Category Archives: Medical Education

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)

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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.

Danger to medicine and research from a no deal Brexit: But who listens to experts these days?

Dr Robert Lecher opines in the Times  letters 12th June 2019: (But who listens to experts?)

Sir, As we enter the next phase of the Brexit process under a new Conservative leader, it is vital to highlight the disastrous impact that leaving the EU without a deal would have on UK medical research and patients. The UK’s scientific excellence is fundamental to our nation’s health and wealth. We have benefited from decades of close engagement with European research programmes and free movement of talented European researchers. A no-deal exit without an adequate replacement immigration system in place would risk leaving the country with a talent deficit that could disadvantage us for years to come.

In the short term, a no-deal exit would halt access to vital funding and disrupt active clinical trials, which are essential for the development of new treatments. In the longer term, our participation in future EU research programmes would be threatened and our relationship with European disease monitoring systems and rare-disease networks would end. This would be devastating for patients and researchers alike.

I urge all candidates seeking to become the next prime minister not to risk our scientific prowess or our future health and prosperity by pursuing a no-deal exit from the EU.
Professor Sir Robert Lechler

President, Academy of Medical Sciences

 

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Japans bias is understandable, and to correct it they need graduate entry to Medical School. So do we…

It is natural for states to want value for money from their medics. The news that Japanese men are given preference to women was broadcast as if it were a scandal. I myself was an undergraduate entrant to Medical School in 1968. I would never have got a place today, with grades B & C at A level. Not the brightest student in my year, I just about coped, but as I matured I got to understand. The result was a full time GP who for 37 years gave good value to the UK Health Services in England and then in Wales.

Japans bias is understandable, and to correct it without excess women, they need to have graduate entry to Medical School. At 21 years old men have matured and do as well as women as has been proven in the UK. All medical students are graduates in USA, Canada, Mexico and many other countries, but Japan takes them straight from High School. (Quartz.com)

The Times reporter (see below) has failed to realise the significance of undergraduate v graduate entry.Image result for graduating doctor cartoon

 

Richard Lloyd Parry reports for the Times from Tokyo: Medical school that blocked women admits they outperform men

It was one of the most extreme cases of institutionalised sexism seen in modern Japan: a top medical school that deliberately made it harder for women to enter. After being exposed for its bias, the university has now allowed women to compete on an equal footing, and they are outperforming men.

Tokyo Medical University caused outrage last year when it admitted that its officials had doctored scores for entrance examinations to give women lower marks. The policy was justified on the basis that women were more likely than the male students to give up their careers at some point to have children, leading ultimately to a shortage of doctors.

After grovelling apologies, the university reports that it has held fair entrance examinations and the female candidates have been more successful than the male.

Last year, before news of the scandal broke, 9 per cent of men passed the highly competitive entrance examination for the prestigious university. The figure was lower still for women hoping to win a place: only 2.9 per cent of them were reported to have passed.

Male candidates, in other words, were more than three times as successful as their female counterparts.

 

The reason for this, however, became clear when the university admitted that it had been marking the scores of female applicants down by 20 per cent.

This year, 26.4 per cent of female applicants passed the exam, compared with 21.8 per cent of men, according to figures in the Asahi newspaper.

The higher overall proportion of successful applicants is explained by the fact that 60 per cent fewer candidates applied to Tokyo Medical University, whose reputation has been besmirched by the scandal.

Broadly similar but less dramatic results are seen in results from other Japanese medical schools. According to research by Asahi, male applicants were 10 per cent more likely to be accepted to study medicine nationally than women. This compares with a 20 per cent difference before the revelations.

To many observers, this confirms an assumption that other institutions in Japan also had a prejudice against women and that, even though they have not been exposed, they are discreetly taking steps to rectify the imbalance.

The university said that it offered places to 44 applicants who were denied them because of the exam manipulation. A total of 24 accepted the places, 16 of them women.

Medical Student debt – time for government to change policy on doctor recruitment

Fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

Women perform better at 18, so change the age at entry to med school

BBC News reported: Japan medical schools ‘rigged women’s results’

The Guardian reported in December 2018: Two more Japanese medical schools admit discriminating against women

In Kyoto the education ministry reports: More men pass entrance exams than women at 80% of Japan’s medical schools: survey

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The proudest day of Grace’s life was graduating as a doctor. Then she began treating patients. Beautifully-drawn cartoon story of a first-year doctor and a widower in hospital.

