Category Archives: Professionals

This is the future for the next decade: fewer GPs and more distant access to all medical skills if you live in rural areas. Breakdown of many systems. Private Health options pending..

There are, according to the Daily Mail, over 10m people who are short of their normal GP service. This is an inexcusable dereliction of duty in a civilised society. Poor manpower planning, poor politics, unequal educational opportunity and standards, and poor funding are responsible, along with the decentralisation of control (devolution) in a system where doctors are free to move. Don’t forget that, as it implodes, you can go abroad for treatment.

You still have the option of private care, and as one doctor explains he knows that the queue-jump goes against everything a mutualised service stands for.

The Nuffield Trust reports on the uncertainties which will follow after Brexit. Staff shortages, drug supply chain problems, are just two. The structure of Social Care may break down as it is dependent on overseas staffing. But whatever shortages there are now will be worse after Brexit. GPs are an international commodity and can take their skills overseas. Most of the former British Empire and Commonwealth countries are also short of GPs, so there is a ready market waiting for newly qualified, or disillusioned GPs.

This temptation to move abroad also applies to consultants whose pension rules make it unproductive for them, however keen they are, to reduce waiting lists. James Phillips for Professional Pensions reports: Pensions tax issues leading to longer NHS waiting lists

The Kings Fund reports on the Health and Social Care system, and its threatened breakdown.

In my own area there is no “choice” (West Wales, Hywel Dda) so that if someone needs a “greenlight laser” they will not get referred. Older fashioned TURP (Transurethral resection of the prostate) has far more side effects and is far more intrusive, with slower recovery times. Consultants in Hywel Dda will not refer for this treatment under the Welsh Health Service, as the money would move with the patient and Hywel Dda would lose cash. There are plenty of other examples of improved care but they are always concentrated on cities, and rural citizens will get them less. In England, provided patients are prepared to wait and to travel themselves, “choose and book” (e.g. Cumbria) allows them access. This does not apply in Wales.

Yes, it would be a good idea to recruit retired GPs, and many like myself would help out, but there are issues around medical indemnity and speed, and most of us would want to see the system founded on a financial rock rather than the quicksand of today.

John Hebditch reports from Aberdeen: Warnings of GP crisis as Abderdeen GP surgery will shut its doors next week.

and also Nearly 60% plan to cut hours and 25% to leave in near future.

Retired doctors urged to relieve rural NHS recruitment crisis

North-east medical practice to close after GP recruitment issues

17 overseas medics offered jobs at Shropshire’s A&Es

150 new medical staff taken on by Shropshire hospitals trust

Call for emergency meeting on Shrewsbury GP surgery closure

Shrewsbury GP surgery closure to affect thousands

Manchester Evening News July 4th.

People across Greater Manchester say they struggle to get GP appointments; “It really is a disgrace for those who genuinely need to seek medical advice urgently”

The Nuffield Trust reports: How far do the NHS’s financial problems really go? The bottom line: Understanding the NHS deficit and why it won’t go away

I still get e-mails advertising jobs in other countries with far less bureaucracy, more clinical freedom, and less intense time pressures, and a far greater income. It is this we are competing with. The only answer is to agree with all our G8 countries that we train more than enough doctors.

Queue jumping – The view of a GP David Wrigley in the Independent 2017

Going Abroad NHS

There is still little Private Practice option in General Practice, but this will change. As delays for serious symptoms become intolerable and all the ruses the experienced use to gain access fail, Private GP, like Private Dentistry will emerge..

A Private GP or a paramedic? Paramedics to replace north Wales’ GP home visits

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

Read the damning nature of this joint report.. GP shortages …. Our very own post-code lottery.

Private Medical Insurance options… Going to get more popular? Our leaders show us the way.

A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.

 

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care? 

The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.

Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…

Image result for honest politics cartoon

BBC News reports 4th July: Social care: Hunt and Johnson urged to consider NHS-style free service

Public Service Executive reports: Peers call for NHS-style free social care system and an extra £8bn to tackle funding crisis

and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”. 

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

New and higher taxes will never solve the problems of health and social care…

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”…

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Nov 2016 NHSreality: NHS funding and rationing: The debate (and the denial) intensifies… It’s going to get worse..

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..

A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)

Image result for honest politics cartoon

 

 

The “Economist” acknowledges health rationing, but does not recognise that it is covert…. More and more anger to come.

