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.

The sticking plaster approach…. “….simply managing decline”.

We are going bust, and without rationing we will only dig a deeper hole. We face lower standards and continuing decline unless we address the reality that we cannot afford Everything for everyone for ever. 

The analysis at the bottom of the page in the Times is partly correct, and just needs to admit to failure if we fail to ration overtly. It is not on line, but the comments are worth attention as well, realising complexity. We already means test Social Care payments, so why not means test health payments? 

NHSreality is very concerned about the amalgamation of Health and SS into one budget, as this will make the need for rationing, currently covert, more evident. The health budget is beyond control, and growing exponentially…

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Joe Mellor writes in “London Economic”  18th June 2018: May’s NHS Brexit dividend is “tosh” & “a sticking plaster solution”

And this was also the approach of Rachel Sylvester: The timid and cowardly PM has ignored the urgent need for bold and radical reform of social care as well as health

….The Conservative splits over Brexit have left No 10 reeling from one political crisis to the next, rather than taking time to think of the country’s long-term future. “Every day is about survival,” says one former No 10 aide. “Theresa May was always cautious but her confidence and her political capital were completely destroyed by the election last year.” The row over the “dementia tax” during the campaign has created a neurosis in Downing Street about the funding of social care, but not dealing with this crisis will be more damaging for the country in the end.

On housing, prisons and immigration, the Tory leader is the “roadblock to reform” whose caution has become more entrenched with each Westminster disaster. Businessmen who visit No 10 find themselves repeating ideas that were received enthusiastically, but never implemented, on previous occasions. One compares it to Groundhog Day but leadership is about progressing rather than being stuck in the same place. “There are occasional flashes of radicalism — when she’s surrounded by the right people — but in her heart of hearts she’s a cautious person,” says one former aide. “It’s all about managerialism.”

On the NHS and social care, Mrs May must be bold rather than simply managing decline.

Kat Lay on June 19th reported in the Times: May prepared to reverse unpopular Tory NHS reforms

…Announcing a £20.5 billion annual increase to the NHS budget by 2023 the prime minister said that the government would “consider any proposals from the NHS on where legislation and current regulation might be creating barriers”. Last year’s Conservative manifesto had included a similar policy but change in this parliament had been thought unlikely.

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In a speech at the Royal Free Hospital in London she alluded to legislation introduced by the Health and Social Care Act 2012 that created hundreds of clinical commissioning groups, responsible for planning and purchasing health services, distinct from trusts that provided the care.

The reforms cost about £1.4 billion and were designed to to give GPs more power over the way money was spent on patients but they were criticised for being too complicated and disruptive. Mrs May said: “I think it is a problem that a typical NHS clinical commissioning group negotiates and monitors over 200 different legal contracts with other, different parts of the NHS.”

Chris Hopson, chief executive of NHS Providers, which represents hospitals, said: “The existing legislation continues to be a barrier to more integrated care and causes unnecessary bureaucracy, so we welcome the prime minister’s offer for NHS leaders to develop proposals for how the legislation may be simplified.”

Mrs May said that the structure of the NHS was too bureaucratic. She added: “Where legislation is making it harder for professionals from different parts of the NHS and different local authorities to work together we should be prepared to change it. Where it is resulting in overly bureaucratic processes we should be prepared to change it. And where it is making it harder to hold NHS leaders accountable for delivering better outcomes for people we should be prepared to change it. We must learn the lessons of the past and not try to design or impose change from Whitehall.”

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So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

Mrs May’s money will make no difference and will not create trained staff. If she admitted there would be no dividend for at least 10 years she would be more honest. 

What if she buys more scanners – where are the radiologists to report and where are the radiographers to provide, and the oncologists to define the treatment, and radiotherapists to treat?

Where is the plant to provide the projected radiotherapy needs?

So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

….”to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

Without this no administration can win the hearts and minds of the professionals who man the system. They know the truth, which is that there has to be rationing; by exclusion, restriction, exception, reduction, prioritisation, etc. What we don’t like is unpredictable post-code rationing which differs for different people with the same condition.

Robert Colvile opines in the Times 18th June: Let’s talk about how NHS spends our money – An obsessive focus on funding ignores the importance of improving efficiency and results

Weeks — months — of furious speculation, and it all boiled down to a simple set of numbers. Would the settlement be closer to 3 per cent or 4 per cent? For five years or ten? Could Theresa May hit the magic figure of £350 million a week? Would Philip Hammond even let her?

Finally, we have some clarity. The NHS will receive, as its 70th birthday present, a real-terms annual funding increase of roughly 3.4 per cent. Not as much as some wanted, but more than many feared. And though it is being billed as a “Brexit dividend”, the prime minister ominously admits that “as a country” — by which she means as individual taxpayers, present and future — “we need to contribute a bit more”.

