Category Archives: Medical Education

NHS needs 5,000 trainee doctors a year

The NHS’s lack of GPs is so acute that ministers must boost the number of medics who train to be family doctors to a record 5,000 a year, the head of the profession is demanding.

The unprecedented rise in the number of GP trainees is needed urgently because the workforce has shrunk so sharply and waiting times for appointments have become so long, said Prof Helen Stokes-Lampard.

The chair of the Royal College of GPs urged the government to increase the number of trainees in England from 3,500 to 5,000 as soon as possible to relieve the strain on surgeries and burnout that are pushing so many to quit.

Boris Johnson will not be able to fulfil his pledge to shorten waiting times to see a GP or a longstanding promise to expand the workforce by 5,000 doctors unless his government ensures that over half of all medical graduates become family doctors, she warned.

Growing numbers of GPs are giving up as a result of a relentless rise in the demand for patient care and the impact of punitive changes to doctors’ pensions. The NHS lost 576 full-time equivalent GPs last year – one in 50 of the total – according to latest official workforce figures published last week. In June it had 28,257 full-time, fully qualified GPs, compared with 28,833 a year earlier.

“GPs and our teams are facing intense resource and workforce pressures and it is causing a growing crisis in our patients’ access to general practice services, which the prime minister pledged to address when he took up office,” Stokes-Lampard said.

“We need to think big, and based on current workforce trends the college estimates that we need to start training at least 5,000 GPs every year to meet the government’s overall target to expand the GP workforce by 5,000 full-time GPs.”

Johnson recently declared “it cannot be right that people are waiting so long to see their GP”. He has promised to improve access but not given any details so far.

Many patients have to wait more than two weeks to see a GP, according to the most recent evidence.

In a letter to Rishi Sonak, the chief secretary to the Treasury, Stokes-Lampard said the rise in the number of GP trainees would need separate funding to the £4.5bn extra that is due to go into primary and community care by 2023-24.

It costs the government an estimated £150,000 to fund a GP during what is usually three years of training, on top of the £250,000 cost of undergraduate medical training.

Although the number of full-time GPs in post is falling, the number of medical graduates entering GP training is at an all-time high. It has risen from 2,671 in 2014 to 3,473 last year, which was the first time the target of 3,250 had been exceeded.

Nigel Edwards, the chief executive of the Nuffield Trust thinktank, said more GPs would mean fewer graduates becoming hospital doctors.

“I completely agree that more GPs are needed. The current shortfall has seen patients’ experience of waits get worse year after year, and created a vicious cycle as overwork makes doctors retire early.

“But we do need to remember there are only so many medical graduates coming through, so realistically we would need to cut back on trainees going into hospital, which may not be easy. And more GPs coming in won’t solve this problem alone if burnout keeps pushing them away again.”

A Department of Health and Social Care spokesperson said: “We have seen a record number of GP trainees enter training and we expect that trend to continue this year. We have also created an additional 1,500 undergraduate medical school places and opened five brand new medical schools so that more doctors are beginning careers in the NHS.

“The NHS People Plan – published later this year by NHS England – will set out our plans for securing the staff we need for the future, including for primary care.”

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

I very much regret that I cannot attend my 50 year medical school reunion. The memories of the “teams” and the convivial mess atmosphere, the mutual recognition of the brutalisation and stress, and the joint need to cover each other were the icing on the cake of a wonderful time. Morale was high. The “cause of all the mahem” is only partly in the article, and an explanation is in the replies.

I remember playing hockey in a team regularly because I had a colleague who played international squash. Our games did not coincide, and so we were able to cover each other despite being on a one in two rota.

I never had to miss a wedding, because there was always a volunteer to do an on call swap.

The mentoring was continuous and the feedback immediate..

Nowadays young doctors are afraid to tell anyone, colleagues or management, that they would like to get married in 6 months time, or to move house in 2 weeks time. 

There is an unwritten rule in medical training: the larger the firm the less willing anyone is to make swaps in their rota. Perverse in that there is more opportunity to trade…

Of course there are many more part time trainees, especially in speciality training and General Practice, and these doctors have children and commitments, but NHSreality regards these as excuses rather than reasons. With a one in two rota the gain was large enough to tempt both parties…..

