Category Archives: Medical Education

An endangered species? You may be lucky to find a GP soon…

An endangered species? You may be lucky to find a GP soon… It will be better in the cities as they have the best schools, and most of the part time, and predominantly female, GPs come from suburban schools. The current situation cannot be solved quickly, and any sensible professional would never have got to this situation. Therefore they should not be expected to find a short term way forward.  Meanwhile the Guardian reports: Record number of GP closures force 265,000 to find new doctors … It’s going to get worse.. and part of the problem is the belittling of GPs in Hospitals, and the lack of exposure medical students get to GP. Access and waiting times are both threatened, even for GPs

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15th July and the Times reports: Hundreds of GP practices forced to close or merge

More than 200 GP practices across England have closed or merged in the last year.
Data from NHS Digital reveals that while just eight practices opened, 202 closed or merged. Practices were affected in all regions, but the north of England experienced the most change, with more than 60 closing or merging, while more than 50 closed or merged in the South East. The Midlands and the east of England had the most new surgeries.
Last year, NHS England announced a £500 million “turnaround package’“ to help struggling surgeries. NHS England data shows that between last summer and this, the same time period covered by the 202 closures and mergers, more patients became registered with GPs across the entire country. Taking into account that some patients may register with more than one GP, 58,492,541 patients were registered with a GP on July 1 this year, up from 57,744,814 the year before.
Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “When practices are being forced to close because GPs and their teams can no longer cope with ever-growing patient demand without the necessary funding and resources, it’s a huge problem.” Dr Richard Vautrey, acting chairman of the British Medical Association’s GPs committee, said: “With over 200 practices closed or merged in the last year and many more struggling to manage their workload pressures, it is time for government and NHS England to step up their efforts to resolve this crisis before even more patients lose their much loved local GP service.”

The Yorkshire Post: ‘Hundreds of GP practices closed or merged in a year’

In Wales the BMA – Welsh General Practitioners Committee (GPCW) has not been listened to for years. BMA in Wales wants faster action on GP ‘crisis’ – BBC News and Hywel Dda is one of the worst (and most rural) areas in Wales.

BMA heatmap reveals scores of struggling GP practices across Wales …

Half of North Wales GP surgeries on ‘verge of closure’ claims doctors …

GP practice closures ‘at record levels’, GPC chair tells BMA annual …

In Scotland on 4th December 2016 the Herald reported: Scotland’s GP crisis deepens as vacancies soar

SCOTLAND’S GP crisis has deepened with one-in-three practices reporting a vacancy, the British Medical Association claims.
Last year the BMA found that almost a fifth of practices surveyed had at least one vacancy for a GP but the figure has since risen from 17 to 28 per cent.
The shock figures follow the closure of a rural GP clinic. Glencairn Medical Practice shut the doors of its Fenwick premises in East Ayrshire on Friday….

BMA – List closures in Scotland

In N Ireland: 20 GP surgeries face closure in Northern Ireland affecting 120,000 …

Patients ‘forced to change surgeries as record number of GP practices …

and in GP magasine in May Nick Bostock reports: General practice in parts of Northern Ireland ‘one closure from collapse’

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New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem

NHS reality  has opined before on how governments should treat populations and doctors should treat individuals. There is a natural and allowable dissonance between them but the media denies this. It is never in the interest of the 4th estate to compromise. Conflicts and opposites are what makes news sell. Nevertheless, public health experts all acknowledge this need, but they are becoming scarcer. Where will common sense rationing decisions for cancer come from.. In The Information Age one might expect a rational discussion.

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Cncer drugs are getting better and dearer – AtraZeneca’s Imfinzi costs $180,000 for a year’s treatment

THE debate in rich countries about the high price of drugs is a furious and frustrating one. The controversy is already having an impact on spending on drugs, suggest new figures from the QuintilesIMS Institute, a research firm. The rate of growth in spending on prescription medicines in America fell to 4.8% in 2016, less than half the average rate of the previous two years (after adjusting for discounts and rebates). Michael Levesque of Moody’s, a rating agency, reckons that pressure over pricing is contributing to a deceleration in earnings growth at pharma firms. Public scrutiny constrains their flexibility over what they can charge and allows payers to get tougher.

