dentists are paid, introduced in 2006, are at the root of many of the problems.

Dentists went from being paid per treatment to being paid for a target amount of work each year under the new contract. They are now paid as much for doing ten fillings as for one.

Those who hit their quota early in the year have no incentive to do more NHS work because they will not be paid any more for it. Those who can’t make their targets face financial penalties.

NHS dentistry gets funding for only half the population, and the profession is struggling to recruit and retain staff.

Three quarters of practices had trouble filling dentist vacancies last year and six out of ten dentists say that they plan to leave the profession or cut back on their NHS work in the next five  years.

Agonising delays for cancer treatment for the Scots

Endometriosis patients have to go overseas

Update 18th June 2019: BBC News 17th June – MP calls NHS summit on Portsmouth dentist closures

DENTIST CLOSURES 13th June The Times

Sir, The reasons that there are such problems over access to NHS dentistry are multifactorial (“Dentist closures leave thousands without access to NHS treatment”, Jun 12). Dentists are faced with working in a target-driven system: if a practice misses targets it is faced with financial clawback and the threat of contract termination. Dentists are paid the same amount if a patient needs one filling or five fillings and two root canal treatments, so the incentive of taking on high-needs patients is zero, as it could mean potential bankruptcy. Costs have risen hugely since 2006, with only small yearly increases in funding for NHS care. Care Quality Commission regulations and General Dental Council guidelines heap pressure on clinicians, meaning more paperwork and less time with patients. Dental litigation is increasing, so the fear of being sued means spending more time writing notes in case of a claim. A new contract was promised years ago but dentists are still left in the dark regarding the future.
Dr Mike O’Reilly

Prestbury Dental Practice, Cheshire

‘… and as the Minister in charge I can assure the public there is no shortage of NHS dentists.’