Abi Rimmer opines in 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.

“The firms were wonderful,” he says. “A lot of people think that the breakup of the firm is one of the causes of all the mayhem in the health service now.”

In 2016 junior doctors throughout England took industrial action over contract changes, and the then health secretary Jeremy Hunt expressed regret at the loss of the firm.

By dismantling the system, Hunt said, “We may have thrown the baby out with the bathwater. Can we bring back the firm or at least the best bits of it?”3 Also in 2016, research from the RCP concluded that the fragmentation of medical teams from frequent junior doctor rotations, rota gaps, and limited induction was central to trainees’ disengagement.4

An answer to junior doctors’ wellbeing?

Junior doctors’ displeasure about their contract and working conditions has pushed their wellbeing up the agenda.5 And the narrative persists that the firm provided yesterday’s medical trainees with something that is missing today.

In a recent letter to The BMJ, the locum Niak-Puei Koh lamented the loss of the firm as “a key cause of disconnect between junior and senior staff, where the feeling of being unsupported seems to be rampant.”6

He added, “The loss of the doctors’ mess, the sitting room for nursing staff, and a specific canteen (away from the public eye) have eroded this sense of community. Bringing some of these back—and even enabling teams to sit down with a cup of tea to discuss the daily chores—might foster a better working relationship and help team members feel less isolated.”

The anaesthetic registrar Joanna Poole laments the lack of a supportive team structure in medicine. “I love medicine, and my colleagues are smart, funny, caring, and inspiring,” she wrote. “But none of my seniors, who I get on well with, knew about my engagement or the death of my dad and my grandad, either because of the rota pattern, busy shifts, or we aren’t designed to ask. We all get asked how our shifts were but not the viscera of our lives.

“In the old days you had a firm or ability to socialise outside of work. We rotate so far geographically now this is difficult. Longer placements would be more humane, with secondment for tertiary specialties,” she said.7

Ellis is not surprised that today’s trainees are struggling. “Eleven hour shifts without a break is inhuman,” he says. Although he worked very long hours as a trainee in the late 1940s and ’50s, the work was less intense and he lived on site.

“If things were quiet you would take some time off: you could go and sit in the garden or pop out to get your hair cut,” he says. “There’s nowhere now for trainees to sit down and read the newspaper and have a cup of tea. We had our own mess but that’s been taken away.”

Without the close team working of the firm, Ellis says, consultants can no longer judge their trainees’ skills or learning needs. “My boss would say, ‘Come on Harold, you’ve seen me do this 10 times. Swap round: you stitch him up, and I’ll cut the knots for you,’” he says.

Autonomy within boundaries

James Morrow, a Cambridge GP, says that the firm built trust that gave trainees more freedom to learn.

“You were given a great deal of autonomy—within boundaries,” he says. “You could push yourself to achieve new things, knowing that there was support, in a non-judgmental way, available from someone who viewed you as part of the core team. And that is incredibly powerful.”

The firm also gave trainees a feeling of stability because they knew who they would be working with, Morrow says. “You looked out for each other, and backed each other up.”

However, the firm also came with disadvantages, Morrow remembers. “Some of the worst times of my life, as well as some of the best times, were working on a firm. The unrealistic expectations to be there all the time, to know everything, were not conducive to a happy life outside the hospital ward,” he says.

“We have improved working hours to a large extent, and that should be retained,” he says, but he’d like to see “if we can bring back some of the magic that made being junior doctor such great fun” by “working as part of a consistent, coherent, collective team.”

Health Education England (HEE) wants to do just that, Sheona Macleod, deputy medical director for education reform, told The BMJ.

Bringing back the best

“It’s not possible to bring the firm back the way it was but HEE is asking, ‘What was good about the firm? What do people miss about it? And how do we provide these things in the current training and working environment?’” she says.

As well as helping to establish a programme to improve surgical training (box 1), HEE has helped to fund guidance from the RCP on how today’s teams can learn together and support each other (box 2).

Box 1

Could a modern firm improve surgical training?

