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.

NI chief asks for an “society-wide conversation on budgetary priorities”, which means rationing..

Marie-Louise Conolly in N Ireland BBC reports 9th October 2019: NI health chief Richard Pengelly warns ‘something has to give’

He will be aware of the denial and the lack of the honest debate asked for by the chief of NHS England (Mr Stevens) in 2014.  The NI chief is asking for an “society-wide conversation on budgetary priorities”, which means rationing..

In the Belfast Telegraph October 17th he warns: Health service faces difficult decisions on budget 

The man in charge of Northern Ireland’s health service has said he cannot afford to pay for lifesaving treatments and pay rises for staff while also tackling hospital waiting lists.

Richard Pengelly, the Department of Health’s Permanent Secretary, said the health service in Northern Ireland is facing a £20m black hole in its budget.

As a result, he said he is unable to adequately fund a range of crucial NHS services.

Speaking at a Chartered Institute of Public Finance and Accountancy conference in Belfast, Mr Pengelly said: “I have stated that my department does not have the money to do everything we are being asked to do.

“It’s now in the public domain that our health and social care trusts are facing a projected £20m deficit this financial year.”

He restated the need for a debate to establish the public’s spending priorities in the face of budgetary pressures.

“While intensive work will continue to ensure their books are balanced, the reality is that the projected deficit represents only a small part of the escalating pressures and demands we are facing in the months and years ahead,” he said.

“Currently these are presented to me with frustration – the argument being that because I don’t do something, it means I don’t want to do it. That is certainly not the case.”

Mr Pengelly said that he had been left with difficult decisions to make and could not please everyone.

“Why wouldn’t I want to reduce waiting lists, increase pay for hard pressed staff and reduce the pressure on those staff by recruiting and training more colleagues?  Why wouldn’t I want to improve mental health provision and focus on suicide prevention, commission new drugs for patients with cancer and other serious conditions?,” he said.

“The truth is I simply can’t afford to do all these things – in fact, I can’t afford to do all the things we currently do.

“And with a fixed budget, I can only do more in some areas by doing less in others. And that is the key challenge.

“It is why we need a society-wide conversation on budgetary priorities and how best to use the limited resources we have.  In the next year alone, the competing demands and pressures could between them add hundreds of millions to an already very stretched health budget.”

Belfast Telegraph Digital

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

Image result for denial cartoon

A sign of the times: sick doctors and dentists need a “new service”.

I must add to a previous post where I implied that there was very little “National” left in our health services. There is, in addition now the Practitioner Health Programme

Image result for sick doctors cartoon

Kaya Burgess reports 21st October 2019 in the Times: NHS helpline for doctors’ mental health

All NHS doctors and dentists will now have access to mental health support after the creation of a service dedicated to the wellbeing of practitioners.

The NHS Practitioner Health Programme has a 24-hour helpline and text messaging service for staff struggling with their mental health, allowing them to seek support from specialists outside their own hospital or practice.

Last week an inquest was held at St Pancras coroner’s court into the death of Miles Christie, 43, a London GP and father of two who took his own life in May. His death prompted his widow to call for more support for medical professionals who may be reluctant to reveal their mental health problems for fear they would be deemed unfit to practise.

Matt Hancock, the health secretary, said: “It bears a heavy weight upon my shoulders when I hear of NHS staff that have taken their own lives and we should never underestimate the psychological strain that frontline healthcare work can have on individuals. Whilst many factors can play a part in such tragic circumstances, we have a moral duty to make the NHS the best employer possible.”

The new service was trialled for hospital doctors in London and then for GPs in England and went live across the country earlier this month for 180,000 doctors and dentists.

All NHS doctors and dentists will now have access to mental health support after the creation of a service dedicated to the wellbeing of practitioners.

The NHS Practitioner Health Programme has a 24-hour helpline and text messaging service for staff struggling with their mental health, allowing them to seek support from specialists outside their own hospital or practice.

Last week an inquest was held at St Pancras coroner’s court into the death of Miles Christie, 43, a London GP and father of two who took his own life in May. His death prompted his widow to call for more support for medical professionals who may be reluctant to reveal their mental health problems for fear they would be deemed unfit to practise.

