Category Archives: Patient representatives

The perverse incentives for government and university are too great…. A different long term plan is needed..

It is expensive to train medics, and the “cost” as shown below, is only a fraction of the real cost. The last estimate I saw was £260,00 in 2016. The market for medics is world wide, made worse by a global shortage and, in the case of the UK, made worse by the universal language of medical science – which is English. With rationing, we have to date given 2 out of 11 applicants places, and the odds have reduced to 1 out of 3! We need them all, and a virtual medical school could supply. Graduate entry is more efficient for the state, and gives males a better opportunity against females, as the men mature later. All this is recorded in NHSreality. ( See links below) The Perverse Incentives for government to apply short term policies, and the universities to generate income before providing the people needed are driving the situation worse. Along with this current doctors are bullied, harassed and overworked. At junior level repeat mistakes are endemic, and if all were recorded as “critical incidents” these doctors would not have time to work. In many countries, especially those from where we import doctors, they are predominantly private and admission is through wealth. These countries have created a caste system in health care, and the best is usually private. The articles below have interesting graphics…..We are already heading there, but it will take a longer term view to turn the juggernaut around.

Britons lose out to rush of foreign medical students Sian Griffiths

….The number of British first-degree students training to be doctors in the UK dropped by more than 500 from 2013-14 to 2017-18, while medical schools increased non-EU student numbers by 12%. While UK students pay £9,250 a year for their medical degree, non-EU students can pay up to £35,000 a year. The courses generally take five or six years….

Exeter, Glasgow and UCL medical schools also increased their overseas undergraduate numbers between 2013-14 and 2017-18 while UK student numbers fell at Durham, Liverpool, Edinburgh and Plymouth.

Jessica Ologbon, 20, said she had felt “numb” when she was rejected by four medical schools after achieving 10 A*s at GCSE and four As at A-level….

…He said: “It’s about money, at the end of the day. You would feel that you were losing out to somebody else who was paying their way in with a chequebook, but the universities have to balance their books somehow.”

Mark Britnell The Sunday Times Med Schools – an opportunity to “train the world” and an advert for his new book:

…We are heading for a global workforce crisis in healthcare. It’s estimated that the world will need an extra 18m health workers by 2030 as the population grows and ages. In the short term the UK is in danger of making a bad situation worse.

…In Britain, frustratingly, there were 20,730 applications to UK medical schools last year but only 6,500 places available. We did not fare much better in nursing: more than 50,000 students applied for 30,000 nurse training posts.

Of course quality is more important that quantity, but we have the opportunity to achieve both. There is a pressing global shortage of health workers, we have a strong NHS brand internationally, we lead the world with our universities and we have some of the best intellectual property — forged over centuries — for education and training at our command.

We should start by putting our own house in order, but, beyond Brexit, we can show the rest of the world that health is wealth. After all, isn’t that what Brexit has asked of us?

Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

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

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

 

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NHS failure is inevitable – and it will shock those responsible into action. “Get ready for the penny to drop.”

The problem with defining failure in a state service is akin to defining bankruptcy in a nation state. If the state can print its own money it can never be bankrupt. If it defaults on it’s debts (usually dollars) it becomes a pariah. But it continues, as Zimbabwe or Venezuela…. The failure of the four health services is apparent to all doctors and nurses. If they can afford it, and have no idealistic scruples they may have PMI (Private Medical Insurance) but if they haven’t they KNOW that they may have to pay up front privately. The media will not be interested in a sustained assault on the “idolatry” which the nation has, and it wont tell us plebeians that there is no “N”HS. The costly measures when the penny drops will not be popular…

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opines in the Guardian 6th April 2018: NHS failure is inevitable – and it will shock those responsible into action

Health service facilities and staff are being stretched to a breaking point that will take costly short-term measures to fix
The author asks why we don’t acknowledge the failure:
I think the explanation lies in the fact that NHS healthcare, unlike, say, the Grenfell Tower disaster, doesn’t give us a calamitous across-the-board failure. It is so varied and comprehensive that while many services may be on their knees or worse, particularly at times of maximum pressure, others will be delivering adequate or even great services at the same time. There is a mixed picture. And for those who don’t want to see or face up to the hard facts, the possibility of highlighting other ones, and carrying on as before, presents itself.
And assuming the slide into mediocrity continues:
If this is where we are now, and there is much evidence it is, the performance of the NHS will now quickly get much worse. And this will, sometime soon, become clear to all. At that point something will have to be done – and will be done.

What will that be? It won’t be a promise to give the NHS an unspecified level of long-term funding some time. It will have to be immediate service increases and improvements with extra resources, to stem the flood of failure here and now: more money, yes, but more facilities, and more staff, all immediately, and, with costs guaranteed by government, feasible using quick-fix and stop-gap means. It will be quite costly, though the extra amount you can usefully spend in the short term isn’t huge.