In 2016, Jeremy Hunt announced that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could improve team working and make junior doctors feel more valued.3

The college started recruitment to the Improving Surgical Training (IST) pilot scheme throughout England, Scotland, and Wales in 2017. At the time Ian Eardley, senior vice president of the college, explained that the modern firm would omit the long hours and frequent on-calls but would re-create the best aspects of the old model.

He said, “The nice things about the firm were that you had a support structure in place; if you had a problem, no matter what hour of the day or night, you always had a person who you knew could help you, who could give you some advice.”8

In August 2017, 48 general surgery trainees in England and 31 core surgical trainees in Scotland took up their posts in the pilot.

Daniel Beral is a consultant colorectal and general surgeon and trainer on the IST programme who is involved in training the trainers in the pilot.

Trainees taking part have longer placements, of up to 12 months, which he hopes will foster stronger relationships with their consultants.

This relationship is key, and the scheme promotes regular meetings between trainees and supervisors. “In the firm structure you often worked for one, two, or three consultants but somebody actually got to know you,” Beral says.

The pilot focuses on the whole clinical team. “In some of the sites, newer team members such as surgical care practitioners or advanced care practitioners contribute to the on-call rota,” Beral says. “This means that there are more people on the rota and the trainees can work more in daylight hours.”

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Feature Medical Training

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

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4105 (Published 10 June 2019) Cite this as: BMJ 2019;365:l4105

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  1. Abi Rimmer

Author affiliations


  1. The BMJ

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.

“The firms were wonderful,” he says. “A lot of people think that the breakup of the firm is one of the causes of all the mayhem in the health service now.”

In 2016 junior doctors throughout England took industrial action over contract changes, and the then health secretary Jeremy Hunt expressed regret at the loss of the firm.

By dismantling the system, Hunt said, “We may have thrown the baby out with the bathwater. Can we bring back the firm or at least the best bits of it?”3 Also in 2016, research from the RCP concluded that the fragmentation of medical teams from frequent junior doctor rotations, rota gaps, and limited induction was central to trainees’ disengagement.4

An answer to junior doctors’ wellbeing?

Junior doctors’ displeasure about their contract and working conditions has pushed their wellbeing up the agenda.5 And the narrative persists that the firm provided yesterday’s medical trainees with something that is missing today.

In a recent letter to The BMJ, the locum Niak-Puei Koh lamented the loss of the firm as “a key cause of disconnect between junior and senior staff, where the feeling of being unsupported seems to be rampant.”6

He added, “The loss of the doctors’ mess, the sitting room for nursing staff, and a specific canteen (away from the public eye) have eroded this sense of community. Bringing some of these back—and even enabling teams to sit down with a cup of tea to discuss the daily chores—might foster a better working relationship and help team members feel less isolated.”

The anaesthetic registrar Joanna Poole laments the lack of a supportive team structure in medicine. “I love medicine, and my colleagues are smart, funny, caring, and inspiring,” she wrote. “But none of my seniors, who I get on well with, knew about my engagement or the death of my dad and my grandad, either because of the rota pattern, busy shifts, or we aren’t designed to ask. We all get asked how our shifts were but not the viscera of our lives.

“In the old days you had a firm or ability to socialise outside of work. We rotate so far geographically now this is difficult. Longer placements would be more humane, with secondment for tertiary specialties,” she said.7

Ellis is not surprised that today’s trainees are struggling. “Eleven hour shifts without a break is inhuman,” he says. Although he worked very long hours as a trainee in the late 1940s and ’50s, the work was less intense and he lived on site.

“If things were quiet you would take some time off: you could go and sit in the garden or pop out to get your hair cut,” he says. “There’s nowhere now for trainees to sit down and read the newspaper and have a cup of tea. We had our own mess but that’s been taken away.”

Without the close team working of the firm, Ellis says, consultants can no longer judge their trainees’ skills or learning needs. “My boss would say, ‘Come on Harold, you’ve seen me do this 10 times. Swap round: you stitch him up, and I’ll cut the knots for you,’” he says.

Autonomy within boundaries

James Morrow, a Cambridge GP, says that the firm built trust that gave trainees more freedom to learn.

“You were given a great deal of autonomy—within boundaries,” he says. “You could push yourself to achieve new things, knowing that there was support, in a non-judgmental way, available from someone who viewed you as part of the core team. And that is incredibly powerful.”