What has been almost completely buried in the coverage of this story, and was certainly overshadowed in her interview on The Andrew Marr Show yesterday, is an equally important aspect of the prime minister’s announcement: her insistence that the money must be spent wisely.

It’s often said that analysts at the Commonwealth Fund consider the NHS the world’s best healthcare system. It’s less often said that it actually came 10th out of 11 nations in terms of “healthcare outcomes” — in other words, the most important bit. Compared with its rivals, the NHS has far too many deaths from strokes and heart attacks, and our closest peers in terms of survival after a cancer diagnosis are Chile and Poland.

As the debate over the funding settlement reached its height, we at the Centre for Policy Studies carried out some simple analysis. It showed that as NHS funding goes up, productivity tends to go down: in other words, it does more with less, and less with more. The most notorious example of this was the great Blair/Brown splurge, which was, as the prime minister points out, misspent to a quite scandalous degree.

It’s not just about the headline figures. Talk to anyone in the NHS and you will come away with a laundry list of complaints about how the service works: the profusion of quangos; the targets and funding mechanisms that often incentivise, or force, people to act in the wrong ways; the fact that it is still far too hard to reward and replicate good performance, both by trusts and individuals, and punish bad.

This is why Mrs May was right to insist that the new five-year budget settlement — itself a welcome injection of certainty — be accompanied by performance improvements. That NHS leaders will be held to account for how it is spent, that the health service will have to become more efficient. That structural issues such as slow adoption of new technology and the disconnect between health and social care must be addressed.

But there is still a limit to what this government, or any government, can do. That is why the prime minister, as the NHS turns 70, should appoint a cross-party royal commission: taking NHS England’s current plan as its starting point, but going beyond that to deliver a full examination of the health service and how it can improve.

The difference between an NHS that matches its best productivity performance over the coming decade, and one that lives down to its worst, is vastly greater — in terms of patients seen, operations carried out and lives saved — than between the prospective funding settlements.

In other words, to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

We will not know until the budget how the new cash will be found (though freezes to tax thresholds are rumoured). But economic growth of 1.5 per cent and NHS spending growth of 3.4 per cent is not a circle that can be squared for ever, unless we either want the state to amputate many of its other functions or to end up paying far more tax: approximately £1,000 extra per individual taxpayer by the end of the decade. (Remember: just as voters complain about the NHS, they complain equally bitterly about the pressure on their pockets.)

Yet if you suggest that part of the answer could be to find ways to deliver extra funding to the NHS outside of general taxation — from charging for missed appointments to introducing top-up payments to get more money from richer patients — you are castigated as a heretic. This, again, is an area where a royal commission could make progress, without the usual party-political brickbats.

The humbug that often surrounds the NHS has a real cost because it stops the health service working as well as it could or should. A few days ago, for example, the head of a left-wing think tank grandly tweeted that “the #NHS is as much a social movement as it is a health system”.

But the NHS is a health system, one that all of us rely on. Yes, it’s packed with dedicated staff, many doing impossibly difficult jobs for little money. But sinking into a sepia-tinted, Danny Boyle reverie about #OurNHS and the #TirelessAngels within it is not the way to make it better. Nor is thinking of all of its problems in terms of how much cheapskate politicians put in, rather than what the rest of us get out.

Robert Colvile is director of the Centre for Policy Studies

 

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The desperate state of General Practice. Black swans will not be diagnosed as often, or as quickly.

There is an ennui in the minds of the nations’ GPs. Disengaged and devalued, and with a job they used to enjoy, the older ones are retiring, the younger ones are leaving early, and those who remain to put up with the conditions are going part time. Throwing money at the problem will not help …. I have resigned myself to the fact that, in the Welsh Health service, I may not see a disgnostic doctor in my final illness. I am likely to see a paramedic or a nurse practitioner. Their skills may be many, and they might be experienced, but they are more likely to miss the “black swan”. A colleague (retited anaesthetist) presented elsewhere with atypical chest pain and symptoms and managed to get treated for his aneurysm before he would have died….. It seems incredible to us retired GPs that the most efficient system in the world, 20 years ago, where 90% of the work was done by 10% of the workforce, has been demolished. Yes, it is too late for me, but it can still be saved if we take the unpleasant medicine. What a boost for Private Healthcare….

David Millett for GPonline 27th November 2017 reports: Record GP recruitment not enough to reverse the crisis (and decline )

BBC News 11th June: £8.8 million investment for GP services in Northern Ireland

Nick Bostock reports 29th May 2018: NHS England unveils £10m spend

Jenny Cook reports for GP online 8th June 2018 that 1 in 10 GP practices could close by 2022

ITV News 8th June: The recruitment time bomb in East Anglia

The Scotsman Leading article 2nd June opines: GP burnout is a threat to us all.

