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.

Doctors are being asked to play God…….. The FT thinks it has the solution…

Philip Stevens in the FT reports: Doctors are being asked to play God – The coronavirus pandemic is presenting hospitals with a terrible choice about whose life to save

web_Nursing coronavirus balance
So who decides between life and death? As the Covid-19 outbreak threatens to overwhelm healthcare systems, it also presents a harrowing human dilemma. We have caught a glimpse of this in Italy. Distilled to its essentials, it can be expressed more or less as follows. Doctor A has one ventilator and two patients in the grip of the coronavirus. Arriving first at the hospital, patient B, a 65-year-old retiree thought to have only a slim, albeit still measurable, chance of survival, is being kept alive on the ventilator. Patient C, a 35-year old teacher who arrived later, is deteriorating fast, but is judged to have a high chance of recovery if transferred to the ventilator. ….

And the FT then opines that it has the solution: How to avoid rationing urgent healthcare during the Covid-19 outbreak

But I’m afraid you will have to buy or register to get the answer.

Ruling political parties will never plan for long term health in our FPTP system. The political parties need to take away the gag from the mouths of their politicians.

Ruling political parties will never plan for long term health in our First Past The Post ( FPTP ) system. Countries that were nearest to the SARS and other viral epidemics, have planned best. Most countries, even those with various PR systems have planned inadequately. Singapore has had a plan, and even there a second wave is possible, but they have far fewer first wave cases. Thus their medics will be much more able to cope. But any form of PR must give a better opportunity to plan than the current UK system. The planning extends from viral epidemics, to manpower, and to financial stability. It is also evident that the “Honest Debate”, asked for by Mr Stevens in 2014, has not been able to take place. Rationing is now common parlance in the media, but not amongst politicians. 

The political parties need to take away the gag from the mouths of their politicians. Their failure has led to a deep abscess in a root canal of a rear molar. If its not removed the whole body will get worse…

See the source image

March 2020: Hardship…? Lets seize the opportunity for more much needed change..

May 2015: Setting sail in a boat already holed. The new government will fail unless it rations health. Proportional representation would be better than the inevitable mess to come..

Dec 2019: A toxic amalgam of 4 “health and social care” services

Nov 2019: A curse on all their houses. Banal debates omit the really important questions. Entertainment has come before long term politics and unity..

and Health services and elections.. PR will give fewer changes in philosophy and bring back trust.

June 2018: How did we get to this? What manpower planning failure. Please let Health Service visas be dependent on good language and cultural awareness.. and integration

and  Jan 2018: Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

Nov 2017: We are creating a “caste” of doctors – by neglect. Neglecting to change our electoral system is equally crass..

Apr 2017: The contestants – who will promise the most irrelevant package? Listen and (later) read their prospectus.

March 2017: The UK Health services are facing a “dead end” – both literally and figuratively if we don’t accept rationing.

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

See the source image

A changing opportunity for the four UK health services.. Solution: avoiding paternalism, for rationing, and for financial probity.

This type of social revolution brings some good thoughts from our media correspondents. Whether their thoughts are translated into action is another matter. Populism, embraced by leadership in the UK, is aware that by changing the services so that they are founded on a rock will be traumatic, controversial, and lose them votes because the opposition will pounce on them. Co-payments – no way. Rationing – never happens, Standards – always rise! These are lies that need to be exposed and debated in an open society.

Lets start with standards. In a short article hidden in a small side column on the Times 4th April, and not on line, :

Medics’ Extra Insurance: Doctors have been given extra government assurance for lower care standards and a commitment that regulators will be lenient on failures at the height of the pandemic. In a letter to medics, seen by The Times, health authorities acknowledged that satff may “need to work in different ways”, adding “We do not want indemnity to be a barrier to delay to such changes”.

Well let me tell you that not only hospital doctors, but also GPs are taking extra risks. For a start not examining the patient and relying on phone and video calls raises the risk. I wonder if GPs, already in meltdown before the crisis, are going to be absolved if they make the inevitable error. We should go the whole way and have no fault compensation.

Co payments. Well Janice Turner  on 4th April in the Times in This fad for fitness could last a lifetime – All the generations are coping with their fears by trying to improve their health, which will be good news for the NHS

….The one notable downside of the NHS is it leads to physical complacency. If we get obese, diabetic, develop joint problems or high blood pressure we just see a GP and are treated “for free”. No need to change your lifestyle: pop a statin. An NHS physio told me patients expect to be fixed in a single appointment, rarely doing the therapeutic exercises at home. Writing about diabetic amputations, I met nurses begging high-risk patients not to live on chocolate bars, and a surgeon who eventually cut the limbs off patients who’d carried on smoking even after losing several toes.

Ms Turner exposes the achilles heel of the paternal society that is the 4 UK health systems. One that even Anneurin Bevan recognised, but felt he had to put up with to get his bill through. We do not encourage people by stick, as well as carrot, to look after themselves.