The firm also gave trainees a feeling of stability because they knew who they would be working with, Morrow says. “You looked out for each other, and backed each other up.”

However, the firm also came with disadvantages, Morrow remembers. “Some of the worst times of my life, as well as some of the best times, were working on a firm. The unrealistic expectations to be there all the time, to know everything, were not conducive to a happy life outside the hospital ward,” he says.

“We have improved working hours to a large extent, and that should be retained,” he says, but he’d like to see “if we can bring back some of the magic that made being junior doctor such great fun” by “working as part of a consistent, coherent, collective team.”

Health Education England (HEE) wants to do just that, Sheona Macleod, deputy medical director for education reform, told The BMJ.

Bringing back the best

“It’s not possible to bring the firm back the way it was but HEE is asking, ‘What was good about the firm? What do people miss about it? And how do we provide these things in the current training and working environment?’” she says.

As well as helping to establish a programme to improve surgical training (box 1), HEE has helped to fund guidance from the RCP on how today’s teams can learn together and support each other (box 2).

Box 1

Could a modern firm improve surgical training?

In 2016, Jeremy Hunt announced that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could improve team working and make junior doctors feel more valued.3

The college started recruitment to the Improving Surgical Training (IST) pilot scheme throughout England, Scotland, and Wales in 2017. At the time Ian Eardley, senior vice president of the college, explained that the modern firm would omit the long hours and frequent on-calls but would re-create the best aspects of the old model.

He said, “The nice things about the firm were that you had a support structure in place; if you had a problem, no matter what hour of the day or night, you always had a person who you knew could help you, who could give you some advice.”8

In August 2017, 48 general surgery trainees in England and 31 core surgical trainees in Scotland took up their posts in the pilot.

Daniel Beral is a consultant colorectal and general surgeon and trainer on the IST programme who is involved in training the trainers in the pilot.

Trainees taking part have longer placements, of up to 12 months, which he hopes will foster stronger relationships with their consultants.

This relationship is key, and the scheme promotes regular meetings between trainees and supervisors. “In the firm structure you often worked for one, two, or three consultants but somebody actually got to know you,” Beral says.

The pilot focuses on the whole clinical team. “In some of the sites, newer team members such as surgical care practitioners or advanced care practitioners contribute to the on-call rota,” Beral says. “This means that there are more people on the rota and the trainees can work more in daylight hours.”

RETURN TO TEXT

Box 2

Maximising learning in the modern workplace

In its Never Too Busy to Learn guidance the Royal College of Physicians sets out how doctors working in modern teams can find the same kind of education and peer support that the firm offered.2

Medicine and patient care have changed substantially since the days of the firm, says Emma Vaux, senior censor at the college and one of the authors of the guidance.

“The team is no longer just doctors. As many as 18 different professionals look after a patient on a medical ward, and they are all contributing something,” she tells The BMJ. “We are working together, so why can’t we learn together?”

The guidance aims to look at “how we can capture the essence of what was really good about the medical firm,” she says, but without rose tinted glasses.

Recommendations from Never Too Busy to Learn for creating and maximising learning opportunities in the modern workplace are:

  • 1 Target your time—make inter-professional board rounds more efficient

  • 2 Use brief learning moments—take a break in the day to teach and have a cup of tea

  • 3 Learn while with patients—make ward rounds and outpatient clinics educational

  • 4 Learn by caring—listen to the experiences and emotions of staff

  • 5 Practice makes progress—integrate simulation into the working day

  • 6 Share professional experiences—role modelling and mentoring can support learning

  • 7 Share learning experiences—use quality improvement projects and grand rounds to increase learning

  • 8 Embrace technology—consider how it can improve doctors’ education

  • The guidance recognises some of the advantages of the firm but also that learning was “inevitably variable, accounting for considerable inconsistency in educational quality and outcomes for trainees, and in the resultant standards of patient care.”2

    But it also gave consultants time to give trainees individualised careers advice, Macleod says. In its ongoing review of foundation training, HEE will “recommend that foundation doctors should have non-clinical training so that they can think about different career options,” Macleod says.

