Category Archives: Professionals

The “State of health and care in England” – is declining and worryingly underfunded…

In The BMJ Chris Ham of the Kings Fund reports on the “State of health and care in England.

(BMJ 2017;359:j4799 This is worrying and there is inadequate funding, but the word omitted by Mr Ham is “rationing” – of course. 

Services are at full stretch and struggling to maintain standards

The annual assessment of health and social care by the Care Quality Commission (CQC) provides a veritable treasure trove of information about the state of services in England.1 Based on inspections of 21 256 adult social care services, 152 NHS acute trusts, 197 independent acute hospitals, 18 NHS community health trusts, 54 NHS mental health trusts, 226 independent mental health locations, 10 NHS ambulance trusts, and 7028 primary care services over three years, the assessment offers grounds for concern and reassurance in equal measure.

The CQC’s headline finding is that most services are good and many providers have improved the quality and safety of care since inspections. Behind this headline lies a much more nuanced assessment, with variations between and within services and evidence of growing pressures on staff and deterioration of quality in some services. Adult social care is identified as a particular concern, with a reduction in nursing home beds, providers of domiciliary care handing back contracts to dozens of local authorities, and an estimated 48% increase in the number of older people not receiving the help they need since 2010.

The CQC argues that health and care services are working at full stretch and that staff resilience is not inexhaustible. It is hard to escape the conclusion that standards in many services are likely to fall in future as a result of continuing financial pressures. Support for this view can be found in evidence by Simon Stevens, chief executive of NHS England, to the House of Commons Health Committee on the day the report was published. Stevens warned that low levels of funding growth for the NHS in the next two years would result in deteriorations in care, a reminder if one were needed of the dangers that lie ahead.2

Challenges for NHS, government, and CQC

The challenge for the NHS arising from CQC’s assessment is to learn lessons from the experience of NHS trusts that are performing well even in the face of financial and operational pressures. According to the CQC, the characteristics of acute hospital trusts that have improved care include strong leadership, engaged staff, cultures that empower staff to improve care, a shared vision, and an outward looking approach. There is more work to do to embed these characteristics in all NHS providers to ensure that patients receive the best possible care.

The challenge for the government is to find a sustainable solution for the future funding of adult social care, described by the CQC as “one of the greatest unresolved public policy issues of our time.” The promised green paper on adult social care provides an opportunity to tackle this problem if the will exists within the government to examine all the options and to move beyond the sticking plaster solutions like the Better Care Fund that have so far failed to deliver.3 A good starting point is the report of the Barker Commission, which laid out the hard choices on tax and spending that need to be confronted in securing sustainable funding for the future.4

The challenge for CQC is to use the intelligence and understanding it has acquired to support improvements in care and not just to hold up a mirror to how services perform now. It also has more work to do to assess the performance of local systems of care as well as the organisations providing care. Its observation that high quality care is delivered when services are joined up around the needs of people reinforces the importance of work to integrate care through implementing the NHS five year forward and sustainability and transformation plans.5

Continuing to give priority to the development of these new care models will not be easy when so much management and clinical time is focused on reducing financial deficits and meeting waiting time targets. The CQC’s warnings about the perilous state of some services could have the unintended effect of strengthening the focus on these operational matters at the expense of work to transform care. Securing the future of health and social care depends on doing things differently, not doing more of the same a bit better, and leaders at all levels have a responsibility to make sure this happens. This must include providing additional funding to sustain services while options for the longer term are explored in work on the green paper.

 

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Here is an idea to fix the NHS: let’s get rid of GPs. Lets see how Scotland’s GPs vote…Dementia is going to overwhelm all our services, including our GPs unless we address reality…

Well, he might not realise it but we are already doing just what Philip Johnson advocates. What with waste and duplication, the inability to live with any uncertainty, and the patients expectation of excellence for minimum contribution, we are ensuring that GPs either retire, leave or get ill. Litigation, complaints, bullying, threats, denial and disengagement are all part of the everyday GPs life nowadays…. Getting rid of GPs is the last thing Scotland is suggesting, and their proposition is to reduce the workload  (December 6th in GPonline: Voting begins on new GP contract for Scotland) . If staff are appointed by Trusts, the salaried GP service will not be far behind, and patients will really see inefficiencies then.. Dementia is going to overwhelm all our services, including our GPs, unless we address reality…

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Philip Johnson writing in The Telegraph opines: Here is an idea to fix the NHS; lets get rid of GPs

If a former head of the Civil Service can’t run a hospital trust, isn’t it time to face up to the reality that the whole system needs reforming?