But the alternative at that point will be a collapse of the NHS. And the sobering lesson is that had the warning signs been heeded and action taken before things came to this pass, the cost of putting things right would have been far less. The breaking point would have been avoided. Once the collapse has been prevented, we can all look at how we get things sorted permanently. Get ready for the penny to drop.

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NHS plan ‘ends public right to choose hospital’ – A form of rationing well known to Wales

The Welsh did not complain about lack of choice when it was begun a decade ago, and the weak BMA in Wales made comment, but no hue and cry resulted in this “lowest common denominator” medicine. Choice is a fundamental plank of a liberal society, and its loss is justified in war, famine, civil war and national emergencies. But rarely has choice been threatened in an advanced democracy/ Standards really are falling, and the right to choice may only be available to those who can afford it. A two tier society once again, and exactly what Aneurin Bevan wanted to avoid when he started the original health service. The Welsh health service has excluded choice because the money moves with the patient. The English will be less accepting of this form of rationing…… Losing choice does work for commissioners in saving money; but it does not work in saving lives. In rural and poorer areas where there are under resourced and under staffed hospitals it may actually do harm. 

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Oliver Wright reports in the Times 22nd Feb 2019: NHS plan ‘ends public right to choose hospital’

Patients’ right to choose where they are treated is being threatened by radical plans to scrap competition in the NHS, ministers have been warned in leaked documents.

Plans to abolish the health service’s internal market are being resisted by Whitehall officials who have told Matt Hancock, the health secretary, that they would quietly reverse 30 years of policy, according to a Department of Health briefing seen by The Times.

Mr Hancock is understood to be ruling out any changes that would prevent patients selecting the NHS hospital or private provider where they are sent for treatment. But he has been told that if he blocks new laws the NHS could blame the government for the failure of a £20 billion reform plan that was expected to save 80,000 lives a year.

The confidential briefing reveals for the first time the scale of changes proposed by health chiefs, which officials believe amount to another major reorganisation of the NHS.

Last month Simon Stevens, the chief executive of NHS England, asked Theresa May to reverse market-based reforms introduced in 2012 by Andrew Lansley, then the health secretary. Mr Stevens wants to make hospitals, GPs and local services work together.

His proposals were presented as a tidying-up exercise, but a briefing for Mr Hancock privately warned that NHS England’s unpublished plans went much further and would undo the internal market introduced by Kenneth Clarke when he was health secretary in 1991. Since then NHS managers have bought services from self-governing hospitals and companies, which were encouraged to compete for business.

The briefing warns Mr Hancock that he must be comfortable with this before signing off, adding: “Removing the internal market will entail undoing some 30 or so years’ worth of policy and legislation in the English NHS, including some of the checks and balances that a market-type approach allows and could have broader implications, for example, how choice works in the NHS.”

Mr Hancock has backed ending enforced competition but he supports patient choice and has little appetite for a Commons battle to reform the NHS.

The briefing warns that Mr Stevens’s position “implies that primary legislation is essential” to implementing the long-term plan, published last month. “This presents a future risk that, in the event that the long-term plan is not delivered, the NHS blames the government if there is no bill. We don’t think you should accept this shift in emphasis.”

Department of Health sources played down a split with NHS England, suggesting a compromise would be found that made clear that legislation was not essential, and which minimised upheaval and protected choice.

NHS England said Mr Stevens did not want to remove patients’ choice on where they are treated. A spokesman said new laws would not be needed. But, he said, as requested by the Commons health and social care committee and the prime minister, “carefully targeted” legislative changes had been drawn up that would provide better services.

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Heath and Safety Executive news 22nd Feb 2019: Patients’ 30-year right to choose where they are treated under threat as part of NHS England reshuffle

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A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

The irony of the lack of doctors, and insufficient access to Primary Care is that it is government who is responsible, and it is successive governments who have ignored the advice of the profession. The Inverse Care Law as defined by Julian Tudor Hart, used to apply to citizens in poorer and deprived areas who got less resources when they needed most. Now it is government who are responsible for the inverse care law as applied to health. As private practice becomes more evident, it will be most available in those areas where people can afford it, and the people living in deprived areas will have to put up with a second class service. Doctors, knowing they are rare commodities, can choose where to live, and will mostly choose where infrastructure and education and housing are best. Most of them come from suburban and inner city schools and these doctors when qualified would rather work part time in their home city than full time in a challenging area.

Daniel Weaver, a GP in Milford Haven, has sent this out on facebook, and has been interviewed for the Milford Mercury. Dr Weaver is an experienced and altruistic GP. His cry for help comes too late in many ways. NHSreality has been highlighting the demise of the “Goose that laid the Golden Eggs” of efficiency and avoidance of overtreatment for 6 years. NHS reality has also pointed out the problems with GP recruitment on many occasions, and asked for more graduate entrants to medicine. NHSreality has also reported on the rejection of 9 out of every 11 applicants when they were all recommended to apply because they were good enough. Rationing of places to medical schools, uninformed manpower planning, and an over dependence on females as doctors (because they are better at undergraduate entry) have all conspired to get us to arrive at this point. The short termism of the First past the post electoral system means there is no incentive to plan capacity over 20 years. Obviously we need to address recruitment, but the  shape of the job also has to change. Golden Hellos are not enough…  The heartfelt letter below is a cry for help on one level, and a daming indictment of government at another. NHSreality only disagrees in that there is no “N”HS any longer. Here is Dr Weavers Post: “If anyone is in the Milford Haven area feel free to share this post”:

I wouldn’t normally do this but I feel compelled to put a message out in response to the increasing levels of aggression and abuse towards staff over recent months. Hopefully this will work as something of a FAQ about recent issues relating to the surgery. This may be a long post, stick with it though and hopefully it will give some clarity.