    Other HEE projects have re-created other positive aspects of the firm. “In the past, your consultant might have suggested that you do research, or follow up on something,” Macleod says. “The flexible portfolio careers work we are doing in Enhancing Junior Doctors’ Working Lives allows people to pursue an interest while they are working.”

    Macleod also recognises that not everyone had good experiences of the firm and some people’s careers were cut short by bullying. “It’s not an easy story to tell, ‘I was going to be a surgeon but this man in my firm made fun of me for six months so I gave up and became something else.’”

    Jeeves Wijesuriya, chair of the BMA Junior Doctors Committee, says that nostalgia for the firm often ignores that when it operated lots of other things worked differently too. “There was less regulation, less oversight and measurement of performance, for example,” he says.

    However, through the ongoing work that the BMA is doing with the government to improve the 2016 junior doctors’ contract, Wijesuriya is hoping that some of the positive aspects of the firm can be brought back.

    For example, he is hopeful that improved job planning for trainees will give them greater autonomy over their work schedules and more quality time with their educational supervisors.

    “At the nub of it is community and a relationship with your boss. The feeling that your educational supervisor isn’t just ticking off the required items without ever taking an interest in you,” Wijesuriya says.

    “What we are trying to develop for junior doctors is relationships with supervisors who are interested in their career and in what they want to do next. That will not just keep trainees in the profession but will also bring the profession together.”

David Oliver: Don’t blame GPs for late cancer diagnoses

Recent articles in the media, published after a study by cancer research on 135,000 people. Medical education teaches GPs to “live with uncertainty” because of the need to ration resources effectively. The access to sophisticated tests is rationed by hospital trusts who wish to limit demand as they have inadequate capacity. If we want earlier diagnosis we have to accept greater expense, more technology, more false positives, and more hopeful and unnecessary treatments…..

Laura Donelly in The telegraph 28th June reports: 

The study by Cancer Research UK found that just 37 per cent of all cancer diagnoses in England involved patients who had been given an urgent referral by their GP, because the disease was suspected. Just 32 per cent of diagnoses for bowel cancer and 28 per cent of 
diagnoses for lung cancer were identified this way.” Many other news media repeated the problem including The Yorkshire Post

David Oliver opines in the BMJ: David Oliver: Don’t blame GPs for late cancer diagnoses BMJ 2019;366:l4625

Being a GP isn’t easy. Under-resourcing, workforce gaps, the rising complexity and volume of work, and a media narrative too often laden with blame add to the challenges. On 28 June the Daily Telegraph ran a column entitled, “GPs failing to spot two thirds of cancers.”1 The article was more measured than the headline. But readers’ fear and anger are rarely tempered by less conspicuous details.

It reported a Cancer Research UK study, which had focused on two common cancers (lung and bowel), analysing 135 000 cases.2 The Telegraph mentioned “average waits of more than eight weeks for diagnosis,” adding that “the vast majority of cases that turned out to be cancer were never suspected by family doctors.”

The study, based on data from 2014-15, had concluded that only 37% of all cancers had been diagnosed after urgent referral by a GP suspecting or wanting to rule out the disease. This was true in 32% of bowel cancer cases and 28% of lung cancer cases. Patients who had not been referred for urgent assessment waited weeks longer for diagnosis. And 35% of lung cancer cases and 28% of bowel cancer cases were diagnosed only when patients presented to hospitals as an emergency.

GPs see a whole range of conditions, often in early stages with undifferentiated symptoms that could easily be many things other than newly presenting cancer. The 2015 NICE guidelines on recognising and referring suspected cancer lowered the positive predictive value threshold for referring cases from 5% to 3%.3 Cancer Research’s Cancer in the UK 2019 report showed that, even in 2015-16, only 19% of cancers were diagnosed as emergencies (and only 6% through screening programmes)—so most were in fact diagnosed through GP assessment and referral.4

The data on Public Health England’s bespoke GP profiles illustrate that cancer still represents only a small percentage of a GP’s overall caseload.5 And some patients, with vague symptoms of cancer not specific to any one organ, risk being sent urgently down the wrong specialist route.

