“Every patient deserves an examination”, or do they? These words were on the wall behind the patients head in one of my training practices. The GP recognised his temptation to omit, especially when hurried, the examination.
I remember a “sore throat study” as a trainee, wen we were shown a number of mostly normal pictures of “sore throats”. With each case there was a description of symptoms, an occupation, and a social situation. If you had a wedding the next day, even if your throat looked normal, you usually got an antibiotic from most doctors. If you were a diabetic you were more likely to get one, etc. What I am trying to explain is the context in which a GP works, and the need not to offend. Sore throat is only a symptom, and everyone needs an examination. We know that throat examination alone cannot predict bacterial or viral infection, and that for the one patient in front of us, their only concern is a speedy recovery. I confess that, in the middle of a winter of excessive sore throats, I once chuckled when the lady in front of me complained of the same. Without allowing me to examine her she left the room indignantly.. When she saw another doctor he diagnosed tonsillitis and gave penicillin. I never assumed anything on sore throats from that point on. This allowed me to pick up several cancers (tonsil and tongue) which others had missed. We are looking at a “Skill Mix change” as the numbers of GPs declines over the next decade. We hope that sore throats will be seen by competent people, and that the occasional cancer, or glandular fever will be picked up correctly.
The Journal of the RCGP Pauline Nelson et al. from Manchester, in the February 2018 edition ends: “…Evidence about the wider system effects involved in workforce re-design is currently lacking but crucially important in light of the aspiration to new models of care. Given these challenges, Buchan and colleagues’ question ‘If changing skill-mix is the answer, what is the question?’11 remains a pertinent one to ponder in primary care today.” Skill Mix change and the GP workforce challenge..full
Just like the NHS 111 system, and the Apps planned to get access, we are planning change without evidence. Commissioners are doing the only thing they can, within the rules of the game, and it is politicians who set the rules. Watch for missed and late diagnoses, increased litigation, poorer outcomes, and perhaps, in view of increasing dental caries, for the return of Subacute Bacterial Encocarditis. The advice is not to fail to examine, but to stop prescribing. But WHO is going to examine, and will they be competent to make the rare but serious early important other differential diagnosis?
The European Convention of Human Rights insists on ones ability as an individual to move ones labour across borders. We may well be abandoning this element of our legislature when we Brexit. However, why should only one group be punished in this way? What about teachers, architects, dentists, lawyers and surveyors? What about plumbers and electricians who emigrate after training for that matter? And what about the Welsh trained doctors who move to England or other parts of the UK. We have a net 20% loss of graduates annually in Wales. Should they be punished for leaving Matthew Paris’ “dustbin” to work elsewhere in the UK as well?
Social mobility is to be encouraged. We regret parochialism, and we usually reject any form of racial discrimination. Coercion is not a good thing.. Despite having the lowest proportion of overseas immigrants we voted for Brexit – first time that is. Brexit, if implemented “hard” will cause more expense, not less, in training doctors, and more shortages of staff.
The perverse incentive for every government to train too few doctors needs to be removed. If we aim at an excess of 10%, use modern methods of education in the community, we can solve the problem in 10 years’ time. Meanwhile, it looks as if it’s going to get worse, as is student debt.
Junior doctors who go abroad to work after benefiting from £220,000 worth of world class training should be forced to pay back some of their costs to the NHS, healthcare leaders say.
Niall Dickson, the head of the NHS Confederation, which represents senior managers, said shortages of staff were now the most pressing concern facing the health service, as he called for major changes to retain more medics.
The former head of the General Medical Council said the NHS should consider forcing doctors to remain loyal to the NHS, by making them commit to at least four years’ service, as happens in the military.
Jeremy Hunt, the health and social care secretary, floated similar ideas at the Conservative Party conference in Autumn 2016, when he set out plans to train an extra 1,500 doctors a year.
However, the idea of penalties for those who leave Britain soon after completing medical school was put…
…Might an unintended consequence of the loss of manufacturing and mining coupled with the decline of the class system and increases in the mobility of labour — all those cultural changes we call “upward social mobility” — be a corresponding increase in downward social mobility? I’m hardly warning of an influx of Old Etonians into “sink” estates, but of the possibility that “ladders out” of deprivation, if climbed, have consequences for those who do not take them as well as those who do. I would never use a word like “residue” for an individual human being — every human being has the possibility of defying the odds — but I wonder whether we have accidentally created self-reinforcing pockets of deprivation that have something of the residual about them? What has the sale of council houses done to the status of those who didn’t buy?….