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…

An “exit interview”? Lord Kerslake was ‘asked to resign’ as NHS trust chairman two days before he quit

Another Christmas of crisis for the NHS

Scottish GPs quitting practices in record numbers

The Scotsman 13th November: Minimum £80k pay for Scotland’s GPs under new contract

Helen Puttick in the Times 14th November: Future of out-of-hours surgeries in doubt after new contract for GPs

Volunteers driving 4x4s queue up to help NHS staff get to and from …

More than 75,000 sign petition calling for Richard Branson’s Virgin Care to hand settlement money back to NHS – Anger grows at reported £328,000 payment to business tycoon’s private healthcare company

The Guardian today 15th December: The state of social care shames us all

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.

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There are many more doctors in the rest of Europe, compared to Wales

NHSreality has long pointed out the deficit in provision of medical school places, the gender bias which means there is less continuity of care, and that graduate entry to medical school would help to correct this. There are still many applicants who are disappointed, mainly undergraduate men, and all should now be given the chance to qualify as a doctor. Doctors do prefer to live in areas with good schooling, and this also needs addressing…. especially in Wales.

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David Williamson in Walesonline December 11th reports: The shocking figures which show how many more doctors the rest of Europe has compared to Wales  There are almost twice as many doctors per person in Austria than Wales.

Shocking figures have revealed how poorly staffed the Welsh NHS has become compared to the rest of Europe.

Wales has fewer GPs than other European countries – including impoverished former Soviet states in Eastern Europe.

There are just 2.8 doctors per 1,000 people in the UK, compared with 3.9 in Spain, 4.3 in Norway and 5.1 in Austria, according to the OECD.

The OECD research shows that the former Communist states of Estonia and Latvia have better provision of doctors per 1,000 people, at 3.4 and 3.2, respectively.

Plaid Cymru says the figure in Wales is just 2.75 per 1,000 people.

Doctors per 1,000 people

OECD

Dr David Bailey, who chairs the BMA’s Welsh Council said more GPs were needed.

He said more training places for young doctors were vital.

He: “Those who train in Wales are more likely to stay here in the longer term.

“We have repeatedly called for an increase in the number of doctors trained in Wales as part of the solution to tackling recruitment challenges.

“The bottom line is that we need more doctors in order to offer patients a safe standard of care.”

The Patients’ Association and the Charities should challenge, and define what is happening in the courts… Crawley: NHS “not rationing” hospital treatments and operations.

Denial in the Shires. Of course the Health Boards / Trusts / Commissioners cannot admit to the “R” word. They are “prioritising”, “restricting”, “reducing”, “limiting”, and “excluding”, different services for different people in different post-codes in different years. So no citizen can find out what, consistently, will NOT be available in his or her area of the country. Ask a retired consultant or GP or Nurse, or Physio in an exit interview whether Rationing is happening and they will almost all say yes. But there are no exit interviews… If policy does not conform with delivery, we have a collusion of denial. This is why the health service staff are disengaged. We need honesty in use of the English language before we can progress, so NHSreality calls for the Patients Association and the Charities together to challenge and define  what is happening in the courts… They may find GP commissioners, infuriated at the current “rules of the game“, help them in their case, and want to change them.

Joshua Powling reports for the Crawley Observer Friday 8th December: NHS “not rationing” hospital treatments and operations. 

Hospital operations and treatments for West Sussex patients are not being rationed, according to health chiefs.

Government reforms put clinical commissioning groups (CCGs), which are led by GPs, in charge of planning and buying healthcare from 2013, but all three organisations covering West Sussex are in special measures in part due to financial deficits.