Currently Robert Street is effectively short of 2 doctors (which is 40% of our manpower) & this is less then ideal. This is in part because of maternity leave, and in part because despite spending thousands of pounds on advertising we haven’t had any success in recruiting since a doctor left a couple of years ago. Why haven’t you had success? Multiple factors including a national shortage of GPs in UK and especially in Wales. Wales is seen as less appealing to work in compared with rest of UK and Canada, Australia as earnings tend to be lower and due to harsher social service cuts problems with social care, social problems end up reaching general practice, and longer out patient waiting lists mean that people are seeing GPs more frequently so there is a harder workload. We are further west than most people want to work, and our practice area is one of relative deprivation, so any GP applying knows they will be busier then those working in more affluent areas.

I came to back to work in Milford because I enjoyed working in the town during my time training in Barlow house surgery and I have a family connection to the town, but unless someone has a connection to the area it’s not easy to get people to relocate from other areas. Many international Doctors in the NHS have families overseas and want to settle in a location with good access to airports etc. or to live in larger cities with people of similar faith or culture. We have up to 3 weeks less annual leave then several other local practices which has been cited as a factor when I’ve chatted to doctors who’ve moved elsewhere, especially doctors with children. We have specifically resisted increasing amount of annual leave we allow ourselves because it would pressurise appointments further.

There are higher paid practices in the region. (practice income is complex depends on multiple factors, like if practice is a dispensing practice or has branch surgeries etc) I have medical friends with whom I have discussed about working in Pembrokeshire. Feedback from them often revolves around issues like the above but more locally uncertainty about local hospital services making doctors nervous about possible knock in increased general practice workload in the region.

The loss of maternity services in the county and loss of 24 hour paediatrics is deterring younger doctors who either have children or are planning to have children. Also the state of the secondary schools in Pembrokeshire at the moment puts some off. Locum rates being paid within our health board and elsewhere mean that potentially a GP could earn more money in a week of locum work then if they were in a stable salaried or partnership role for a month. Locum doctors don’t have to follow up patients or results and usually will cap themselves to a limited number of consultations eg 12 in morning or afternoon and 1 home visit. Existing locums have low incentive to get permanent jobs with a practice. There is ironically also a shortage of locum doctors. We are continuously looking for locums, and getting them when we have a chance. We cannot compete with health board for locums as their rates far exceed what a normal general practice can pay.

Another factor is we are not a training practice, I will come back to this later. Would it be financially beneficial and better for work life balance for doctors to leave and do locum work? Yes in short, but if another doctor left it would cause the practice to collapse entirely and we feel a duty to each other, staff and the local area. This is the danger about locum work being so lucrative in the current climate, it actually risks destabilising things further. Why aren’t we a training practice? We’ve been desperate to get training status since I joined the practice, it’s something I’ve always wanted to do, I’m passionate about training and this is something I’ve always been involved in in different forms from my time in medical school. Aside from wanting to train there is also evidence that the surgeries that cannot recruit and have to close are much more likely to be non training practice. Why is that? GP training practices have a registrar or registrars who effectively work as a doctors while completing their GP training, this increases number of doctors available to see patients in training practices. It also allows doctors to test working in a practice. Many trainees will end up in taking a job in a practice they trained at if they had a good experience. The good news is that we have had the first indication that can start the process of becoming a training practice which gives possibility of progress in the next year towards this goal.

Why is it so hard to get routine appointments? Unfortunately at the moment we are often down to 2 doctors a day, as we are frequently seeing 40-60 emergency appointments daily there is limited capacity for routine appointments. This is entirely manpower related. We are working harder then ever. We have effectively close to 3000 patients per full time equivalent GP currently. To put this into perspective a Nuffield Health study in 2011 showed national averages for Scotland was 1400 per GP, England was 1500 and Wales a little over 1600. We are short staffed at the busiest time of the year without locums. If there are 3 doctors in, the routine slots are put on in addition to emergency but these obviously go quickly especially if people are trying to see a particular doctor.