Without overseas staff, doctors midwives and nurses, the Health Services would collapse. Many of our own fo overseas. The majority of doctors from the Indian subcontinent have been trained at private medical schools, and although the state does train many, they are a minority. With the media exposing false and illicit degrees, the 4 health services in the UK need a healthy scepticism when examining the CVs of desperately needed staff. This includes midwives and nurses. As the Health Services implode further, Trusts may be so desperate that they really don’t mind imposter degrees servicing their citizens. The perverse incentive to appoint and examine the evidence later may be too great..
A “diploma mill” in Pakistan has sold fake degrees to thousands of British workers and companies, including NHS doctors and a defence contractor, according to leaked documents.
Axact sold more than 3,000 qualifications in Britain over two years, including PhDs and medical doctorates, an investigation by BBC Radio 4’s File on Four found. The company has invented hundreds of universities online and uses fake news stories in an attempt to fool employers who check fake references on CVs.
Buyers of fake post-degree qualifications between 2013 and 2014 included NHS nurses, consultants and an ophthalmologist, according to the BBC. A British engineer based in Saudi Arabia spent almost half a million pounds on fake documents, it was claimed.
Dozens of websites selling fake degrees have been closed in recent years but the authorities struggle to keep up because they are usually based abroad. Pakistan opened an investigation into Axact nearly three years ago but the company continues to operate a global network from a call centre in Karachi.
In Britain the crackdown on bogus degree sellers is led by Higher Education Degree Datacheck. Its chief executive, Jane Rowley, said that only a fifth of British employers properly checked qualifications when hiring staff.
The BBC investigation claimed that the defence contractor FB Heliservices bought fake degrees for seven employees, including two helicopter pilots, between 2013 and 2015. Its parent company, Cobham, said disciplinary action had been taken.
The purchases were a “historic issue” and had no impact on safety or training, Cobham said.
Neyland looks set to lose one of its two doctor’s surgeries.
Argyle Medical Group is planning to close the St Clement’s Surgery, it announced on Wednesday.
It means Neyland patients will have to pay £1.50 a time to cross the Cleddau Bridge to attend appointments in Pembroke Dock’s Argyle Street surgery.
Argyle Street itself is already under major pressure with photographs over recent months showing patients in large queues trying to get appointments.
In a statement posted on Facebook on Wednesday evening, Argyle Medical Group, said: “Argyle Medical Group has submitted an application to Hywel Dda Local Health Board to close the Branch Surgery at St. Clements Neyland.
“The reason for this application is to consolidate & maintain patient care services at a time of reduced GP numbers at the practice.
“Despite concerted attempts at GP recruitment over recent years the practice has been unsuccessful. The practice has been successful in recruiting a further Nurse & Pharmacy practitioner & is continuing to try to recruit further such practitioners.
“The practice plans to increase its capacity to deal with urgent medical problems by offering increased clinical practitioner appointments. These practitioners will be backed up by a GP to provide immediate advice as needed. It is planned this service will be provided from Argyle Surgery, Pembroke Dock alone.
“Argyle Medical Group will continue to provide the full range General Medical Services to its registered patients in Neyland & the surrounding area. In order to facilitate the enhanced same-day service at Argyle Surgery it is proposed that appointments at St. Oswalds Surgery, Pembroke will change from a same day to a pre-booked appointment system.
“The practice consider this action to be the only option to enable a safe level of clinical care to be offered to all its registered patients at a time when recruitment & retention of clinical staff is extremely challenging.”
The move has sparked anger in the town with patients blasting the decision as ‘absolutely disgraceful.’
Neyland county councillor Simon Hancock said the move cannot be allowed to happen.
He has organised a meeting for Neyland residents.
Cllr Hancock said: “A public meeting will be held at Neyland Athletic Club next Thursday 25 January at 7pm to protest against the proposed closure of St. Clement’s Surgery. It cannot be allowed to happen.
“A campaign committee will be formed. Please come along to show your support for a matter of enormous importance for every person and family registered there.”