The Mirror 10th May  reports that over 2% of the population are “Having to change practices” amidst mass closures.

GP online also reports that the numbers quitting vastly exceed those recruited.

Pulse reports on the £80k pay for EU doctors, refundable if they quit! 

The Mailonline reports thsat 40% of new doctors are quitting within 5 years of qualifying.

.The Soctsman berates the government for new medical school places being “too little and too late.”

June 2017: The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

July 2016: Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

Any GP you want: so long as you’re healthy

See the source image

See the source image

Challenge doctors over your treatment, NHS patients told. Choices need to be made, and a paternalistic doctor might be appropriate for some, but increasingly few.

One of the difficult discussions a GP can have is whether to raise the possibility of the “private” option with a patient. Some doctors leave it up to the patient to raise the issue, and some believe they should raise it if they feel the patient might be best served privately. What is the answer? In NHSreality opinion, all GPs and consultants should discuss the BRAN test… If a doctor’s first duty is to “put the patient at the centre of their concern”, he needs to point out that infections could be lower away from his DGH, and that survival rates are better in centres of excellence.

Should oncologists come out honestly about what is not available, but what they might like to give? Not without consulting with another Dr, preferably the GP.

 

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Kat Lay reports 15th June 2018: Challenge doctors over your treatment, NHS patients told

Patients will be told to challenge their doctors under guidance suggesting they should question the drugs and treatments they are offered.

Doctors and patients should follow what the Academy of Medical Royal Colleges has called the “Bran” test, which asks about the Benefits, Risks and Alternatives to a treatment, and what would happen if they did Nothing.

The academy, which represents 24 medical royal colleges and faculties, issued the guidance as part of a programme designed to reduce over-medication and decrease interventions of little or no value.

“This is all about enfranchising patients and giving them a sense of ownership of the way they are treated,” Professor Dame Sue Bailey, who leads the campaign, said. “Too often patients just accept what a doctor is telling them without question. We want to change that dynamic and make sure the decision about what treatment is taken up is only made when the patient is fully informed of all the consequences.

“Too often there’s pressure on both the patient and the doctor to do something, when doing nothing might often be the best course of action.”

The first part of its programme, published in 2015, encouraged the NHS to stop using 40 tests, treatments and procedures, including plaster for “buckle” wrist fractures in children. The latest tranche comes after NHS England said last year that it would no longer fund certain treatments including some dietary supplements and homeopathy.

The academy has now listed more than 50 further tests, treatments and procedures, which they said “may have little value or could be replaced with a simpler alternative”.

The list includes a recommendation to extend the length of contraceptive pill prescriptions to a year, to reduce visits to the GP, and simplifying advice on vitamin D supplementation to tell everyone to take them during the winter, not just the frail and elderly. It also says that doctors should not use drug treatments to manage behavioural and psychological problems in patients with dementia if they can be avoided, and talk to relatives and carers before a diagnosis, rather than just relying on a basic cognitive test.

Antibiotics in dying patients, the academy said, could be avoided because they “may not prolong life and can cause discomfort through side-effects”.

The advice is supported by Healthwatch, a watchdog. Imelda Redmond, its national director, said: “The campaign is all about encouraging meaningful conversation between doctors and patients, enabling people to have a greater say over their treatment and care while also ensuring precious NHS resources are used to their best effect.”

• A senior health service official said last night that four in ten GPs quit the NHS within five years of finishing their training. Ian Cumming, head of the NHS’s staffing body, said: “Forty per cent of all the people who completed training five years ago as GPs are not working in substantive GP employment or as long-term locums. They are doing short-term locums, they are doing other things.”

Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions.

Kat Lay in the Times reports 15th June 2018: NHS (England) must use extra funds to fight cancer

Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions. If the people have a choice they will choose local, ahead of improved outcomes and travelling. As the population ages, and more people survive cancer, we will need more radiotherapy and oncology services. The shortage of Radiologists and Oncologists is so severe that the potential for improvement is threatened.

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The NHS will be expected to improve cancer survival rates and put a greater focus on maternity safety under a multimillion-pound funding package due to be announced within days.

Theresa May appeared poised to set plans to boost the NHS budget by more than 3 per cent after intensive meetings yesterday between No 10, the Treasury and the health team.

At a conference of health service managers in Manchester, Jeremy Hunt, the health secretary, said: “We need to make sure we unite the NHS and British people with a small set of bold ambitions as to how we want to transform our system. To get our cancer survival rate to the best in Europe; to transform our maternity safety so it is as good as Sweden; to truly integrate health and social care; to make sure we have waiting time standards for mental health that are as strong and powerful as the standard for physical health.”