Matt Hancock, the health secretary, said: “It bears a heavy weight upon my shoulders when I hear of NHS staff that have taken their own lives and we should never underestimate the psychological strain that frontline healthcare work can have on individuals. Whilst many factors can play a part in such tragic circumstances, we have a moral duty to make the NHS the best employer possible.”

The new service was trialled for hospital doctors in London and then for GPs in England and went live across the country earlier this month for 180,000 doctors and dentists.

There is a team of 200 specialists, which will expand further, dedicated to supporting practitioners. The service has a budget of £7 million a year.

The Department of Health and Social Care said: “Once a patient contacts the service they are provided with a link to the app where they can book appointments with a clinician of their choice.” This addresses concerns that doctors may end up being seen or treated by someone with whom they work.

The NHS Practitioner Health Programme: For confidential advice call 020 3049 4505 

What is National About the Health Services in the UK? I have thought of 10 areas…

Image result for sick doctors cartoon

The whole health service is short of consultants as well as GPs and Nurses. The lead in time to train replacements is so long that it has to get worse.

In the BMJ this week “Fewer trainees, fewer ads, fewer physicians” is an honest and diplomatically understated  argument by Andrew Goddard and Rob Hardwood based on “the 2018 annual census of consultant and higher specialty trainee physicians”.

 …..the report on the census said that this year there was a big reduction (33%) in the number of consultant posts being advertised. “A number of factors may have contributed to this fall, including the lack of trained HSTs [higher specialty trainees] to meet the demand in shortage specialties and the deteriorating fi nancial situation within the NHS, but this is a worrying pattern,”

The whole health service is short of consultants as well as GPs and Nurses. The lead in time to train replacements is so long that it was always going to get worse, and it has. This will impact on neonatal care, obstetric care, care in all distant and remote places, and where educational standards are lowest. It is these areas where recruitment is hardest.

Kaya Burgess in the Times reports 19th October 2019: Rise in twin baby death rate caused by ‘lack of special care’

The number of twins dying before, during or shortly after birth is increasing after several years of falling, prompting fears that their mothers are not being given specialist care.

Survival rates for twins and triplets improved after The National Institute for Health and Care Excellence (Nice) published guidance in 2011 recommending that women with multiple pregnancies be cared for by specialist obstetricians and midwives.

Between 2014 and 2016, the stillbirth rate of twins fell from 11.07 to 6.16 per 1,000 births. The neonatal mortality rate of twins — those dying before their first birthday — fell from 8.01 to 5.34 per 1,000 births between 2013 and 2016.

Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries, an Oxford University research group, has found that the rate of deaths is rising again. Between 2016 and 2017, the number of twin stillbirths increased from 6.16 to 6.99 per 1,000 births, while twin neonatal deaths also rose from 5.34 to 5.45 per 1,000 births.

In 2017, 164 twins were stillborn compared with 145 in 2016. Over the same period the rates fell for babies from a single pregnancy. A twin baby has almost double the chance of being stillborn and more than three times the chance of dying in infancy compared with a single baby.

Keith Reed, of the Twins and Multiple Births Association, said: “This is a wake-up call to all maternity units in the UK. Our research has proven that having a specialist team delivering care in accordance with Nice guidance reduces stillbirths and neonatal admissions . . . The quite significant upturn in stillbirths is likely a result of lessening adherence to the Nice guidance.”

Alexander Heazell, of the Royal College of Obstetricians and Gynaecologists, said: “We are concerned by the disparity in stillbirth and neonatal mortality rate for twins and triplets in 2017 compared to singleton pregnancies, especially as there were gradual improvements in the outcome of multiple pregnancies since 2013.

“This change is in part due to a welcome reduction in the stillbirth rate for singleton pregnancies, which are now at their lowest recorded rate, which was not mirrored in multiple births.”

One in every 65 births was a multiple birth in 2016, up from one in every 100 in 1984. This is due to more older mothers, who are more likely to release more than one egg during ovulation, and rising rates of IVF, which produces more twins.

 

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…

Image result for wrong blood cartoon

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”.