How long will the UK citizens put up with untruths? How long will it take for the proper debate to begin? The Economist recognises rationing, Enoch Powell in “A new look at Medicine and Politics” recognised rationing in 1966. We cannot go on without knowing what (for us) will be unavailable. It is surely a human right to be able to plan for your own health, your family’s health, your death, and illnesses. No wonder citizens are getting more and more angry..

If we want to win the cooperation and hearts and minds of medical staff we need to find out the truth about what they think. BMA conferences full of retired and burnt out doctors may reject the “long term plan” but there is no link with the doctors at the coal face.

Image result for angry patient cartoon

Not only is devolution a failure (certainly in Wales) but the 4 different systems allow different language of obfuscation, different methods of rationing, and outcomes. The anger will be the same.

The East Anglian daily Times shows how angry and dissatisfied the citizens are becoming. If you multiply the figures up over 200 health staff are attacked daily in the UK.

NHS GPs Economist 0619 Whats up Doc June 2019

Enoch Powell 4 Supply and Demand – Rationing  Minister of health for 3 years 2nd Edition 1974

Toni Hazell 28th June in GP mag: Here are two potential problems with primary care networks.  Huge hurry, and who takes responsibility?

Andrew Papworth reports 30th June 2019 in the East ANglian Times : “NHS staff aren’t punchbags”: Shock as six workers a day attacked in Suffolk by patients.

BMA ARM: Doctors spurn NHS long term plan

NHS patients ‘face more treatment rationing since coalition restructuring’

Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

Image result for angry patient cartoon

Image result for angry patient cartoon

 

Methods of rationing in 1966. Warrington shows that we have since invented many more….

A new look at Medicine and Politics: chapter 4 –  J Enoch Powell 1966. We have invented many more since Enoch Powell’s day, and the latest from Warrington is how rich or poor you are…

The answer for this post-code lottery is for GPs to send all their patients elsewhere. Since the money moves with the patient, Warrington and Horton will get none.

https://www.sochealth.co.uk/national-health-service/healthcare-generally/history-of-healthcare/a-new-look-at-medicine-and-politics/a-new-look-at-medicine-and-politics-4/

METHODS OF RATIONING

The preceding pages have been devoted to examining how the medical profession is affected by the system that has been adopted for the purchase by the state of a certain quantity of medical care outside the hospitals. That quantity, as already explained, is indirectly fixed by the remuneration the state offers, which determines in the longer run the number and quality of those contracting to provide that care.

Thus, outside as well as inside the hospitals the figure on the supply side of the equation is fixed at any particular time by those complex forces that determine the state’s decisions on expenditure. With this figure demand has to be brought into balance. Virtually unlimited as it is by nature, and unrationed by price, it has nevertheless to be squeezed down somehow so as to equal the supply. In brutal simplicity, it has to be rationed; and to understand the methods of rationing is also essential for understanding Medicine and Politics. The task is not made easier by the political convention that the existence of any rationing at all must be strenuously denied. The public are encouraged to believe that rationing in medical care was banished by the National Health Service, and that the very idea of rationing being applied to medical care is immoral and repugnant. Consequently when they, and the medical profession too, come face to face in practice with the various forms of rationing to which the National Health Service must resort, the usual result is bewilderment, frustration and irritation.

The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. This is not possible where its very existence has to be repudiated.

In the hospital service probably the most pervasive, certainly the most palpable, form of rationing is the waiting list. The waiting list is a complex phenomenon in itself. One component can be likened to a reserve of working materials: if the hospital resources are to be continuously used, there must be a waiting list. The simplest case is that of a consultant available (let us suppose) during a two-hour session. If there were no queue in the out­patient waiting-room, there might be gaps between one consultation and another when the consultant would not be productive— not, at least, in that sense. So it is always arranged that there shall be plenty of people waiting when the great man arrives, so that there is no danger of the expensive mill even momentarily lacking grist. Similarly, if the capital and resources represented by operating theatres and their staffs are to be intensively used, there must be, so to speak, a cistern from which a steady flow of cases can be maintained.

This element of the waiting list is only incidentally a rationing device, though even here time is serving as a commutation for money: a consultant in private practice can accept the dis­continuity of work implicit in a good appointments system, because his patients are in effect buying his waiting time as well as his consultation time or, putting it another way, the patient finds his own time worth more to him than the consultant’s.