And rationing: In Paul Nurse opinion in the Times 4th April: ‘Boris knows he’s out of his depth. Suddenly experts are useful again’

…The country is, he warns, paying the price for ten years of austerity. “If you’re always strapped for cash, you will invest in what’s going to be needed next week, and not what might be needed in ten years.” Too often, the political debate about the NHS “focused too much on short-termism — what money can be saved here — and you do have to have a longer-term perspective,” he says. The calculation that “we’re tying up money in something that is unlikely to be used . . . is OK if you’re running a business, but it isn’t so OK if you’re running a healthcare system”.

The pandemic also, he argues, proves the importance of “left-field” scientific research that may not be immediately useful. “I work with yeast, and people think that’s utterly useless. But what we discovered some years ago is what controls how a yeast cell divides . . . and then we showed that’s the same in humans. That is absolutely critical for cancer.”

The next big challenge is to create a coronavirus vaccine.

It needs more money, resources, people and plant. But we cannot afford it if “Everything is free for everyone for ever”.

Kat Lay in the same paper thinks that the Pandemic is set to future-proof the NHS

but NHSreality would contend that is only if we face the issues above honestly.

…New ways of working, including centralised hubs co-ordinating cancer care, are likely to persist even after the pandemic has passed, experts say…..

…He estimated that even after the pandemic, up to half of GP appointments would be online or by telephone.

Efforts are focused on how GPs can access patient records securely from home, with many having to travel to surgeries to conduct remote appointments…

Hospitals, too, have moved outpatient appointments online. The move ties in with a pre-pandemic ambition to reduce travel and thus air pollution.

Pando, a communications app for healthcare workers, is being downloaded by more than 1,000 doctors daily.

Last week, Matt Hancock, the health secretary, wrote to all NHS organisations giving them legal backing to set aside the normal confidentiality for patients until at least September if sharing patient data was deemed relevant in helping the fight against Covid-19.

 

 

We are facing the same scale of infections as all the other G8 countries..

We are looking at the same curve in all the G8. This information was processed and analysed by David M. Thank you. It does look as if whatever we do, other than lock-down, makes little difference to the final outcome.

My understanding is that if on a ventilator you have 1:5 chance of survival

2020-04-03 Coronavirus deaths – UK v Italy Spain France Germany US

The charts I have seen in the media tend to show the trajectories from a common point such as the 3rd, 10th
or 100th death. I have taken a different approach and instead have found which time lag gives the best fit
between the deaths in the UK and each of the major western countries. The results are very interesting and
are captured in the graphs below.
My simplistic conclusions
• The best fits are found if one assumes that in the UK the contagion is running 15-days behind that
in Italy, 7-days behind that in Spain, 4-days behind France, 3-days ahead of Germany and 4-days
ahead of the US.
• It would appear that no matter what approach to deal with the crisis each western country is
taking, we are all following a time-lagged (almost-) synchronised trajectory. [Let’s hope that we
can collectively find a way to change that trajectory.]
• The rate at which deaths are rising in the UK is now faster than at the same stage in Italy, Spain and France……….

NHS Liabilities and negligence costs. Minister fails to answer the question from Mr Hunt. Lack of candour and honesty continues..

The perverse incentive for a current minister to think and act short term, because of the First Past the Post system is evident.

Asked by Lord Hunt of Kings Heath

Asked on: 17 March 2020 in Parliamentary Business Questions

NHS: Negligence:Written question – HL2693

Continue reading

Will YOUR local trust be candid (honest and truthful) in a timely manner? No way….

In an epidemic of plague managers and bureaucrats have to draw a line between complete honesty, which might lead to anxiety and panic, and modified truths, which reassure and support the population through difficult times. But is this against HMG and GMC rules since 2013, which obligates a “duty of candour”.

It is unlikely that your local trust will be entirely honest and truthful, and this may be in your best interest. Unfortunately, the track record means that their honesty and decision making has been questioned so much in the past few years, especially in rural areas, threatening to close the local DGH, that the public will likely be dissatisfied whatever they are told. 

I was in favour of a new build hospital, but in Pembrokeshire. All hospitals are out of date almost as soon as they are built because of advances in science and technology. So we should only build hospitals with a short life expectancy, and there should be twice as much ground space as needed, so that the replacement can be built alongside, while the cardboard and plastic of the first one is demolished. But a new build out of the area will distance patients from loved ones, lose the community support, and because of poor infrastructure lead to loss of lives.

At present there is a problem if you have a coronary or a stroke, as increasing covid-19 admissions may mean home is safer, and yet the old fashioned thrombolytic, (treatment before stent) is not being encouraged. It could be given at home…. This would be appropriate rationing… And of course, we are being told rationing will have to take place – as if it never happened before!

See the source image

The BMJ leader, by Fiona Goodlee ( Covid-19: weathering the storm: BMJ 2020;368:m1199 ) gives a good indication of the way we are now, our focus oon immediacy and avoidance of blame until its all over… My post on Scapegoating was not meant to be political, as it showed all parties to be at fault. 