Cllr Hancock, who is mayor of Neyland, added: “The proposed closure of the surgery is completely unacceptable and will put patients in Neyland and the surrounding villages at risk.
“A town of the size of Neyland needs good quality medical facilities and the Argylr Medical Group will be breaching their responsibilities in seeking to close their Neyland base.
“People without transport will be disadvantaged, people will have to pay travel costs and the consequences when the Cleddau Bridge is closed to all traffic are too shocking to contemplate.
“I hope we have an excellent and representative turnout to the public meeting to fight the proposed closure. Simply this is a battle Neyland cannot afford to lose.”
Fellow Neyland county councillor Paul Miller, said: “‘While I understand recruitment of GP’s is difficult this proposed move is a serious betrayal, by the Argyle Medical Group, of its patients in Neyland.
“I’ll be standing side by side with the people of the town in opposition to what would be a serious backward step in the provision of vital medical care.
“The Health Board must block this request and engage with us in an urgent conversation about providing a sustainable GP service for Neyland.”
Preseli Pembrokeshire MO Stephen Crabb said: “This is hugely disappointing news that St Clements Surgery feel the need to close due to a failure to recruit.
“Pembrokeshire is a fantastic place to live and work and more should have been done by the Hywel Dda University Health Board and the Welsh Government, who hold power over the NHS in Wales, to ensure that St Clements Surgery had staff in place to remain open.
“The Welsh Labour Government have known about recruitment problems in rural practices for a long time and have failed to come up with a strategy.
The Times second leader 20th December is telling, not only that health is second, after defence, but also in telling the truth. Apart from the fact that there is no NHS, NHSreality concurs on every point. Doctors are “stressed out”. What is omitted is the increasing numbers of women as a percentage of the whole, many of whom go part time. Postgraduate entry would address this gender inequality. As we move further into the understaffing crisis, and those with means elect to go privately in a default 2 tier system, those rejected, in applying to all the medical professions over the last 30 years, should be asking why?.. Even within training we are seeing omissions. The poor results for infant mortality compared to our peers is a result of only half of GPs getting Paediatric experience. A six month post is unnecessary, and 3 month posts could double paediatric exposure. It is not enough to get all children to see paediatricians immediately, as there are not enough of them either. Overseas doctors are declining after the Brexit vote, but many of these will have been trained privately overseas…. the assumption that our medical workforce is there on merit also needs challenging. Our whole manpower system needs re-planning and depoliticising, and to take away the perverse incentives for short term planning..
The NHS is facing an understaffing crisis. A report from the General Medical Council highlights three developments, each of them a surmountable problem on its own, but indicative of a looming problem when taken together.
First, the United Kingdom is deeply dependent on doctors and other healthcare workers who have qualified abroad. In some fields and some geographical areas this is both acute and dramatic. For example, more than half the workforce in obstetrics and gynaecology, and almost half of the nation’s psychiatrists are currently non-UK graduates. Meanwhile, in the east of England, 43 per cent of doctors are not UK graduates. In the West Midlands, 41 per cent are not. In the East Midlands, the figure is 38 per cent.
Britain is an attractive country in which to live and work so it is scarcely surprising that many doctors, who are often relatively young and mobile, wish to do so. Yet an attendant problem is that they wish to do so less and less. Perhaps due to a change in atmosphere since the EU referendum, or perhaps merely due to the falling pound, the number of foreign-trained doctors working in Britain is decreasing, not rising. Between 2011 and 2017, the number of foreign graduates on the medical register has shrunk by 6,000, with the fall coming not only from the EU but also south Asia.
Meanwhile the need for doctors is growing swiftly. Although the number of doctors working in Britain is increasing slowly, thanks to domestic recruitment, the demands of healthcare are rising even more quickly. England, for example, has experienced a 27 per cent increase in patients visiting accident and emergency in the past five years. This places a heavy toll on doctors and other healthcare workers, which in turn makes them less likely to remain in the profession.
Jeremy Hunt, the health secretary, attracted censure when he banged a drum for more British doctors in his party conference speech, but he was right to do so. There is nothing discriminatory about making public services sustainable and if doctors are reluctant to come from elsewhere, they will have to come from here. The Department of Health’s plan to add up to 1,500 more medical training places each year from September 2018 is therefore welcome. The creation of more places should be accompanied by incentives to take them up and to stay beyond the training. This could include easing the burden on junior doctors by providing more training opportunities.