Waiting lists, however, normally exceed the minimum related to full employment of the medical resources. They are then directly rationing in their effect. For example, they ration demand for the more able, experienced or celebrated advice and treatment compared with the less: the waiting lists of consultants in the same department of a hospital can differ greatly in length. It is sometimes said that consultants regard a long waiting list as a status symbol and preserve it with the same care and pride as an Indian would a string of scalps. Certainly, consultants are very possessive about their waiting lists. But the taunt is as uncomprehending as it is uncharitable. There has to be some differential rationing for different qualities of an article, and if not price, then, for example, time: better surgeon, longer wait, and vice versa. No wonder consultants, family doctors and patients too resist equalisation of waiting lists, which would mean that rationing by time would have to be replaced by some even less rational or intelligible form of rationing, such as rotation or the initial/letter of the surname.

Generally, the waiting list can be viewed as a kind of iceberg: the significant part is that below the surface— the patients who are not on the list at all, either because they are not accepted on the grounds that the list is too long already or because they take a look at the queue and go away. Naturally, no one knows how many these are. Indeed, the very question is rather absurd, as it implies some natural, inherent limitation of demand. But the part of the iceberg above the water is doing its work, directly as well as indirectly, by attrition as well as by deterrence.

It might be thought macabre to observe that if people are on a waiting list long enough, they will die— usually from some cause other than that for which they joined the queue. Short of dying, however, they frequently get bored or better, and vanish. Here again, time on the ‘waiting list is a commutation not only for money— measurable by the cost of private treatment with less or no delay— but also for the other good things of life. It is an interesting phenomenon of the waiting lists for in-patient treatment that at the holiday season and around Christmas time it may be necessary to go quite far down a lengthy waiting list to get patients willing to accept the long-awaited treatment in sufficient numbers to keep even the temporarily reduced hospital resources fully employed.

I  cannot  but  reflect sardonically  on  the  effort  I  myself expended, as Minister of Health, in trying to ‘get the waiting lists down’. It is an activity about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to ‘strafe’ the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity— otherwise it would lengthen —but of a backlog which, once ‘cleared off’, ought not to be allowed to recur.

Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca, tamen usque recurret: though you drive Nature out with a pitch­fork, she will still find her way back.

In a medical service free at the point of consumption the waiting lists, like the poor in the Gospel, ‘are always with us’. If at any moment of time they do not exist, they have to be re-invented, or rather they reproduce themselves effortlessly and automatically. Ministers come and Ministers go: the hospital service spends a rising fraction, or it spends a falling fraction, of the national income; but the ‘waiting list at 31st December’ in the Ministry of Health’s annual reports still stays the same, a reliably stable feature in an otherwise changing scene. On New Year’s Eve 1959 it was 442,519; on New Year’s Eve 1960 it was 475,643; I962, 474,353; 1963, 470,297; 1964, 475,863; 1965, (oh dear!) 498,972. And what had it been, pray, on New Year’s Eve 1951, back in those early, primitive days of the National Health Service? Why, 496,131.

At the same time, Ministers of Health are broadly truthful when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. For one thing, ‘urgent’ and even ‘critical’ are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the ‘urgent’ cases, seen or treated at once, and the ‘non-urgent’ cases on the waiting list— or, as the case may be, not on the waiting list at all. The latter are squeezed down— or off— by the former. To point to the fact that no ‘urgent’ case goes untreated as evidence that supply and demand can be brought into balance without rationing is like arguing in a famine that because nobody dies of starvation, there need have been no rationing system.

A  DOUBLE  STANDARD

In the last resort the waiting list, or the queue in the general practitioner’s surgery, is one aspect of rationing by quality. In the days of the reform of the poor law and abolition of outdoor relief for the able-bodied, this used to be known as the principle of ‘lesser eligibility’. What are called the ‘deficiencies’ of the National Health Service— the large number of patients per general practitioner, the age and quality of many of the hospital buildings, and so on —are not deficiencies in the literal sense of the word, that the service falls short to a measurable extent of an objectively definable standard. They are those consequences of the quantity and quality of medical care being purchased by the state that help to equate the demand with the supply. The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service.