Why don’t you see more patients? During the average day which is usually 10+hours, often the only break is to go out and get food to eat at desk while going through results or letters or for toilet. Although I was not on call today I didn’t get a chance to have lunch so when I got home at 6:45 I ate for the first time since breakfast. This isn’t unusual. I am on call on average 3 or 4x per week either in the AM & PM during an on call there is a continuous stream of messages, script requests queries etc. In addition to usual duties emergency surgeries and home visits and things are often very frenetic and pressurised. Apart from seeing patients in the surgery GPs have do go through letters from hospital, amending medication and arranging tests and referrals. We will often have many letters daily, for example I went through a little over 70 letters this morning. GPs have to write letters for referral or to other agencies, appeals, DWP forms, forms relating to end of life, death certificates, cremation forms. GPs have to also go through Emails from NHS/health board/and check safety updates on medications which get posted through. Review results, bloods results get reviewed and often require further action, same with scans, we will often get results for around 30 patients each daily to go through more if someone is away and we are covering them.

Home visits: these are the least time efficient part of the day. Often if spread out a GP can spend over an hour driving between houses and nursing homes which takes time away from doing other jobs. Phone calls: I can have up to an hour of phone call requests or more in a day. Prescriptions and sick notes. In a typical week each GP is signing several hundred repeat medication prescriptions, along with sick notes. OK, I get that you are busy, what else have you tried? We have tried employing a physiotherapist to see patients presenting with muscular/joint problems to take pressure of the on call, allowing GPs to see other patients. Did it work? No most patients refused to see a physiotherapist and they insisted on seeing a GP.

GP Triage: this is a service which exists due to pressurised situations. A lot of issues can be managed over the phone and potentially saves an unnecessary appointment being used on the on call which can be used for someone else. The GP can access the notes and takes a history/arranges investigations or a face to face appointment if required. We pay for this out of practice budgets. It’s not ideal but it is better then nothing and there is no alternative option at this moment in time.

What about health board? in June we applied with Barlow House and Neyland surgeries for some existing Welsh assembly sustainability money to go towards employing a paramedic practitioner who could take some pressure off the home visits situation. Nothing has been forthcoming. We, on a temporary basis, have attempted to close our practice list although the health board have resisted this. This is given current intense pressure a logical step to try to preserve our resources and time for existing patients as we are aware of the access issues. They are not offering help. What else are you doing? We have been training a practice nurse to become a nurse practitioner, meaning she will be able to see some of the simpler emergency appointments.

Why can’t I get through on the phones? It’s not ideal but we have a finite number of reception staff. At peak times we have up 100 people trying to get through and without a call centre there are likely to be delays. Being on hold is common for doctors too and I often have to wait 20 minutes+ when contacting the hospital to refer a patient in for other reasons.

Image result for overwork cartoonThe NHS in general is struggling to deal with the amount of people who use the service, it’s far from ideal but there is no obvious solution, and no additional funding to help with this. Why do routines only come out on a Thursday? If everyone who wanted a routine appointment phoned up every day it is going to increase phone traffic and difficulties getting through, in other words it would make the problem worse. It’s the same reason why people are encouraged to put in repeat medication requests through via their pharmacy or by dropping a slip in. There is the option of signing up to request repeats online which is super useful, but not many people do this. Thursday is traditionally the quietest day of the week so that time in the PM is least worst time of the week. Why don’t you just abandon all routine appointments and just do book on the day system? This gets discussed periodically but when it has been trialled before people complain about it. Why do reception staff ask me about my symptoms if I want an emergency appointment? They are not being nosy, sometimes people phone to get an appointment with a GP when actually it would be unwise & they should call 999 or go to A&E, for example if having a stroke or suspected fracture. Sometimes the issue is something that can be better dealt with by a pharmacist, a dentist or is completely non medical. Additionally if I am doing an on call, I need to be aware who the likely most ill people are, eg if someone is doubled over in agony with a possible appendicitis or acutely suicidal, I will need to see them before I see someone with mild earache or trapped wind. Will shouting at staff or being abusive help? No, please try and be patient and don’t take frustration out on staff. Everyone is working hard and it’s not an easy time for anyone. Taking it out on staff increases the likelihood of people walking away which makes the problem worse. I still want to complain! Feel free although hopefully this will help put your concerns into perspective. We are very stretched and this entirely relates to staffing issues beyond our control along with a difficult local healthcare environment. I am a doctor, I am not a politician and I have no influence on the larger, complex problems facing our county or country. There are multiple practices in difficulty in the county and elsewhere in Wales, and increasing numbers of doctors handing practices back to health boards due to being unsustainable and impossibly challenging working environments. In summary we are working hard and have been trying things. Why aren’t Barlow House having the same issues? It is harder to get an appointment with us then Barlow House Surgery but this is resource linked. They are fully staffed with permanent GPs and usually have between 2-3 GP trainees giving them roughly double our capacity, despite this they are still busy and working hard as well, as demand continues to rise in part because of problems in social care and secondary care being moved onto general practice. We get continuous complaints about difficulty getting appointments and problems with the phones but hopefully this gives extra insight into reality on the ground. Positive aspects for future are: more trainees coming from local scheme in next few years increases chances of us recruiting in a year or two. Dr Skitt won’t be on maternity leave for ever. We may be able to have trainees in the next 12 months which will help. We and another practice in Pembrokeshire will hopefully soon have a CPN attached to the surgery who may be able to help out with mental health related issues. This is a Welsh assembly funded pilot and hopefully will be positive. Age wise there are no doctors coming up to retirement soon unlike some other practices around the region. My colleagues are grafters and work as hard as any clinicians I’ve ever worked with in my entire career. If we do recruit and become a training practice Milford Haven is will be in an advantageous position compared with most of the rest of Wales with full compliment of relatively young doctors. I appreciate in the short term this isn’t much consolidation but at moment priority is survival. I apologise in advance but I’m not planning to respond to comments on this post as I made a decision some months ago to try and avoid social media and to try to prioritise spending any free time I have with family and friends rather then online. This was a decision ironically I took because of how late I tend to get home from work and the impact my job has on the people around me. Feel free to share this though.