Fiona’s text is below:

The UK is at last in near lockdown. While further measures may be needed, the government’s announcement on Monday 23 March has brought the country nearly into step with its European neighbours. If we are indeed only two weeks behind Italy, the peak of the covid-19 pandemic is on its way. There is an eerie calm, as when the sea recedes before the tsunami. Few of us can imagine what lies ahead.

For some, especially in London, the wave has already hit. Intensive care units are full, and hard decisions are becoming harder. On BMJ Opinion Daniel Sokol hopes that hospitals will establish “ethical support units” to help clinicians choose which patients to prioritise (https://bit.ly/2WIlTsI). In our rapid responses David Barer makes a stark call for people aged over 60 to prepare for a lack of ventilatory support and to express their preferences for palliative care until WHO declares an end to the pandemic (bit.ly/3bqvubU).

Every aspect of the NHS is being reorganised to meet the increased demand, say John Willan and colleagues (doi:10.1136/bmj.m1117), but 20% of its workforce is either ill or in self isolation. Healthcare workers are at higher risk of infection, and personal protective equipment is still lacking, despite government assurances. The waiting and workload are worsened by fear and fatigue. Staff, already stretched, are now scared.

Could some of this have been avoided? Many think so. Over the years, opportunities to research influenza-like illness have been missed and money squandered on ineffective antiviral drugs (doi:10.1136/bmj.m626). The NHS has been stripped of resilience by years of attrition compounded by lack of investment in social care. Public health services have been systematically decimated and dismantled. The UK’s idiosyncratic response to the pandemic has been guided by questionable modelling rather than by long established fundamentals of communicable disease control (https://bit.ly/2UzRZnI).

David Oliver counsels against political point scoring: there will be time enough for that when this is over, he says (doi:10.1136/bmj.m1153). So we should for the moment focus on things that will help us weather the impending storm. An urgent return to community contact tracing, says Allyson Pollock (bit.ly/2ULmgAj). Testing of frontline healthcare workers, says Julian Peto (bit.ly/2QJLjCx). Lowering the baseline of underlying illness, say Robert Hughes and colleagues (bit.ly/33PhNRa). To these, like Mary Black (bit.ly/2JcjiiF), I would add three more necessary things: candour about the scientific and political uncertainties, kindness to ourselves and each other, and courage.

March 2020: Many governments and many ministers of health have made mistakes… They should be candid.

May 2019: Whistleblowing protection is important, but exit interviews that prevent the need for whistleblowing are more important.

Jan 2017: Candour and Transparency? – what a farce

April 2016: National NHS whistleblowing policy published. Doomed to fail. The duty of candour will be outgunned by fear of reprisal.

March 2016: Stephen Bolsin – Bristol Scandal Whilstleblower mock interview in BMJ confidential. The duty of candour shows no sign of overriding the culture of fear and bullying.

Dec 2015: The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

Nov 2015: Constructive deconstruction – of the ischaemic bowel in the UK Health Systems.. Politicians need a duty of candour like Mr Smallwoood

March 2013: No more covering up errors, NHS told. (A new “Duty of Candour”.)

March 2020: Doctors will ration health care if they have to. But the situation that led to the under capacity- shortage of staff, equipment, beds, plant and then morale, needs an independent enquiry

CV19. Lets see who we can scapegoat for our unpreparedness…? The magnificently ( unlucky ) 13

Image result for dishonest health cartoon

 

Will the epidemic/pandemic lead to a rethink of hospital closures?

The first antibiotics were developed during the first world war (Sulfonamides) and Penicillin was discovered and then isolated and purified between the wars. Anti viral drugs are not successful, and stocks of Tamiflu have proved useless for this coronavirus 19. We have been complacent for years, even though BillGates was warning us of the viral potential in 2015.

The move towards larger and more efficient hospitals, encouraged by all advanced thinking in the last decades, may change.  If we are to think about infectious diseases and the way we approach them in the future, we may wish for separate “fevers” hospitals as there used to be in the 1960s and 1970s. We may wish to retain more local but less sophisticated hospitals, so that the caring and the organisation of volunteers is easier. Fevers hospitals seemed to have had their day… until now,

When women gave birth in the past, it was often in a separate maternity home, and they were transferred to the nearby hospital if they needed surgery. This happened in my home town of Haverfordwest, and in many other Welsh towns.

When I am ill, and perhaps even terminally ill, i want to be near to my family. The closure of hospitals will make this aspect of care and modern medicine distant and unpopular. Unless we persuade and induce families to look after elderly parents in their own home, the hospitals will not cope. Why is terminal care in hospices only partially funded in any one of the 4 cradle to grave Health Services?

With an ageing population we need both local and specialist hospitals. With pandemics in mind we need fever hospitals again. Maternity care, given the amount of cross infection and the risk in this pandemic, might once again be better isolated from the general hospital.

While we are re-thinking health, why not appoint every Medical Student who aspired to do the subject this year? Those who cant make it can be weeded out at the 2nd MB stage. We need every one, and if there were 11 applicants for each place, as in the past, why not appoint all 11?