This is why it is absurd to declaim against a ‘double standard’ of medical care, inside and outside the National Health Service respectively. The standard inside is that which balances demand with the amount supplied by the state; the standard outside is that at which the supply and demand for medical care balance in the market, given the existence of the National Health Service. The standard in question is not necessarily one of purely medical treatment, if indeed the purely medical aspect of care can be divorced from the others. For example, it may well be that a patient acutely ill or gravely injured may be treated as skilfully, efficiently and safely in a National Health Service hospital as in an expensive private hospital or ‘nursing home— often, I would guess, more so. But the paradox is capable of rational explanation. The ancillary aspects of medical care— amenity, privacy, attention in convalescence, a degree of freedom, choice and individual self-assertion—may be valued no less than the essentials that affect life and limb. Indeed, they are sometimes valued more highly, surprising though that may seem. There can also be an element of pride, prejudice, snobbery— call it what you will— that values the identical article more highly when it is purchased than when it is received gratis.

The principle of lesser eligibility has always been applied, cannot help being applied in some form, wherever provision is gratis. It was applied before the National Health Service started in the voluntary and municipal (ex-poor law) hospitals and, indeed, from the beginning of time wherever medical care was rendered free at the point of consumption. Since eligibility is a form of rationing, we naturally find that it, like the waiting list, is also used to establish an order of priority. This is the reason why, for instance, the geriatric and long-stay mental hospital wards are, and have always been, the most ineligible in the service. The priority accorded to the demands of acute illness requires that rationing be applied more severely to the chronic.

Two instructive contrasts outside the National Health Service will illustrate the rationing function which lesser eligibility performs in it. One is the striking contrast between the two forms of old people’s accommodation: the workhouse and the new-style old people’s home. The former was designed to meet a legally unrestricted duty to admit; the latter corresponds to a discretionary and highly discriminating right to admit or not to admit. Consequently the poor law institution had to ration by ineligibility, and still in practice does if it continues to exist, while the new-style home explores ever-rising standards of amenity and care under the shelter of a rationing system of a different kind. Similarly, the paradox of the relatively high standard of the subsidised local authority house, although it is subsidised, is explained by the fact that the demand is tailored to the supply by the discretionary waiting-list itself, and consequently the supply can be rendered in a relatively eligible form.

Parkinson’s Law

The fact that the necessity for these covert forms of rationing springs from the very nature of the National Health Service and not from any particular level of supply attained in it is borne out by ‘Parkinson’s law of hospital beds’, which asserts that the number of patients always tends to equality with the number of beds available for them to lie in. Thus, the ratio of hospital confinements to total births ranged in 1965 from as low as 53.8 per cent in East Anglia to 78.4 per cent in Wales—the national average   was  69.8  per cent. Yet the pressure on maternity accommodation was at least as high in the latter part of the country as in the former. Again, the number of hospital beds for acute disease in the North-West of England is almost twice as great as in the South-East: in 1961 there were 3 per thousand population in East Anglia against 5.6 in the Liverpool region. Yet the pressure of demand, as evidenced, for example, by length of waiting lists, shows no comparable variation. There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting.

It is unfortunate that the nature and the value of rationing by waiting and by ineligibility in the National Health Service are not recognised, at least by the professions. For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidences of ‘inadequacy’ and as blemishes that it lies within the power of politicians to remove, given the insight and the will.

Martin Bagot in The Mirror updated 2yh June reports Warrington’s plans to charge 20K for a hip replacement. It would be cheaper and safer to go abroad.

 

 

Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding? If we don’t keep the gatekeeper role for GPs the system will get constipated.

A recent report in the Times (Not on line) opines “Gatekeeping by GPs called into question. This is not new, as you can see from the debate following Matthew Paris’ article in 2015. The problem is not referrals, but the 90% who do not need a referral. Allowing others, less trained in dealing with uncertainty, will lead to more referrals, longer waits and a constipated system. The useless 111 service where there has seen no reduction in GP workload is another attempt to wriggle off the hook of under capacity and poor manpower planning. In his Imperial College funded report, Geva Greenfield and others report: “Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding?”.

One solution is to make patients pay for their GPs and let them have appointments free with the nurses and paramedics. A two tier system by design. Lets see the comparisons in referral rates, expense and survival!! The result would be anarchy.. (sic) Geva Greenfield says “There is a trade-off that needs to be found between GPs serving as hgatekeepers to secondary care, and at the same time allowing patients to see a consultant when they wish”. We are trying to treat patients, and the governement are treating populations. Money matters, and the services are all rationed. (covertly)

Image result for money and NHS cartoon

Image result for money and NHS cartoon

This is the sort of thinking “outside the box” of current opinion that we have to get to talking about openly.