Patients’ own circumstances or care preferences also play a part in delayed diagnosis. A study by Abel and colleagues on 4647 NHS patients with a cancer diagnosis from presenting as an emergency found that 29% reported no prior GP consultation. Percentages were substantially higher in older, male, and deprived patients.6

Also consider that, if more patients were referred as urgent cases, our hospital services in radiology, specialty medicine, oncology, and surgery, which already have their own major workforce and workload challenges, would struggle to cope. Indeed, they’re already struggling, not least in balancing patients with suspected cancer against those with equally pressing clinical (if not target) priorities.

A Nuffield Trust analysis7 of performance against cancer waiting time targets showed that, since measurement started in 2009, we’ve generally maintained the operational standard of at least 94% of patients who are referred by GPs as “urgent” being seen within two weeks, with only a recent dip in performance. However, it also showed that the metric of at least 85% of such patients starting treatment within six weeks of referral has been breached for the past four years and has recently declined further. NHS England’s clinical review of national access standards is ongoing,8 partly in response to such issues.

Cancer Research UK has a fantastic track record of raising awareness, in line with its charitable mission. It’s just a shame that, in this case, the resulting media narrative placed excessive blame on GPs, using old data. I’m not sure that this helps patients or doctors.

Laura Donelly in The telegraph 28th June reports: Revealed. GPs failing to diagnose 2/3 of cancers

GPs are failing to spot two thirds of cancer cases, study … The Sun

The Yorkshire Post

 

 

 

The value of the UK’s health information – and only partial value at that.

Most of the useful data in the 4 health services has been collected by GPs. It is this data which is valuable. Hospitals collect data in un-co-ordinated and dysfunctional ways which are not team based. As long ago as 1996 I suggested joined up systems but this was rejected. We are not much further forward today, and your complete real time medical records will NOT be in your local A&E, some 23 years later, unless you are very lucky. The value of the information would have been MUCH more today had this opportunity been taken. Reading the article below suggests that all dispensations are joining in with the agreement with google. Lets hope it does not backfire.. The information could be used to expose differences in treatment and outcomes in different post codes, and for research opportunities for many doctors in the profession. Lets hope these opportunities are not rejected…

Image result for information gathering cartoon

Philip Aldrick opines and reports in the Times July 20th: NHS patient data has £10bn price tag

The value of NHS patient data has been set at almost £10 billion, the first time it has been given a market value.

The professional services company EY said that by charging private health companies to develop new products with the data, the health service would benefit by £4.6 billion a year in better targeted, more personal care and would gain £5 billion a year in operational savings and new income streams.

Getting NHS records into a condition in which they could be used by companies would not be cheap. EY said: “There will be significant process and technology costs associated with aggregation, cleaning, curating, hosting, analysing and protecting the transformation of these raw data records.”

Although it is common in the US to sell health data, it is one of the first attempts to put a market value on Britain’s 55 million patient records, which are increasingly being used by health tech companies to develop diagnostic tools and medicines.

In the US, Flatiron Health was sold to the pharmaceutical group Roche last year for $1.9 billion (£1.5 billion) for its patient records.

EY said: “NHS patient data holds an indicative market value of several billion pounds to a commercial organisation.”

The government has been championing the use of technology to improve patient outcomes and give the health science industry a boost. Babylon Health, Sensyne Health and Google’s Deepmind are among the companies mining NHS data with artificial intelligence. Among the opportunities are better diagnosis, new procedures and personalised medicine.

A code of practice was recently published by the Department of Health and Social Care on the use of health data by businesses. The NHS is a unique dataset because it covers the population from birth to death. In other countries the data is broken up, making it harder to collate in large volumes.

Lord Drayson, the chief executive of Sensyne Health, said: “The quality and scale of NHS data, covering a population of over 50 million people, provides the UK with a competitive advantage.

“Policy that encourages ethical and fair collaborations between the NHS and the life sciences industry could help to fund NHS services in future, as well as significantly improving the quality and affordability of care.”