There is also a need to look beyond doctors and traditional nursing roles. The Department of Health should consider a drive to expand the workforce by training more clinical pharmacists, physician associates, and nurses with the ability to prescribe medicines. That would leave junior doctors more time to spend caring for patients and undergoing training, and would lighten their administrative burden. In addition, such a step would provide further incentives for prospective doctors, many of whom are discouraged by rumours of a gruelling lifestyle.
The government is waking up to the need to plan for the staffing of the health service in five to ten years’ time, but there is much more to do if ministers are to fill vacancies quickly enough. There will be little point in giving the NHS its notional extra £350 million a week if there are no staff to spend it on.
Doctors who trained abroad account for almost half of all those working in parts of the UK as the profession faces “crunch point” and more young doctors take time out due to stress.
The General Medical Council’s annual report said that many regions and specialities relied on foreign-trained doctors, who could leave the UK. It added that there were too few doctors to treat rising numbers of patients, and doctors were being “pushed beyond their limits”.
The State of Medical Education and Practice showed that 54 per cent of junior doctors took a break after finishing foundation training, a rise from 30 per cent in 2012. “Goodwill and commitment to always go the extra mile” kept the NHS running, it said. “This level of sacrifice is neither right nor sustainable.”
The number of doctors on the medical register has grown by 2 per cent since 2012. Over the same period in England there has been a 27 per cent increase in patients going to A&E, and the GMC said that an ageing population was putting pressure on services.
While the number of UK graduates on the medical register rose by more than 10,700 between 2012 and this year, the rise was offset by a fall of 6,000 in foreign-trained doctors.
Charlie Massey, chief executive of the GMC, said: “We have reached a crucial moment — a crunch point — in the development of the workforce. The decisions that we make over the next five years will determine whether it can meet these demands.”
A fifth of doctors in training said they felt short of sleep while working. In 2014, when 43 per cent of new doctors took a break from training, 22 per cent took a one-year break and 8 per cent took a two-year break. Others may never return. More than half of those taking a break said that it was because of burnout, and most wanted a better work-life balance.
The GMC said that reducing the pressure on doctors and improving the culture and making jobs and training more flexible would be vital to recruiting and retaining doctors.
In the east of England 43 per cent of doctors were trained overseas. In the West Midlands the figure is 41 per cent, and 38 per cent in the East Midlands. More than half, 55 per cent, of specialists in obstetrics and gynaecology trained overseas.
About 14 per cent of doctors in the UK trained in south Asia, but their numbers have dropped by 7 per cent since 2012. The number of doctors from Africa, Australia, New Zealand and North America also fell.
The Department of Health said: “The NHS has a record number of doctors — 14,900 more since May 2010 — and we are committed to supporting them by expanding the number of training places by 25 per cent.” The department was working to improve retention, it added.
BEYOND THE STORY
The health service turned to Britain’s former colonies in South Asia during labour shortages in the 1960s and again in the 2000s when there were too few homegrown recruits.
Today, too, it leans heavily on overseas doctors. A third of doctors in the NHS trained outside the United Kingdom. The reliance has raised concerns that the NHS may be fuelling a “brain drain” in poorer countries where doctors are desperately needed, although others argue that training in the UK can improve those doctors’ skills.
It comes down to the simple fact that the UK does not train enough doctors to meet the demands of its population.
Historically, NHS workforce planning has suffered because it needs to happen over a much longer period than the average lifespan of a government. Last week Health Education England set out the first NHS staffing plan in 25 years, admitting that 190,000 extra frontline staff would be needed.
…Office for National Statistics data, for 2015, puts UK under-five mortality at 4.5 per 1,000 births although rates have improved 51 per cent since 1990, when 9.3 children in 1,000 died.
But in Portugal child mortality has improved 76 per cent and by 61 per cent in Ireland.
Professor Sarah Neill of Northampton University, said: ‘Infection is a major cause of avoidable childhood deaths in the UK, particularly in the under-fives, yet we know little about the factors that influence when children are admitted to hospital.’ …
Albert Einstein is credited with the observation that insanity is doing the same thing over and over again and expecting a different outcome. He could have been describing the NHS.