No Out of Hours service for taxpayers in Pembrokeshire. Be prepared to camp wherever you are sent…

As readers know there is no NHS, and in Pembrokeshire citizens who pay their taxes have no  GP Out of Hours Service/ Doctors on Call – in Pembrokeshire County …  

If you are elderly, or have young children, it looks as if you will have to camp in Casualty, and even that is poorly staffed, incompletely covered, and failing. NHS 111 is an appalling service. Confidence is failing, and private care will have to step in when the demand for it occurs. If there are deaths this might be sooner rather than later.

ITV news reports that for the second week running “GP shortages mean Out of Hours closures. 5th April 2019.

and prior to this, on 29th March: Out of Hours GP service closed again at Withybush Hospital this weekend.

For those who don’t know the area, the nearest (and also failing) DGH is 35 miles and many agricultural vehicle obstructions away, in Carmarthen. The situation is akin to the loss of services in Chester, except this is worse: it is access to emergency care rather than cold planned care that has been rationed out by successive administrations (of all colour).

The service in West Wales is now an official failure… but nobody is admitting their complicity in this disaster. The Post Code lottery is worse for distant and remote places. We are expecting a decision on a new hospital… 

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GP shortages this weekend mean that out of hours services in Carmarthenshire and Pembrokeshire will be closed intermittently. 5th April ITV News 

Hywel Dda University Health Board says they are continuing efforts to fill the shifts but expect the following disruptions:

  • Withybush General Hospital – closed 12am to 8am on Sunday.
  • Prince Philip Hospital – closed 2pm on Saturday until 8am on Sunday.
  • Glangwili General Hospital – closed from 10:30pm on Saturday to 8am on Sunday.

Analysis by Health Reporter James Crichton-Smith:

The fact that Hywel Dda is struggling to fill its GP out of hours rota is not a new one.

Health boards across Wales regularly have gaps in GP out of hours cover and Hywel Dda has previously warned of a shortfall at weekends, like it has this afternoon.

Read more:

Staffing problems and poor morale affecting GP out of hours

Health Board has had no doctor available overnight

The cause is a simple, and familiar, one. There simply aren’t enough GPs in Wales.

Efforts are ongoing to try and change this. The Welsh Government has its Train. Work. Live. campaign – and it has been getting results.

But training new GPs and attracting them to Wales takes time. The challenges are in the here and now.

August 2013:A series of intellectually and ideologically bancrupt administrations has led us to a GP recruitment crisis.

April 2019: GP suicides: LMCs call for action to reduce “appalling” numbers

March 2016: Top GP warns of threat to NHS as BMA calls emergency conference

August 2014: Recruitment rationing: GP magazine calls on political parties to support general practice

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Should the media and popular perception trump the evidence? Only if a health service is not rationed and rational…

NICE has an invidious job, and in an “unrationed” health care system it is asked to look at the evidence. The trouble is that some people respond to some treatments rarely, and the state should not be expected to pay for them if the chances are low. Our health service is rational as far as it can take logic. But it is not rationed overtly: people do not know what will not be available for them – until they need it. A good yardstick: would a private insurer cover it?

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James Kirkup for the Times April 3rd 2019, defends NICE: Don’t attack Nice for relying on facts instead of emotion.

The National Institute for Health and Care Excellence marks its 20th anniversary this week. Nice is a world-leading example of how to make difficult choices about allocating scarce resources. It approves the use of medicines and other treatments on the basis of hard-headed calculations, not politics or popularity.

Centralising and codifying decisions on medicine helps to avoid “postcode lotteries” and largely keeps politicians out of the process. Reflecting its 1990s origins, Nice is a very centrist institution: created and run by people focused on evidence not emotion, it just does what works.

Which is possibly why it’s under attack. In the post-truth age of Trump and Brexit, the Nice approach seems almost anachronistic and in a recent Commons debate MPs of all parties lined up to criticise the institute for not providing drugs for a range of rare conditions afflicting their constituents.