He was still having “difficult” discussions with Mrs May and the Treasury over the precise details of a long-term funding plan, but an announcement is expected soon. NHS leaders say they need funding increases of 4 per cent a year, in line with assessments by think tanks. The Treasury is thought to be reluctant to provide that much.

Brexiteers want rises in health service spending to be funded by the so-called Brexit dividend — money available after Brexit that would have gone to the EU. They worry, however, that Philip Hammond, the chancellor, will suggest funding it through tax rises.

NHS sources fear that a “big picture” announcement could amount to a fudge because it will not spell out the exact funding increases on offer. That would mean health chiefs including Simon Stevens, chief executive of NHS England, waiting until November for the details.

There is also likely to be disappointment at a decision to keep social care funding, which is delivered through councils and is the subject of a forthcoming green paper, separate.

A report from the Institute for Public Policy Research, a left-wing think tank, has called for social care to be free of charge for people with substantial needs as part of a new long-term health funding settlement. Social care is currently means tested. Making it free would bring the care system into line with the NHS, where healthcare is free at the point of need.

Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Rationed – Start of cheaper technique for breast cancer is delayed in UK despite adoption elsewhere. GP commissioners should be demanding intra-operative radiotherapy.

Cancer drugs fund is illogical. More money should be spent on radiology and radiotherapy.

Cancer chief quits amid radiotherapy shortfall

Artifical Intelligence is no threat to doctors, but it’s potential needs to be managed. A shortage of Radiologists is more bad news for the future.

 

Artifical Intelligence is no threat to doctors, but it’s potential needs to be managed. A shortage of Radiologists is more bad news for the future.

All specialities depend on radiologists, and radiology. They, along with GPs have to have a deep knowledge of the whole human anatomy and physiology. Their skills are moving from diagnosis into treatment, as some tumours can be infarcted (have their blood supply cut off) at the same time as a diagnosis is made. Kidneys in particular lend themselves to this treatment. Artificial Intelligence is no threat to doctors, but it’s potential needs to be managed. A shortage of Radiologists is bad news for the future. The Economist confirms that in their view they will still be needed, but their skills will develop and change. Computers will become more and more useful for the reporting of routine, but more complex judgements have to be made by physicians. Radiologists are also the first physician to know of a bad diagnosis or prognosis, and therefore they are often “breaking bad news”. So their communication skills need to be good, as well as their radiological ones.

The Economist 7th June opined: From A&E to AI – Artificial intelligence will improve medical treatments – It will not imminently put medical experts out of work

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The whole article is below

Artificial intelligence will improve medical treatments

The RSNA News (Radiological Society of North America) points out the desperate shortage of radiologists in Scotland. Why is there such a “deepening gap in the workforce”, and what is a possible “big picture solution” that involves providing doctors form the UK rather than from 2nd and third world countries who can ill afford to lose them?

RSNA News June 2018

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Interview with Dr Ian Martin, Radiologist Withybush Hospital, Pembrokeshire 12th March 2013

 

 

 

Social care ‘close to collapse’ in most councils. The difference between public and private places, in the same homes, is “covert”, and needs to be routinely exposed.

Whilst Norway has a National Investment fund, which represents joint savings for unforeseen events, the UK has nothing. My pension is not funded from savings, or from my earnings, but from todays younger people in work. The reality of the shortfall for social care, and the difference between the bills paid by private customers as opposed to the state’s, are scandals. Families must ask for the difference between the private and the public funded places when their member first enters a home. Even if they still go ahead and are admitted, the truth is then out in the open. The difference between public and private places, in the same homes, is “covert”, and needs to be routinely exposed.

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Greg Hurst reports in the Times 12th June 2018: Social care ‘close to collapse’ in most councils

Three quarters of local authorities fear that their provision of residential homes and domiciliary care is close to collapse because of rising demand and reduced funding.

A survey found that 78 per cent were concerned that they may be unable to meet their duty to ensure a stable market for social care. Nearly half, 48 per cent, said that providers of home care, which are mainly private companies, had ceased to trade in their area in the past year and 44 councils said that companies had given up contracts because they were losing money.

The survey of 152 councils was by the Association of Directors of Adult Social Services. In addition to arranging adult care they have a duty to stimulate a diverse market for care provision.

The government announced a £2 billion boost for the care system last year. Jeremy Hunt, the health secretary, is to publish plans to reform social care next month.

Comment from the Times:

The welfare state model is going to have to change. People are going to have to save for their retirement (and no, NI is not going to do it for you) like they do other things such as a mortgage and not expect the state (that is other taxpayers) to provide support because you couldn’t be bothered providing for it yourself. Of course there will be means tested exceptions, that it what the state is there for, a social safety net for those in true need who didn’t have the option of preparing for retirement. Being profligate whilst working and expecting others to pick up your bill when retired, doesn’t count!

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