In one area, however, earnings are expected to keep rising: cancer. Oncology is the industry’s bright spot, says Mr Levesque. The grim fact is that two-fifths of people can now expect to get cancer in their lifetime because of rising longevity. This is one of the reasons why the number of new cancer drugs has expanded by more than 60% over the past decade. The late-phase pipeline of new medicines contains more than 600 cancer treatments. New cancer drugs are being approved more quickly….

Cost effective but unaffordable: an emerging challenge for health systems – New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem (BMJ 2017;356:j1402 )
New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem

With hospital wards overflowing and trusts in deficit, the introduction of cost effective but expensive new technologies places increasing strain on NHS finances. The National Institute for Health and Care Excellence (NICE) and NHS England plan to tackle this problem by delaying the introduction of interventions with a “high budget impact.”1 The change may deliver short term savings but is flawed.

What prompted the new policy? In 2015 NICE recommended the use of several new drugs for hepatitis C.2 Although they were judged clinically useful and cost effective, NHS England considered them unaffordable, with annual costs of between £700m and £1bn, and delayed adoption.34

From 1 April 2017, the current requirement to fund NICE recommended technologies within 90 days will not apply for those with annual costs that exceed £20m (€23m; $24m).1 Instead, NHS England will be granted up to three years—longer in exceptional circumstances—to conduct commercial negotiations.1 As a result, patient access to some new technologies will be substantially slowed…

Views expressed during the consultation on this policy were far from supportive. Respondents recognised the pressures on the NHS, but less than a third believed that a budget impact threshold should be introduced, and only 23% agreed with delayed implementation for technologies exceeding the threshold. When the views of NHS commissioning bodies were excluded, figures for support fell substantially.1

The policy brings affordability into NICE’s remit in an unprecedented way. To date, NICE has based its recommendations on an ethics of opportunity costs.5 New technologies are judged principally on their incremental cost effectiveness ratio, a measure of their cost effectiveness compared with existing interventions. Judgments sometimes reflect broader social and ethical values, but cost effectiveness is normally the main consideration.5

The budget impact test means that technologies costing the NHS more than an additional £20m a year will be “slow tracked,” regardless of their cost effectiveness or other social or ethical values. This risks undermining the existing opportunity costs framework. Consider infliximab, currently recommended for both acute exacerbations of ulcerative colitis and severe active Crohn’s disease.67 Its list price is the same across indications, but the total cost of treating the handful of eligible patients with ulcerative colitis is far lower than that of treating the 4000 eligible patients with Crohn’s disease. Under the new approach use for Crohn’s disease would probably fail the budget impact test, delaying introduction; use for ulcerative colitis would not.

Budget impact is essentially the price per patient multiplied by the number of patients treated. Yet the prevalence of someone’s condition should not determine their access to treatment. The principle of equity means that like cases should be treated as like; the NHS Constitution requires the NHS to respond to the clinical needs of patients as individuals.89 The new test requires NICE to treat patients in one group less favourably than those in another solely because there are more in the first group than the second. It is numerical discrimination. And if large numbers of patients experience delays, the policy threatens widespread harms.

Affordability is driven by public expenditure, a fundamentally political matter. NICE and NHS England should be commended for seeking to square the circle on affordability when the current government’s response is inadequate. Perhaps the policy aims to pressurise industry to lower its prices when volumes are high. But this is to use large patient groups as a bargaining chip.

NICE’s justification for pursuing its approach—that “no alternative solutions” have been put forward—is invalid in our view.1 The recent consultation did not ask for other options. Had it done so, several could have been canvassed. NICE’s methods assume that the NHS will pay for new cost effective interventions through disinvestment, removing existing treatments that are relatively cost ineffective. This rarely happens.1011 A systematic and transparent programme of disinvestment, though difficult, could increase the resources available to fund new technologies. An increase in the NHS budget would, of course, help too. But even without that, NICE’s cost effectiveness threshold could be updated for all technologies, so treating patients equitably.12 More widespread use of risk sharing on costs might also help to reduce total budget impact. Or, most controversially, the 90 day funding requirement for NICE approved technologies could be removed entirely and the power to make decisions about affordability given back to politicians or NHS England.