Hard-headed calculation is easily depicted as cold-hearted disregard for “ordinary people”. Nice decides which drugs are worth funding according to how many “quality adjusted life years” (QALYs) each treatment will deliver. Brutally utilitarian, perhaps, but that’s the nature of a finite health budget: a pound spent treating Patient A cannot be spent on Patient B. All that remains is to decide where that pound will do the most good.

It’s an uncomfortable reality to explain and sell, especially to people desperate for treatment. Sadly, some politicians aren’t even trying. That Commons debate was led by Labour’s Liz Twist, who came close to suggesting a populist approach to allocating medical resources: “QALYs, and everything else, that means nothing to people on the street,” she said, demanding instead an approach based on “fairness”, whatever that means.

She’s not alone in suggesting that popular perception should trump evidence. A Home Office white paper on immigration last year said that ministers wanted fewer migrant workers because of “the public’s view” that foreign labour drove down wages — something the government’s own economic evidence does not demonstrate

There are certainly improvements that could be made to the Nice model: the definition of a QALY can be revisited, and the wider NHS might benefit from buying more drugs on an “outcomes” basis, where suppliers get paid according to results. But funding medicines on the basis of what you think “people on the street” want would be a step backwards. Britain may be sick of experts, but getting rid of them is no way to help the sick.

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How can the NHS offer fulfilling, lifelong careers? The managers have no idea why doctors quitting in droves…. Exit interviews?

The exit interview is a rare event in the 4 health services. The BMJ opinion from Wilson and Simpkin is honest and powerful, but their drawing attention to the absent “exit interviews” now needs attention, and from a completely independent HR company. None of the staff will trust the “in house” services. Yes, its got that bad, and its going to get worse. Life expectancy has peaked already and went down this last year….

The BMJ offers some advice on workforce retention: How can the NHS offer fulfilling, lifelong careers? BMJ 2019;364:l1100

With morale and retention among UK doctors declining, The BMJ hosted a discussion at last week’s Nuffield Trust health policy summit, asking what the NHS can do to support clinicians throughout their careers. Abi Rimmer reports

“Enabling people to pursue their other interests is one key thing,” said Rakhee Shah, paediatric registrar and research associate at the Association for Young People’s Health, kicking off discussions. She highlighted the importance of giving clinicians more control over their working lives.

Ronny Cheung, consultant paediatrician at Evelina London Children’s Hospital, took this further, saying that it was also important to give clinicians control over their everyday workload. He said that his trust, Guy’s and St Thomas’ NHS Foundation Trust, had been “trying to make time and space for teams to come together.”

“It’s about regaining control,” he said, “and investing in people to allow them to do that.” This not only made staff feel more valued but also helped to remind them what they enjoyed about their work. “It has a multiplying effect,” he said.

Claire Lemer, consultant at Evelina London Children’s Hospital, highlighted the importance of food for staff. She described a successful initiative at her hospital that encouraged the executive team to provide food for clinical and administrative staff……

……The demise of the firm structure of working in hospitals had reduced support for clinicians, said Morrow….

…The panel also discussed how the intensity of clinical work affects clinicians’ ability to maintain a long term career in the NHS. Lemer said that, in some specialties, “the pressure and intensity of work is so extreme that it’s not sustainable for a whole career.”…

…Cheung also warned that the rigidity of medical training pathways was denying doctors the flexibility they needed, as they were forced to choose a specialty so early in their career.

“If we squeeze people into these pathways we shouldn’t be surprised if people break free, and we shouldn’t be surprised that we’re developing a workforce that isn’t particularly happy,” he said.

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The NHS is failing to look after its staff and patients, expert warns

Abi Rimmer, The BMJ

Anne Gulland, The BMJ

Opinion from Hannah Wilson and Arabella Simpkin is honest and ends with the paragraph: (This was not available in the on-line edition)

Quitting in DrovesHannah Wilson and Arabella Simpkin P 473 of the BMJ

Surprisingly, while there is little literature that discusses both the quantity of doctors that leave the NHS and the factors that may drive them, there is no literature discussing the attributes and characteristics of doctors that leave. To understand what is driving the flight, we must first ask who are the doctors that quit? Surprisingly exit interviews are rarely held. Yet this is critical information to develop interventions and strategies to stem the leak.

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