On November 26th 2018 Chris Smyth reported in the Times: Bypassing GPs could help to diagnose cancer sooner

In Pulse 2015: GPs should give up their Gatekeeping Roles

Matthew Paris on June 16th 2012 reported in the Times: GPs – little more than glorified receptionists

In this age of medical specialisation, if family doctors didn’t exist we wouldn’t feel the need to invent them

Next Thursday, family doctors plan to strike. Striking doesn’t suit the profession’s humanitarian image. Interviewed, doctors’ leaders struggle to insist (on the one hand) that nobody needing medical attention will be denied it, without implying (on the other) that few will suffer if doctors aren’t there.

How much, though, would we suffer? If family doctors had not existed, would we today have found it necessary to invent them?

We pay general practitioners more than we pay airline pilots, but they are becoming glorified gatekeepers: a portal to the more specialist medical care that our health service offers in growing measure. As GPs have receptionists, so the NHS itself uses GPs as its receptionists. Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?……..

……..Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The response June 18th 2012:

Sir, Matthew Parris (Opinion, June 16) is not quite correct in describing GPs as “becoming glorified gatekeepers”. We have already had that role (among others) for decades.

It is true that part of this role is to refer to secondary care, but he seems to miss the corollary of this; that we also judge when not to refer, thus saving patients, and the country, the burden of over-investigation and over-treating. The internet has expanded everyone’s access to specialist knowledge, but has not, perhaps, increased our ability to apply that knowledge appropriately. We know more, but understand less.

Mr Parris also fails to acknowledge that GPs have a vital role in the other direction of travel; from specialist care to the community. In this past week I have picked up the care of patients after their discharge from heart by-pass surgery, psychiatric in-patient treatment, dermatology, gynaecology, child autism and palliative care clinics.

In addition, we need to manage patients whose symptoms and conditions cover several specialties, as well as those who have exhausted all secondary care investigation without any diagnosis being reached.

“A decent grasp of the whole thing” is exactly what GPs need.

Dr Jonathan Knight
GP, Ipswich

Sir, Matthew Parris assumes that his interaction with his GP is typical of the work that GPs do. I have been working in general practice since 1987 and my experience is very different. We spend most of our time managing long-term illness such as high blood pressure, diabetes, kidney disease and asthma. When I was in training in the 1980s these conditions were managed in hospital but are now managed mainly in primary care. Of course I do not profess to be an expert in everything so I may refer to colleagues for opinions about aspects of a patient’s care, but they are then usually discharged to my care.

Allowing less-qualified health professionals to manage patients has never been shown to be more cost effective than using GPs.

It is this system of every patient having a GP, enshrined in Bevan’s original vision for the NHS, that other health systems around the world have strived to emulate. We should not discard it lightly.

Steve Charkin
London NW3

Sir, Matthew Parris says that he believes he could refer himself appropriately to a specialist, but he is not our typical patient. GPs’ time is predominantly taken up with the very young and the elderly, particularly those with chronic, complex and multifaceted medical conditions. For these folk, it is their GP who sees the “big picture”, the context and impact on the individual and their family, while each specialist focuses in on his own area of expertise. Approximately 90 per cent of healthcare needs are met in the community, by GPs and their practice nurses, with only 10 per cent of care being hospital-based, at far greater expense. It is true that a GP’s role includes “gate keeping” access to expensive specialist opinion, but I would suggest this is essential.

As Mr Parris concedes, most GP consultations do not lead to a referral to a specialist. His vision of a future without GPs to manage the majority of our health concerns would be financially unsustainable and bewildering to many. Would a woman with lower abdominal pain and back ache refer herself to a gynaecologist, urologist, gastroenterologist, oncologist or orthopaedic surgeon? Does she need a specialist at all if it is just a urine infection? How does she know?

While a single day of industrial action will cause no more inconvenience than the extra bank holiday for the Diamond Jubilee, Mr Parris belittles our role at his peril.