June 15th Philip Aldrick: If NHS patient data is worth £10 billion, put it on the balance sheet and save lives too

Google ‘poised to profit’ from NHS patient recordsAldrick Nov 24th 2018 in the Times and August 18th: Peer holds key to unlock the value of NHS patient data

General Practice is “Closing Down” … Presentation for a unified IT system rejected 1996 / 2001

Image result for information gathering cartoon

Image result for information gathering cartoon

 

 

Whistleblowing Champions – in Scotland only (for now). Apply through NHSreality, or Holyrood.

With permission (I assume) from Peter Gregson in Scotland, I can publicise the new Whistleblowing Champion, in Scotland only for now, then apply for the job through the link below. The other 3 UK dispensations may follow suit, but you never know: after all there is no National Health Service any more, except for emergencies. Congratulations to Pete for getting this success… Now we need to measure outcomes, especially longevity in post and unemployment rates..

Image result for whistleblowing cartoon

This is Pete’s e-mail to me:

Here is the video of the event at Holyrood  –  www.tinyurl.com/blastvid

It lasts 90 minutes, but I think it’s good stuff.

The PA to the Health minister Jeane Freeman has asked for the link and says he’ll send it onto Jeane. I’d be impressed if she watches it.

I will send the link to the members of the Health Committee.

One of them, Alex Cole-Hamilton (LibDem) has asked to meet Rab and I. That should happen before the end of July.

Would any of you be interested in a new job? These are paid Whistleblower Champion posts.

https://applications.appointed-for-scotland.org/pages/job_search_view.aspx?jobId=1674&JobIndex=1&categoryList=&minsal=0&maxsal=150000&workingPatternList=&keywords=&PageIndex=1&Number=4

Finally, if you know of anybody who wants to log a whistleblowing concern with us, give them this link www.tinyurl.com/scottishNHSwhistleblowers  We’ll make sure the new Independent National Whistleblowing Officer, Rosemary Agnew, takes note.

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NHS Scotland must tackle bullying problems ‘head-on’ – Dr Lewis Morrison for the BBC News 25th June

Third high-level resignation from NHS Highland board in as many .. NHSH vice-chairwoman Melanie Newdick .Press and Journal 16th July

Surge in calls to Scotland’s NHS whistleblowing hotline – 19th April

Holyrood: NHS Whistleblowing champions ‘can come straight to me’, says Jean Freeman October 2018

Non-executive Whistleblowing Champions – NHSScotland – Apply here

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Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding? If we don’t keep the gatekeeper role for GPs the system will get constipated.

A recent report in the Times (Not on line) opines “Gatekeeping by GPs called into question. This is not new, as you can see from the debate following Matthew Paris’ article in 2015. The problem is not referrals, but the 90% who do not need a referral. Allowing others, less trained in dealing with uncertainty, will lead to more referrals, longer waits and a constipated system. The useless 111 service where there has seen no reduction in GP workload is another attempt to wriggle off the hook of under capacity and poor manpower planning. In his Imperial College funded report, Geva Greenfield and others report: “Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding?”.

One solution is to make patients pay for their GPs and let them have appointments free with the nurses and paramedics. A two tier system by design. Lets see the comparisons in referral rates, expense and survival!! The result would be anarchy.. (sic) Geva Greenfield says “There is a trade-off that needs to be found between GPs serving as hgatekeepers to secondary care, and at the same time allowing patients to see a consultant when they wish”. We are trying to treat patients, and the governement are treating populations. Money matters, and the services are all rationed. (covertly)

Image result for money and NHS cartoon

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This is the sort of thinking “outside the box” of current opinion that we have to get to talking about openly.

On November 26th 2018 Chris Smyth reported in the Times: Bypassing GPs could help to diagnose cancer sooner

In Pulse 2015: GPs should give up their Gatekeeping Roles

Matthew Paris on June 16th 2012 reported in the Times: GPs – little more than glorified receptionists

In this age of medical specialisation, if family doctors didn’t exist we wouldn’t feel the need to invent them

Next Thursday, family doctors plan to strike. Striking doesn’t suit the profession’s humanitarian image. Interviewed, doctors’ leaders struggle to insist (on the one hand) that nobody needing medical attention will be denied it, without implying (on the other) that few will suffer if doctors aren’t there.

How much, though, would we suffer? If family doctors had not existed, would we today have found it necessary to invent them?