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Deprivation differences…. especially across the UK – revisited

Early deaths: Regional variations ‘shocking’ – Hunt

Poverty in Wales

How to kill the goose and create a shortage of 10,000 GPs – Patients kept waiting as new doctors shun GP jobs

Hands up – who want’s to be a GP today?

Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

The Horse has bolted but “play it again Sam”…

“GPs to receive ‘golden hellos’ in hiring drive”….

The benefits to the NHS of staying in the EU

No harm at this political juncture, or reminding NHSreality readers of The benefits to the NHS of staying in the EU (The Times letters 4th April 2016.

Sir, As health professionals and researchers we write to highlight the benefits of continued EU membership to the NHS, medical innovation and UK public health.

We have made enormous progress over the decades in international health research, health services innovation and public health. Much of this is built around shared policies and capacity across the EU. The future for European citizens’ health lies in teamwork.

EU trade deals will not privatise the NHS as negotiations now contain clear safeguards. Decisions on NHS privatisation are in UK government hands alone.

EU immigration is a net benefit to our NHS in terms of finances, staffing and exchanges. Medical tourism brings surplus funding.

Finally, leaving the EU will not provide a financial windfall for the NHS. The UK’s contribution to the EU budget is part of an agreement allowing access to the single market. If we pulled out, adverse economic consequences far larger than any nominal savings are widely anticipated. This jeopardises an already cash-strapped NHS.

Our health services, health-research collaborations and public-health protection are more robust within the EU. Leaving would damage the progress we have made together. Brexit should carry a health warning.