The three CCGs are part of a new regional NHS initiative called clinically effective commissioning, which looks to standardise policies for when patients should undergo certain treatments and procedures.

According to a recent West Sussex Health and Social Care Committee (HASC) report, the aim of the project is to make sure commissioning decisions across the region are consistent, reflect best clinical practice, and represent the most sensible use of resources.

But last Friday James Walsh, vice-chairman of the HASC, asked: “What exactly is being proposed? Is this some form of rationing or delaying treatment?”

He explained that rather than dealing with statistics, they were talking about patients who had problems, many of which interfere with their daily lives.

Geraldine Hoban, accountable officer for the Horsham & Mid Sussex CCG and the Crawley CCG, explained the changes were bringing in more consistent thresholds for treatment.

She said: “We are not doing this for arbitrary reasons or to save money. This is based on up to date clinical evidence.”

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She added: “This is about people having procedures which we do not believe adds the clinical value they need.“It’s not rationing, it’s about adhering to the clinical evidence.”She went on to outline the ‘significant financial challenge’ facing the healthcare system in West Sussex, and how these changes were taking place before ‘we starting making some difficult decisions about difficult services’. They also found that previously some procedures had no formal policy, while in others such as orthopaedics activity the area was a significant outlier.

Other revisions were required were policies did not improve outcomes or patient experience. So far the clinically effective commissioning programme is split into three tranches. The first two have been reviewed by all the CCGs and updated where necessary in line with National Institute for Health and Care Excellence guidance.

Changing the rules of the game

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Third way for Scottish GP contracts?

Margaret McCartney opines in the BMJ (2017;359:j5628) : Third way for Scottish GP contracts? 

The proposed Scottish GP contract is clearly intended to shore up doctors and support primary care, and there’s much in it to like. It effectively underwrites premises so that younger GPs won’t be dissuaded from joining a practice that owns its buildings. It includes a minimum income expectation for 40 hour full time GP equivalents, some 20% of whom in Scotland earn less than the proposed minimum of £80 000. It contains impressive statements on the link between workforce morale and patient experience and says that not all patients need a doctor’s expertise to be treated. And help is promised through pharmacists and physiotherapists stepping in and up, as well as nurses and receptionists being trained to do more. It reads as though GPs, taking on the role of expert medical generalist and team leader, will become quasi-salaried. The critical issue for me is this: health boards, under the new contract, will be responsible for managing the team to which the GP provides clinical leadership. Some of this may make sense, and district nurses and health visitors in my area have long been employed by the health board. But it’s also a recipe for fractured relationships. Morale comes, often, from team support. Make the team a group of temporary, ever moving players, and we lose that sustenance and create administrative mess. A team of regular district nurses whose coffee cups are stored in the tearoom, who know the staff and patients, is a different proposition from a team who can’t offer

patients continuity of care (and who don’t know what the octogenarian down the road likes—or what she’s usually like). Another big issue with the contract is its reliance on advance care planning to reduce admissions despite large uncertainties about whether this is possible. My fear is that GPs will continue to fill the gaps created around work that others don’t take on—and that we may have little choice in what that work is. It’s striking, and impressive, how well some other professionals have laid out what they can do and what resources they need to do it. I don’t think that GPs, as a group, have ever articulated this well enough. I can see two futures. One is where GPs see the most complex patients, filling in workforce gaps where needed and doing lots of paperwork. The second is where we become salaried and clearly define what it is that we do and what resources we need. As it stands, this would inevitably lead to waiting lists for GP appointments. What about incorporating another way—a rigorous and bottom-up identification and exclusion of the administrative and system waste that GPs don’t need to do? I have little doubt that the will to make a good contract is there. But, as proposed at present, we retain responsibility without necessarily the resources to discharge it. Margaret McCartney is a general practitioner, Glasgow

margaret@margaretmccartney.com Follow Margaret on Twitter, @mgtmccartney

In Wales they really can waste money: £68m unveiled for health and care hubs

BBC News reports 6th December: £68m unveiled for health and care hubs

The profession will not see this as positive. It marks the beginning of the end for self employed GPS. It is probably a waste of money, and it is part of the direction of travel, where fewer and fewer people have access to the expertise needed when they are ill. Differential diagnosis, risk analysis and safety netting are all part of a Drs training, and in the case of GPs, living with uncertainty so that good gatekeeping ensures minimal waste. These GP “Geese” who laid those golden eggs are not here now….