We pay general practitioners more than we pay airline pilots, but they are becoming glorified gatekeepers: a portal to the more specialist medical care that our health service offers in growing measure. As GPs have receptionists, so the NHS itself uses GPs as its receptionists. Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?……..

……..Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The response June 18th 2012:

Sir, Matthew Parris (Opinion, June 16) is not quite correct in describing GPs as “becoming glorified gatekeepers”. We have already had that role (among others) for decades.

It is true that part of this role is to refer to secondary care, but he seems to miss the corollary of this; that we also judge when not to refer, thus saving patients, and the country, the burden of over-investigation and over-treating. The internet has expanded everyone’s access to specialist knowledge, but has not, perhaps, increased our ability to apply that knowledge appropriately. We know more, but understand less.

Mr Parris also fails to acknowledge that GPs have a vital role in the other direction of travel; from specialist care to the community. In this past week I have picked up the care of patients after their discharge from heart by-pass surgery, psychiatric in-patient treatment, dermatology, gynaecology, child autism and palliative care clinics.

In addition, we need to manage patients whose symptoms and conditions cover several specialties, as well as those who have exhausted all secondary care investigation without any diagnosis being reached.

“A decent grasp of the whole thing” is exactly what GPs need.

Dr Jonathan Knight
GP, Ipswich

Sir, Matthew Parris assumes that his interaction with his GP is typical of the work that GPs do. I have been working in general practice since 1987 and my experience is very different. We spend most of our time managing long-term illness such as high blood pressure, diabetes, kidney disease and asthma. When I was in training in the 1980s these conditions were managed in hospital but are now managed mainly in primary care. Of course I do not profess to be an expert in everything so I may refer to colleagues for opinions about aspects of a patient’s care, but they are then usually discharged to my care.

Allowing less-qualified health professionals to manage patients has never been shown to be more cost effective than using GPs.

It is this system of every patient having a GP, enshrined in Bevan’s original vision for the NHS, that other health systems around the world have strived to emulate. We should not discard it lightly.

Steve Charkin
London NW3

Sir, Matthew Parris says that he believes he could refer himself appropriately to a specialist, but he is not our typical patient. GPs’ time is predominantly taken up with the very young and the elderly, particularly those with chronic, complex and multifaceted medical conditions. For these folk, it is their GP who sees the “big picture”, the context and impact on the individual and their family, while each specialist focuses in on his own area of expertise. Approximately 90 per cent of healthcare needs are met in the community, by GPs and their practice nurses, with only 10 per cent of care being hospital-based, at far greater expense. It is true that a GP’s role includes “gate keeping” access to expensive specialist opinion, but I would suggest this is essential.

As Mr Parris concedes, most GP consultations do not lead to a referral to a specialist. His vision of a future without GPs to manage the majority of our health concerns would be financially unsustainable and bewildering to many. Would a woman with lower abdominal pain and back ache refer herself to a gynaecologist, urologist, gastroenterologist, oncologist or orthopaedic surgeon? Does she need a specialist at all if it is just a urine infection? How does she know?

While a single day of industrial action will cause no more inconvenience than the extra bank holiday for the Diamond Jubilee, Mr Parris belittles our role at his peril.

Dr Isabel Cook
Reading

Sir, Before getting rid of GPs Matthew Parris might be wise to wait until he is a bit older when he may have to see more than one specialist at the same time. He will find that the treatment for one condition often aggravates another and he will then be grateful for a generalist’s opinion. He will also find it more efficient to keep seeing the same GP so that he does not have to keep repeating his past history.

Dr Richard Stott
Epsom, Surrey

Sir, As a GP I know Matthew Parris is right. A lot of what GPs do is pointless or could be done by others. So there is a simple solution: stop giving us work.

John Booth
Middlesbrough

Sir, There is overwhelming evidence that GPs deliver highly effective, cost-effective care to our patients. Moreover, we do so with the trust of our patients, and with care and kindness.

I invite Mr Parris to sit through a surgery with me at any time, where he will see first hand how GPs care for the elderly, the frail, the disadvantaged and the ill. I’m sure that afterwards his perceptions of general practice will be different.

Professor Clare Gerada
Chair of Council, Royal College of General Practitio

 

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.