Even if it is no longer feasible politically for NICE to ignore overall affordability in individual technology appraisals, budget impact could be a special consideration, modifying the cost effectiveness calculation alongside other social or ethical values. This would allow for a nuanced, case-by-case deliberative response and bring affordability into the existing opportunity cost framework.5

All these options raise important ethical and political challenges. But they should be considered before NICE commits to an inequitable approach that few support. The recent consultation should have marked the start, not the end, of a more substantial debate about the role of affordability in the NHS. It is not too late to correct this mistake.

Footnotes

  • The authors form part of the Social Values and Health Priority Setting Group (ucl.ac.uk/socialvalues) and are grateful to its members for stimulating discussions. We thank Catherine Max for contributing to the drafting of this editorial and the reviewers, Piotr Ozieranski and Iestyn William, for their comments.

The Information Age one might expect a rational discussion.

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

Not everyone wants to be a doctor. It needs some intelligence, memory, staying power and determination, as well as all round education and communication skills. This is why “graduate” entrants are better bets for the state’s investment. If it costs £250,000 to train a doctor, then we as taxpayers want the best value from our investment.

Currently the drop out rate and the emigration rate are high. Preventing nurses and doctors from the EU from coming here will make the short term skills crisis worse.

There is a new advert in the media, for a medical school in Malta with training and exams run by Barts and the London Hospitals trust.

Studying in Malta.

This is basically a second private medical school for UK provision. The first was at Buckingham, and there is competition for places. Costs and overheads will be cheaper in Malta… With 11 applicants for every 2 places in the UK Medical Schools, there should be plenty of aspirants.

So who will apply? I have no idea of the fees, but lets assume that it will be in the order of £250,000 over 5 years, and add to that travel and accommodation, say £10,000 per annum. The total is a minimum of £300,000. This opportunity is a beginning for what goes on in the Indian subcontinent, where most training places are private. Doctors in the UK from the Indian subcontinent are more likely to be privately trained than not. They are also more likely to come from affluent families who have invested in their children’s education for the long term.

If all 9 failed applicants went to private medical school, and remember that their careers officers all recommended and supported their applications, there would eventually be the same excess of private doctors in the UK. If the government is tempted to reduce the places it funds because of oversupply, then the caste system gets worse.

The short-termism of governments in a first past the post electoral system is now evident to everyone in the UK. (Particularly those who have died early as a result of system failures) But the politicians and the media collude to be against any form of PR (proportional representation) Fair voting systems mean everyone feels they have a chance to influence power.

The protest vote at Brexit referendum was because we don’t have PR. The referendum on PR was ill timed, and mismanaged by Mr Clegg and colleagues, but now there is a real feeling that the time for PR is here. It is present in Scotland and Wales, and could easily be applied to change the House of Lords, and reduce it’s overheads. Would we like GP education to be privatised in the same way?

Don’t be led by the media ring in your nose: vote Liberal for a longer term view, and Proportional Representation. (which form is another debate).

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GP leaders to debate future of NHS, industrial action and ‘zombie GPs’. “GPs’ first priority must be their own health”..

The most important word any resilient GP needs to learn is how to say “No”. Our profession is well paid, and the argument is not about pay. The conditions of work, the restriction of choices, and the shape of the job have become so onerous that many feel like zombies. In a national incident such as a train crash the Drs need to ensure they are safe before treating the victims. They need to secure the site. They need to make decisions which perhaps amputate on site, or allow some victims pain killers only, whilst others are saved. The train crash which the UK health services are now having is similar. As Clare Gerada is correct; “we have to look after ourselves  first”.