Professor Martin McKee CBE, Professor of European Public Health, London School of Hygiene and Tropical Medicine
Professor Sir Simon Wessely, Vice Dean, Academic Psychiatry, King’s College London Dr Mike Galsworthy, Programme Director, Scientists for EU
Lord Bernie Ribeiro FRCS, Past President, Royal College of Surgeons London
Lord Nigel Crisp, Former Chief Executive NHS, London
Baroness Elaine Murphy FRCPsych, Professor of Psychiatry, London
Lord Alderdice FRCPsych, Senior Research Fellow, Harris Manchester College, University of Oxford
Professor Dame Jill Macleod Clark, Professor of nursing, University of Southampton
Sir George Alberti, Visiting Professor, King’s College, London
Sir Harry Burns, Professor of Global Public Health, University of Strathclyde
Sir Iain Chalmers, Co-ordinator, James Lind Initiative, Oxford
Sir Ian Gilmore, Professor, University of Liverpool
Sir Richard Thompson, Immediate past-president, Royal College of Physicians, London
Sir Robin Murray, Professor of Psychiatric Research, King’s College, London
Sir Sam Everington, GP, London
Sir Cyril Chantler, Formerly Chairman of The King’s Fund and the UCL Partners academic health science network, London
Mr Carl Philpott, Honorary Consultant ENT Surgeon, University of East Anglia
Professor Dominic Harrison, Director of Public Health, Blackburn with Darwen
Dr Anna Batchelor, Consultant anaesthetist, Newcastle upon Tyne
Dr Arpana Verma, Director Centre for Epidemiology, University of Manchester
Dr Christine Robinson, Research Assistant, University of Manchester
Dr Christopher A Birt, Honorary Clinical Senior Lecturer in Public Health, University of Liverpool
Dr Clare Gerada MBE, Former Chairwoman, Royal College of General Practitioners London
Dr David L Cohen, Consultant Physician, Northwood
Dr David Nicholl, Clinical Lead for Neurology & Neurophysiology (writing in a personal capacity), Sandwell & West Birmingham NHS Trust
Dr David Wrigley, GP, Carnforth, Lancashire
Dr Dominic Hurst, Clinical Lecturer in Primary Dental Care, Queen Mary University of London
Dr Geeta Nargund, Medical Director, Create Fertility London
Dr Harry Rutter, Senior Clinical Research Fellow, London School of Hygiene and Tropical Medicine
Dr Henry McKee, GP, Belfast Trust
Dr Iona Heath, Retired general practitioner, London
Dr Jane Young, Consultant Radiologist and Head of London School of Radiology, Whittington Health
Dr Jennifer Mindell, Reader in Public Health, UCL, London
Dr John-Paul Lomas, Specialist Trainee in Anaesthetics, Manchester
Dr Kevin O’Kane, Consultant in Acute Medicine, Guy’s and St Thomas’ NHS Trust
Dr Leila Lessof OBE, Former Director of Public Health, London
Dr Linda Papadopoulos, Psychologist, London
Dr Michel Coleman, Professor of Epidemiology and Vital Statistics, London School of Hygiene and Tropical Medicine
Dr Nicola Shelton, Reader in Population Health, London
Dr Omar Bouamra, Medical Statistician, University of Manchester
Dr Richard Horton, Editor-in-Chief, The Lancet, Elsevier
Dr Roberta Jacobson OBE, Honorary Senior Lecturer, Institute of Health Equity, London
Dr S Vittal Katikireddi, Senior Clinical Research Fellow, University of Glasgow
Dr Suzy Lishman, President, The Royal College of Pathologists
George Davey Smith, Professor of Clinical Epidemiology, University of Bristol
Jan van der Meulen, Professor of Clinical Epidemiology, London School of Hygiene & Tropical Medicine
Mr Gary Clough, Research Assistant, University of Manchester
Mrs Louise Johnson, Well North Executive Co-ordinator, University of Manchester
Ms Clare Huish, Research support assistant, Manchester
Ms Rosalynde Lowe CBE, Former Chairwoman Queen’s Nursing Institute, London
Prof Alastair H Leyland, Professor of Population Health Statistics, University of Glasgow
Prof Frank Kee, Clinical Professor, Queen’s University Belfast
Prof Gerard Hastings OBE, Professor, Stirlng and the Open University
Prof Humphrey Hodgson FMed Sci, Emeritus Professor of Medicine , UCL
Prof John S Yudkin, Emeritus Professor of Medicine, University College London
Prof Jonathan Weber, Director, imperial College Academic Health Science Centre, Imperial College London
Prof Mark S Gilthorpe, Professor of Statistical Epidemiology, University of Leeds
Prof Trevor Powles CBE, Head Breast Cancer Cancer Centre, London
Professor Peter Kopelman, Emeritus Professor of Medicine (formerly Principal), St George’s, University of London
Prof Martin White, Programme Leader, Food Behaviours and Public Health, University of Cambridge
Prof Ray Powles CBE, Head, Haemato-oncology, Cancer Centre London
Prof Sir Mike Owen, Professor of Psychological Medicine, Cardiff University
Prof Tim Helliwell, Vice President for Learning, Royal College of Pathologists, Liverpool
Professor Adrian Renton, Director of Institute of Health and Human Development, London
Professor Aileen Clarke, Head of Division of Health Sciences, Warwick Medical School
Professor Allan H Young, Director, Centre for Affective Disorders, King’s College London
Professor Alwyn Smith CBE, Former President, UK Faculty of Public Health, Manchester
Professor Carol Dezateux, Professor of Epidemiology and Hon Consultant Paediatrician, London
Professor David Edwards, Professor of Paediatrics and Neonatal Medicine, Guy’s and St Thomas’ Hospital Trust
Professor Debbie A Lawlor, Professor of Epidemiology, University of Bristol, Bristol
Professor Derek Cook, Professor of Epidemiology, St George’s University of London
Professor Dorothy Bishop FRS, FBA, FMedSci, Professor of Developmental Neuropsychology, University of Oxford
Professor Gabriel Scally, Visiting Professor of Public Health, Bristol
Professor Jane Salvage, Nursing consultant, Lewes
Professor John Ashton CBE, Director of Public Health, Cumbria
Professor John Malcolm Harrington, Emeritus Professor of Occupational Medicine, Budleigh Salterton
Professor John Middleton, University of Wolverhampton, Wolverhampton
Professor KK Cheng, Director, Institute of Applied Health Research, University of Birmingham
Professor Liam Smeeth, Senior Clinical Research Fellow, London School of Hygiene and Tropical Medicine
Professor Lindsey Davies, Past president, UK Faculty of Public Health, London
Professor Martin Bobak, Professor or epidemiology, University College London
Professor Maurice Lessof, Former Professor of Medicine, Guy’s Hospital
Professor Patrick Saunders, Director, Carolan57 Ltd
Professor Peter Whincup, Professor of Epidemiology, St George’s, University of London
Professor Raymond Agius, Professor of Occupational and Environmental Medicine, University of Manchester
Professor Rod Griffiths CBE, Past President, Faculty of Public Health, London
Professor Rod Hay, Professor of Cutaneous Infection, King’s College NHS Trust London
Professor Rosalind Raine, Head of Department of Applied Health Research, UCL
Professor Rosalind Smyth CBE FMedSci, Director, UCL Institute of Child Health
Professor Simon Capewell, Chairman of Clinical Epidemiology, University of Liverpool
Professor Salman Rawaf, Professor of Public Health, Imperial College
Professor Shah Ebrahim, Hon. Professor of Public Health, London School of Hygiene Tropical Medicine
Professor Shanta Persaud, Professor of Diabetes & Endocrinology, King’s College London
Professor Simon Heller, Professor of Clinical Diabetes, University of Sheffield
Professor Sir Munir Pirmohamed, David Weatherall Chairman of Medicine and Consultant Physician, University of Liverpool
Professor Stephanie Amiel, Professor of Diabetic Medicine, King’s College London
Professor Trisha Greenhalgh OBE, Professor of Primary Care Health Sciences, University of Oxford
Dr Rachel Scantlebury, Public health registrar, London
Dr Verma Amar Nath, Retired General Medical Practitioner (NHS), Birmingham
Dr Ingrid Wolfe, Director, Children and Young People’s Health Partnership, Guy’s and St Thomas’ NHS Foundation Trust
Sir Eric Thomas, Former Vice Chancellor, University of Bristol
Lord Ara Darzi OM, Paul Hamlyn Professor of Surgery, Imperial College
Baroness Sheila Hollins, Former President Royal College of Psychiatrists, London
Lord Naren Patel, Former President Royal College of Obstetricians and Gynaecologists, Dundee
Professor Anna Gilmore, Professor of Public Health, University of Bath
Mrs Alexandra Johnson, CEO Joining Jack, Joining Jack, Wigan
Richard Fitzgerald, Consultant Radiologist, Royal Wolverhampton Hospitals NHS Trust
Anne Lennox, Chief Executive, Myotubular Trust
Professor Alison Woollard, Associate Professor, University of Oxford
Dr Simon Stockill, Medical Director, NHS Leeds West Clinical Commissioning Group
Professor Michael Laffan, Professor of Haemostasis and Thrombosis, London
Mr Daniel Mayhew BSc, Development Technician, Cambridge
Dr Martin Yuille, Reader, University of Manchester
Dr Alastair Cardno, Senior Lecturer in Psychiatry, University of Leeds
Ben Caplin, Senior Clinical Lecturer, UCL
Professor Chris Inglehearn, Ophthalmology, University of Leeds
Professor Matthew Hotopf, Director NIHR Biomedical Research Centre at the Maudsley, King’s College London
Dr Carolina Lopez, Consultant Radiologist, Bedford Hospital NHS Trust
Dr Chiara Marina Bettolo, Consultant Neurologist, Newcastle upon Tyne
Professor Peter Openshaw, Professor of Experimental Medicine, Imperial College London