This great national institution celebrates its 70th anniversary next year and is pretty much funded and organised along the same lines as it was in 1948. Since then the population has grown by 14 million; average life expectancy has risen by 20 years; scientific advances have made treatments that were once unimaginable commonplace; and consumer-driven expectations have replaced the sullen acquiescence of yore.
At the same time, nursing has become a profession for graduates, junior doctors work fewer hours, GP surgeries are over-subscribed and their appointments system…
Dementia cases will triple around the world within a generation, the World Health Organisation has warned.
Caring for people with dementia will cost $2 trillion in little more than a decade, double today’s figure, threatening to “overwhelm health and social services”, the WHO says.
The international health agency is urging governments to wake up to the threat posed by the incurable condition as the global population ages.
The WHO estimates that today’s 50 million dementia sufferers will reach 152 million by 2050 as it launches the first global monitoring system for dementia. “Nearly 10 million people develop dementia each year,” Tedros Adhanom Ghebreyesus, the WHO’s director-general, said. “This is an alarm call: we must pay greater attention to this growing challenge and ensure that all people living with dementia get the care that they need.”
He wants countries to tell citizens how to cut their risk of dementia through healthier living, train health staff in dealing with the condition and implement plans to care for rising numbers of patients. Experts believe that prevention is crucial as there are no treatments to slow the brain damage that underlies dementia. Dominic Carter, senior policy officer at the Alzheimer’s Society, said: “With an ageing population and no way to cure, prevent or slow down the condition, dementia is set to be the 21st century’s biggest killer.”
Jackie Doyle-Price, the care minister, confirmed yesterday that the government would scrap a planned £72,000 cap on care costs, as it struggles to reform a crumbling elderly care system.
•Growth in life expectancy has stalled across many areas of the UK. Figures from the Office for National Statistics show the overall rate of improvement in life expectancy at birth during the first half of this decade was 75.3 per cent lower for males and 82.7 per cent lower for females when compared with the first half of the previous decade.
Honesty and Candour are at risk. In a post truth world we need to control the damage being done to the medical profession. Without a no-fault compensation scheme this situation will get worse. Already precedent has been set by demanding access to Trainee doctors “educational portfolio”, and these two cases together are worrying. A sinister development in the role of the GMC the position of a trainee, and the risk of a worsening, defensive culture of fear. Gagging with such behaviour is really another form of bullying.
MEDICINE ON TRIAL
Sir, We are concerned that the General Medical Council (GMC) is putting the culture of candour in medicine at risk and perpetuating an injustice by seeking the permanent erasure from the medical register of Dr Hadiza Bawa-Garba. Dr Bawa-Garba, a trainee paediatrician, was convicted in 2015 of negligent manslaughter after the tragic death of Jack Adcock in 2011.
The Medical Practitioners Tribunal Service (MPTS) then had to decide if she was fit to continue to practise. It heard that her clinical practice was generally regarded as excellent, with no other concerns flagged against her. It recommended she could apply to return to service as a doctor after 12 months’ suspension. The MPTS identified “multiple systemic failures” within the service. The evidence for these failures was not fully examined at the criminal trial; had they been, this would almost certainly have reduced her purported culpability.
The GMC is now appealing, via the High Court, seeking to have her struck off. We know of no evidence that terminating Dr Bawa-Garba’s medical career will make any patient safer. On the contrary it promotes a climate of defensiveness. In 2001, the joint declaration by the government and the GMC recognised that “honest failure should not be responded to primarily by blame and retribution, but by learning and by a drive to reduce risk”.
We urge the GMC to recognise that many within and outside medicine are already losing confidence in it and that this case could define its future.
Dr David Nicholl, consultant neurologist, Birmingham; Sir Peter Bottomley, MP; Nick Ross, journalist; Captain Niall Downey, doctor, pilot & patient safety trainer; David Field, professor of neonatal medicine, University of Leicester; Professor Sir Iain Chalmers, James Lind Initiative, Oxford. Plus a further 769 names at manslaughterandhealthcare.org.uk/letter
The real man smiles in trouble, gathers strength from distress, and grows brave by reflection. Thomas Paine Article from Pulse magazine once again the opportunity to learn from mistakes will be lost in order to satisfy the thirst for cash for claims bonanza that is going on in the UK. Good luck retaining doctors with […]