Nick Bostock reports on GPonline 3rd May 2017: GP leaders to debate future of NHS, industrial action and ‘zombie GPs’

GP leaders at next month’s LMCs conference will discuss whether the NHS can survive chronic underfunding, whether GP contractor status has ‘reached the end of the road, and whether industrial action should be back on the table to defend the profession.

The conference in Edinburgh on 18-19 May could also discuss whether deceased GPs could be resurrected to ease the GP workforce crisis, and call for health secretary Jeremy Hunt to be sacked ‘for presiding over the worst time in the history of the NHS, missing targets, longer waiting lists and low morale’.

Pressure looks to be growing from the profession for a wide-ranging overhaul of GP funding, with LMCs set to warn that overall funding is too low, and that distribution through the Carr-Hill formula and other contract mechanisms is unfair.

Motions put forward by LMCs warn that no funding mechanism will deliver fair funding for GP practices until overall funding is increased. The GPC warned earlier this year that despite pledges to raise funding through NHS England’s GP Forward View, the profession remains underfunded by billions of pounds.

GP funding

But LMCs will question whether the existing funding formula gets the balance right between different priorities, with a motion put forward by Glasgow LMC warning that ‘careful consideration has to be given to the balance of the funding formula between deprived patients, remote and rural patients, elderly patients and those patients not in any of these groups who may face their funding being eroded’.

GP leaders will also call for a list of core GP services to be defined – a step the GPC has long opposed – in part to maintain services as new care models take shape across the NHS. The GPC has consistently argued that it is simpler to define non-core work, for example using its Urgent Prescription document to list services that practices should receive additional funding for.

The conference will also hit out at the rising cost of indemnity, warning that increased fees are driving GPs out of the profession. LMCs will argue for greater transparency from medico-legal organisations about risk criteria that can lead to sharp rises for individual GPs.

GPs will also warn that contract uplifts have not covered rising indemnity costs in full, and that direct reimbursement of costs would be a better option for practices than payments based on list size.

Locum GPs

Plans to improve communication with sessional GPs, with a proposal for a ‘national communications strategy to secure adequate communication of guidelines and patient safety communications to locums’ will also be discussed at the conference.

Broader ‘themed debates’ at the conference will discuss issues such as NHS rationing, independent contractor status, working at scale and workload.

One debate will look at whether the NHS can survive given overall underfunding, and whether co-payments for services should be considered. Another will consider whether independent contractor status has reached the end of the road and how it could be protected.

Further debates will look at whether GPs should remain within the NHS – in Northern Ireland GPs have suggested they will quit the NHS en masse if two thirds of practices hand in resignations – and whether there is ‘still a need to consider appropriate forms of action, and would this be effective or counter-productive’.

Another debate will encourage GPs to discuss whether the QOF has reached the end of its useful life – as NHS England chief executive Simon Stevens has suggested.

A motion put forward by Shropshire LMC, meanwhile, suggests ‘the urgent funding of a bioengineering program designed to immediately triple-clone all UK GPs, including the recently retired, in order to facilitate our prime minister’s glorious vision of a truly 24/7 health service’.

It adds: ‘The project should ideally extend to exploration of the resurrection of deceased general practitioners, though conference acknowledges that some health consumers might find zombie GPs unpalatable at first (assuming they even notice the difference.) However, we believe that public fears about human cloning and the walking dead could be swiftly allayed by the persuasive powers of the undisputedly veracious Mr Jeremy Hunt.’

Alex Matthews-King in Pulse 24th April reports: NHS England asks CCGs for rationing heads-up following media scrutiny

Isabella Laws on 2nd May reports Clare Gerada: GPs’ first priority must be their own health, warns former RCGP chair – GPs must put maintaining their own health above caring for patients and running their practices, former RCGP chair Dr Clare Gerada has warned.