Missed appointments are a distraction. In the factory model there has to be a disincentive for poor quality (and to make a claim).

Recent news on missed appointments may be confusing the public. GPs are pleased to have a little reflective and organisational and administrative time when a patients does not attend. They may already be late, and then the time is merely used to catch up. In GP land, before GPs were excused from “emergencies”, all patients had to be seen before you went home. Not so today. In Hospital land, consultants have limited numbers, and GPs have followed suite. The least popular careers in the 4 health services are, guess what, emergency medicine. Victims of a career in A&E have to contend with long and difficult shifts, overdemand, and under capacity. The mopping up which GPs used to do has moved to A&E, and with less experienced doctors seeing the patients. Missed appointments are a distraction. In any factory  model ( mutual insurance system ) there has to be a disincentive for poor quality ( and to make a claim) .. Once we ration overtly, and probably introduce co-payments, morale in all areas will improve, recruitment will be better, and the “reality” of life will sink in to the public as a whole. Phil Collins in the Times opines that “..The factory model of healthcare is no longer appropriate in a nation made healthier by the success of the first seven decades of public healthcare.” But even he shies clear of the need for autonomy, responsibility for self, and for sticks as well as carrots to encourage good health. If missed appointments cost millions, most Drs don’t really care. It’s a distraction, a side issue. Politicians have yet to arrive for their reality appointment… (see below)

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BBC News 2nd January: Missed GP appointments ‘cost NHS England £216m’

July 2nd in the Times: Attlee ‘would be shocked by abuse of NHS’ – “The prime minister who created the NHS would be horrified that patients are abusing it by missing appointments”, his granddaughter has said.

Jo Roundell Greene, the granddaughter of Clement Attlee, said that when the health service was created people were “so grateful”, but some now took the system for granted.

We have to shut hospitals to save the nhs – Phil Collins opines in the Times 4th Jan 2019…    “…Public Health England, the government’s health agency, has been highlighting the threat from diabetes which, on current trends, could take up a fifth of the whole NHS budget by 2035.”

The Times letters to the Editor 2nd and 4th Jan 2018: Missed hospital appointments and the NHS

Sir, I challenge the supposition of the chief nursing officer for England that missed clinic appointments are so costly (“Timewasting patients are costing NHS £1bn a year”, Jan 2).

When, some years ago, we looked into the problem in my orthopaedic and fracture clinics, we found that most non-attenders had recovered, or no longer needed our treatment. Most were judged to have been given precautionary appointments by less experienced junior doctors.

In some areas patients are now sent mobile phone text reminders of their appointment, with plans to supplement this with a similar email policy. This and better supervision and training of young doctors should resolve the problem for most cases.