Dr Isabel Cook
Reading

Sir, Before getting rid of GPs Matthew Parris might be wise to wait until he is a bit older when he may have to see more than one specialist at the same time. He will find that the treatment for one condition often aggravates another and he will then be grateful for a generalist’s opinion. He will also find it more efficient to keep seeing the same GP so that he does not have to keep repeating his past history.

Dr Richard Stott
Epsom, Surrey

Sir, As a GP I know Matthew Parris is right. A lot of what GPs do is pointless or could be done by others. So there is a simple solution: stop giving us work.

John Booth
Middlesbrough

Sir, There is overwhelming evidence that GPs deliver highly effective, cost-effective care to our patients. Moreover, we do so with the trust of our patients, and with care and kindness.

I invite Mr Parris to sit through a surgery with me at any time, where he will see first hand how GPs care for the elderly, the frail, the disadvantaged and the ill. I’m sure that afterwards his perceptions of general practice will be different.

Professor Clare Gerada
Chair of Council, Royal College of General Practitio

 

Dont have a stroke in Scotland. Tribalism leads to another cause of rationing.

Preventing a stroke by keeping fit, not getting diabetes, and keeping the blood pressure down is all very well. But it means that we still have strokes, only older. The cost of looking after a stroke victim is long term, and beyond the time horizon of our politicians. On the other hand, treating strokes early fairly and universally will cost money, and in the immediate future. By saving the lives of stroke patients there should be a long term saving on health and social care costs, and a patient may well succumb to a different illness eventually.

If you think treatment and support is bad in Scotland, its even worse in Wales! Regional rationing, some of it from tribal causes…

Helen Puttick on June 12th reports from Scotland: Stroke patients miss out on vital treatment as doctors prolong row

Infighting between hospital doctors threatens to block access to a life-changing treatment for stroke patients in Scotland, it has been claimed.

Relationships among specialists in Glasgow have soured to the point that psychologists are needed to improve workplace culture, a report concludes.

They were expected to help introduce a new treatment, thrombectomy, which can spare stroke patients lifelong disability by swiftly removing blood clots from the brain. NHS England is spending £100 million implementing the procedure, but plans to introduce it in Scotland have not been published.

The only Scottish hospital to have performed the procedure was Edinburgh’s Western General, but it was never a routine service and last year was withdrawn because of a lack of specialist staff and funding. About 600 patients could benefit from the procedure, but in 2017 it was performed 13 times.

It is understood that personality clashes between doctors and prolonged periods of sickness have resulted in disruption in Glasgow. A report, obtained by The Times via a freedom of information request, has revealed that a history of tension has made it difficult to attract and retain specialists, known as interventional neuroradiologists (INR).

It says: “Poor collaboration and discord have impacted on recruitment into the INR service in Glasgow and could compromise introduction of a thrombectomy service. Ongoing monitoring of behaviours in the Glasgow service is required and appropriate mentoring/coaching put in place to enable the service to move forward.”

Jane-Claire Judson, chief executive at the charity Chest Heart & Stroke Scotland, said: “People who have missed out on a thrombectomy in Scotland will be angry at this news. Any discord and delay must stop; everyone needs to work together to put stroke patients and their families first.”

Insiders have expressed frustration at the time it is taking to develop thrombectomy services in Scotland.

The report says: “At the present time, in common with many parts of the UK, there is not capacity within the current consultant interventional radiology workforce within Scotland to provide a mechanical thrombectomy service. However, there is ongoing engagement with national bodies to determine if other specialty consultants can be trained in this technique.”

A spokesman for NHS Greater Glasgow and Clyde said: “Staffing issues, skills shortages and relationships have been at the core of the challenges facing the service. The aim of these actions is to provide enhanced clinical leadership, effective teamwork, collaboration and communications and this is already having a positive impact.

“Our recruitment process is progressing and we are optimistic of recruiting a third consultant very soon.”

Eight-hour A&E waits on the rise
Hundreds of patients have been stuck waiting in Scottish emergency departments for more than eight hours with long delays hitting the highest level for the time of year since records began (Helen Puttick writes).

The latest figures show that 313 patients queued for over eight hours in the week to June 2, with 75 stuck for 12 hours or more.

The proportion of patients seen within the Scottish government’s target time of four hours has dropped to 88 per cent, the lowest figure for early June since weekly data was first released in 2015.

Edinburgh Royal Infirmary, where 63 patients spent more than eight hours before being admitted or discharged, had some of the worst delays.