It’s the shape of the GP’s job that needs to change. The pharmacist will see you now: overstretched GPs get help…The fundamental ideology of the Health Services’ provision. Funding of this type admits 30 years’ manpower planning failure

NHS ‘is like a train just before a crash’ (and it is now happennin g in slow motion)

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NHS managers still growing as GP posts fall

The Observer reports 15th April 2017: Number of NHS managers still growing as GP posts fall again – Doctors say ministers’ ‘bureaucracy busting’ shakeup has failed to switch resources and manpower to the front line

The number of NHS managers has grown by almost 18% in the four years since the government introduced a “bureaucracy-busting” shakeup of the health service, according to the latest official data.

The rise of about 4,650 in total management posts since April 2013, when the controversial Health and Social Care Act came into force, contrasts with an alarming fall in the number of GPs over recent months at a time of unprecedented demand for health care. The figures have drawn criticism from the British Medical Association (BMA), who say ministers are failing in their central objective of shifting more resources and manpower from back-office posts to the front line….

Managers are at odds over rationing, and management recognises the case, but the “rules” don’t allow them to speak out.

 

Decline and fall of General Practice

The decline of General Practice has been evident to all of us close to the “hot end” for some years now. Watch for Private healthcare development and demand as the systems implode and let us all down. It will begin with GPs in large towns and cities, and progress to private A&E departments. There is no plan and politicians are in denial. Standards are falling, especially in training, and it looks as if differential post-code outcomes and life expectancy will follow in the next WHO report on the UK. The hot end is getting so hot it might become a desert..

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Kat Lay reports in The Times 12th April 2017: Thousands of GPs plan to quit in next five years

Seven in ten GPs intend to stop seeing patients, take a career break or reduce their hours within the next five years, according to research.

Two family doctors in every five intend to walk away from the profession, according to the study, with the proportion rising steeply with age.

By age 56, almost 90 per cent said that they would quit within five years, compared with less than 20 per cent of under-45s.

The figures come from a survey of doctors in the southwest but GPs’ leaders said that they were indicative of the whole of the UK, with low morale pushing people out of the profession…..

Emily Fletcher and others in the BMJ open report:

Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners

Zara Aziz in the Guardian 12th April : Time for a rethink on GP numbers; The GP recruitment crisis is only going to get worse as overwork and low morale push doctors out of the profession. More funding is desperately needed

The training and competence of doctors – letters in the Times following Doctors who trained abroad ‘far more likely to be incompetent’

‘My private GP surgeries can take the strain off the NHS’

 

 

What – no crisis? The NHS’s biggest challenge is convincing the public it has a plan ….

The answer is an overtly rationing plan…..

Anastasia Cox reports in The Guardian 2nd March: The NHS’s biggest challenge is convincing the public it has a plan 

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The British public has begun to talk of an NHS in crisis. This is a perception based on headlines decrying the state of the service; reports from healthcare staff (the NHS is the UK’s biggest employer; most people have at least one person in their social circle who works in it); and occasionally participants’ own bad experiences (although most still receive a great service – a tension that can give rise to “I was lucky” syndrome). Meanwhile, according to Ipsos Mori’s January issues index, 49% of respondents said that the NHS is one of the biggest issues (pdf) facing Britain today, a nine-point jump since December 2016 and its highest level since April 2003.

Public opinion abhors a vacuum. In the absence of a clear, concerted and disciplined message, people fill the gaps with their own assumptions, experiences and prejudices…..

Tara Aziz in the Guardian 12th April 2017 reports: Time for a rethink on GP numbers 

On 21st February she reported: Don’t blame GPs for NHS crisis. Blame chronic cuts to social care

and also reports that “Two in five GPs in south-west of England plan to quit”, survey finds – Study exposes potential doctors’ crisis in NHS, with GPs found to be considering leaving the job or reducing their hours

Kailash Chand opines 8th April:  If general practice fails, the whole NHS fails

and Sarah Marsh reports: Record number of GP closures force 265,000 to find new doctors

Surge in number of patients having to change practice comes despite NHS pledge to invest £2.4bn in GP services by 2020

The Observer sees Brexit as a distraction, NHSreality agrees, and now Syria is also

Forces lobbying for equality, the NHS and social mobility will soon be in fierce competition with new interests – such as farming – for attention and resources

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