Reappointments need be sent only to those unable to decide for themselves, such as children, or the few deemed at serious risk should they miss their checkup.
Paul Moynagh
(Retired orthopaedic consultant surgeon)

Sir, The chief nursing officer tells us that patients who fail to attend their hospital outpatient appointments are costing the NHS nearly £1 billion annually. This is almost certainly nonsense. In almost all of my 25 years as an NHS consultant in ear, nose and throat surgery (which has a heavy outpatient workload), we would evaluate the missed appointments rate regularly and increase the planned numbers per clinic accordingly. This is standard practice across the service.
Prof Antony Narula
Wargrave, Berks

Sir, I feel we are not made sufficiently aware of the costs of NHS services we use. If the cost of each medication were printed on the package we may be persuaded to use it carefully.

I was horrified to be told by the pharmacist that my bottle of medicine cost £300. I now make sure that I don’t waste a single drop.
Elizabeth Bass

Shepton Mallet, Somerset

and on 4th Jan:

MISSED APPOINTMENTS
Sir, I cannot understand how missed appointments are costing the NHS £216 million (report, Jan 2). The so-called cost of an appointment is a notional figure; if the appointment does not happen, it costs nothing at worst and saves money at best. If a patient fails to show, not only can an overworked GP catch their breath (or catch up, because they will almost certainly have got behind) but they won’t have to do expensive tests or prescribe expensive drugs. So this £216 million is fake accounting.

What might be interesting is why appointments are missed. The patients may have got better; their mother-in-law may have been admitted to hospital as an emergency; or there was no one to take them to the surgery.
Dr Andrew Bamji

Rye, E Sussex

Sir, In my experience missed appointments can be due (in part at least) to the NHS’s own systems. For example, my wife was called by her consultant’s secretary to ask why she had not attended an appointment; she replied that she had not been given an appointment (the letter, which had a second-class stamp, arrived the next morning).

My daughter has had a number of similar experiences: once the letter dropped through the letterbox 30 minutes before the appointment was due. After another appointment she was called by a secretary at the hospital, who asked why she had failed to attend. My daughter replied that she had, in fact, attended. She was then asked to relate, in detail, what the doctor had said to her.
Malcolm Hayes

Southam, Warwickshire

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Can the NHS be saved? Only with different local and global thinking, and changing the “rules of the game”.

All of us in the caring professions know the answer to this question, and indeed that there is no “N”HS any longer. The Guardian knows the answer….. Iain Robertson Steel, a retired medical director acknowledges the problem (But suggests no answer/solutions), but on 26th April  in the Western Telegraph I suggested a “fourth option” for people in Pembrokeshire.  This last is only for local needs, and a letter suggesting a global rethinking was in the Western Mail 25th Jan 2018 is at the bottom of this post. What can save the 4 health services is not clever reorganisations, but an honest debate on overt rationing, and making it clear to everyone what is not available free, for them. ( Changing the rules of the game )

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Can the NHS be saved? The Guardian – Dennis Campbell – 

…the Guardian’s health policy editor Denis Campbell spent a day in King’s College hospital in London. He found staff and patients who are devoted to the NHS but who can also clearly see what is needed in order to sustain the service for future generations.

A long-term plan designed to secure the future of NHS England has been delayed once again by Brexit. But as Britain’s health service heads into its annual winter beds crisis, the Guardian’s Denis Campbell visits King’s College hospital in London to find out what staff and patients need for the future – and how much it will cost. 

“The Welsh NHS and social care is a shambles and no longer sustainable or fit for purpose.” Dr Iain Robertson Steel in the Western Telegraph 7th December.

Health service needs to be remodelled Western Mail 25th January 2018

From the perspective of west Wales there is no British health service.

I do not have access or choice to anywhere outside my own rural trust (Hywel Dda) unless the service needed is not available here. Even a second opinion has to be within the same trust.

There are four, and possibly five health services if Manchester is included. The WHO has said it will no longer report on an “NHS”.

The lack of choice, the covert rationing, and the unequal access to tertiary centres, primary care, and palliative care threaten to bring on civil unrest.

A Welsh mutual of three million people cannot offer the same quality of healthcare as one of 60 million. Even if the Welsh Government has tax-raising powers, there are not enough taxable earners to rise above the decline.

We seem to have forgotten the power and improved health outcomes in large mutuals. Since the UK’s health service has to be refashioned, now seems a good time to unify again, and re-establish the same rights across the country.

Increasing taxation to pour more into a holed bucket should not appeal to most taxpayers.

We need a new health insurance system (the original NHS was insurance based) and the caring professions will remain cynical until what replaces “in place of fear”, avoids bringing it back.

Dr Roger Burns

Haverfordwest

Pembrokeshire GP urges a “fourth option”. Western Telegraph 26th April 2018

The finances are in such a mess, that local post code and unexpected rationing is everywhere… The “Rules of the game” need to be changed…..

Changing the rules of the game

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