But it may be attractive to part time GPS with families often married to other doctors.

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ITV News 6th December covers the initial reaction of the profession: Plans for 19 new health and care centres…..

…Dr Charlotte Jones, chair of the BMA’s General Practitioners Committee says she’s concerned about the lack of involvement of local clinicians:

Whilst we welcome improving access to services closer to people’s homes, it’s difficult to assess the impact this will have without knowing the intricacies of how it will work. It’s concerning to us that the initial reaction from LMC members suggests that they haven’t been involved in the design of the scheme.

It’s vital that local clinicians, who understand the needs of the local community, are involved in service design to ensure that patients receive the services they deserve.

As part of the work to improve access to local services, investment is desperately needed to ensure the GP estate is fit for purpose. Robust premises strategies must be developed, with the full involvement of LMCs. – Dr Charlotte Jones, Chair GPC Wales

Dr Ian Lewis reports 26th November in Walesonline another money spend, mostly from charitable fund raising, which will cut out the GP. By deskilling the GP how does society gain? This is the opposite of utilitarianism. (Greatest good for the smallest number) and brings back the suggestion of the Court Report in the 1970s#; A child health centre in West Wales could be created 20 years after it was proposed – The venture has been in the pipeline for almost 20 years and is estimated to be worth £2.5million

Just as there wont be enough Doctors, there won’t be enough care homes. There are many opinions, but NHSreality fears that Wales is pouring money into a number of buckets which have holes in them. There are just not enough trained people: GPs, Nurses, Physiotherapists, Psychologists, OTs, Psychotherapists, Radiologists, Anaesthetists, you name them…

Mark Smith reports in Walesonline 4th December: The Welsh care homes under threat for not meeting standards – Care homes in Wales are under threat of being suspended or de-registered

BBC News 21st September: NHS reform can cut costs, says local council leader

BBC News 4th December: Cash ‘ploughed into NHS’ preventing change, AMs warn

BBC News 5th December: Welsh Government ‘sticking plaster’ on health services

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After promising to clone GPs, and failing, Mr Hunt promises to “make” more radiologists… Importing them will block our own for years. Exporting films abroad is an option…

The strict and high standard training of radiologists has been threatened by cutbacks, just like GPs. Numbers have been insufficient for years, and although “Intelligent computerised reading” may reduce the numbers needed in the longer term, but short term there is a terrible risk. Will patients be asking for their X rays to be read by a consultant, and if this is not possible in their DGH then they should ask for the films to be read privately… The result of long term under capacity rationing is here and now: a two tier health service. Trusts who insist patients who go privately are put at the bottom of NHS waiting lists might have a problem with patients already admitted to hospital. Will they send them home again? Instead of recruiting from abroad, and blocking our own youngsters from Radiology careers, the films should be sent abroad pro tem. (Commissioning export?)

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The Times December 5th reports: Hunt promises 300 more radiologists for NHS England

The NHS will take on 300 more radiologists in England, Jeremy Hunt, the health secretary, has said. The pledge is part of the Cancer Workforce Plan, intended to tackle what one charity called a “crisis in the diagnostic workforce”. Another 200 clinical endoscopists, who use tiny cameras on flexible tubes to investigate suspected cancers inside the body, will also be appointed. It is hoped that the new staff will be trained by 2020, according to Health Education England.

Mr Hunt said: “We want to save more lives and to do that we need more specialists who can investigate and diagnose cancer quickly. These extra specialists will go a long way to help the NHS save an extra 30,000 lives by 2020.” However, the all-party parliamentary group on Cancer said that NHS England would “struggle” to achieve ambitious plans to improve cancer care. John Baron, the chairman, said that the cancer strategy was in danger of being derailed and added: “Corrective action now needs to be taken.”

They dont really care – they have known about the shortage of Radiologists coming for decades..

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

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