The figures released by NHS Scotland yesterday also showed that there were long waits at Wishaw General and Hairmyres hospitals, which are both in Lanarkshire.

Waiting times tend to drop in the warmer summer months.

August 14th Eric Sinclair comments in letters:

Sir, As a stroke survivor, I was angered and depressed to read that thrombectomy for stroke patients in Scotland is to be further delayed, not just by Scottish government bureaucracy but by the workplace culture among Glasgow clinicians (“Stroke patients miss out on vital treatment as doctors prolong row”, Scotland edition, Jun 12). The cabinet secretary for health promised action on thrombectomy by May this year. This has not happened.

Now, apparently, the workplace culture among some clinicians is preventing progress. This is nothing short of scandalous. Thrombectomy is a procedure that every year could avoid the unnecessary blighting of hundreds of lives by severe disability. It has the potential to save the NHS and social care millions of pounds. It is being invested in heavily in the rest of the UK and around the world, yet there seems no apparent urgency by the Scottish government to make this procedure available to Scottish patients who suffer a stroke.
Eric Sinclair

Aboyne, Aberdeenshire

ITV News 18th June: Charity warns of “desperate need for support” for stroke survivors in Wales

 

The firm: does it hold the answers to teamworking and morale?

The BMJ The firm: does it hold the answers to teamworking and morale? (BMJ 2019;365:l4105 )

Rotations and shift patterns mean that junior doctors often struggle to feel part of a team. Some want to bring back the “firm” way of working. But is this feasible, and was the firm really part of a golden age for trainees, asks Abi Rimmer

In the discontinued “firm” system—a model of medical apprenticeship—groups of doctors worked together to provide patient care.

Firms generally had at least one permanent member, a consultant, who led the firm and after whom it was named. Some four of five trainees of varying seniority weren’t permanent members of this firm, but they belonged to it, and for many it was a consistent source of professional and emotional support.1 The quality of education and training that trainees received, however, varied.2

The firm’s demise came after 2005 when trainees began rotating more frequently under the Modernising Medical Careers programme. From 2009 European working time regulations shortened doctors’ working hours. Junior doctors spent less time on the wards and their involvement in teams became far more transitory.

But many doctors would like to see the firm reinstated, seeing it as an answer to today’s problems of disenfranchisement and low morale among junior staff.

The cause of all the mayhem

When the firm functioned well, says the Royal College of Physicians (RCP), it provided “a structured development process, role modelling of professional behaviour, mentoring, and a good balance of challenge and support.”2

Harold Ellis, a retired professor of surgery who qualified in 1948, describes his firm as being like a family. In a firm, Ellis tells The BMJ, there would be one or two consultants known as “the chiefs,” a senior trainee known as “the registrar,” a junior trainee known as the “house physician” or “house surgeon” who lived in the hospital, and medical students……

Re: The firm: does it hold the answers to teamworking and morale? Reply 13th June 2019

Firms would wither in this age of individualism.

Firms that thrived in past had a wise head leading it; collective responsibility was cherished and self sacrifice was applauded not derided.

In firms, good and bad decisions had ownership and learning from mistakes is encouraged without a sword hanging over the head.

But the firms of the past would not survive the current “age of individualism”. Now individual rights reign supreme without even a symbolic nod to group responsibility. Good firms place patient needs first and hence is incompatible with a clock watching culture.

Today:

Re: Consequences of losing firm: true or false ?

Having had surgical training between mid – 80s and early 90s in traditional firms led by a consultant and supported by senior registrar, registrar and house surgeons (senior and junior) and following completion of the training , worked as a consultant till date, has given me an opportunity to appreciate the gains and losses incurred under both schemes. In all honesty, both systems have their inherent advantages and disadvantages, and both are not perfect. When one speaks to trainees of current system, they favour the present system of training with shift system as this is thought to be more humane and safe in comparison to the past system which included long hours of on calls (24 hours on week days and 72 hours on the weekends) with potential risks to the patients and doctors from lack of rest and exhaustion. Lack of continuity of patients care and incomplete connection with the patients and team are the major barriers to comprehensive training in the current system. However, eight years of structured current surgical training programme (core and specialist training) with well described curriculum and objective examinations (MRCS and FRCS) on completion of stipulated training, is at par with surgical training schemes internationally, including USA and Australia, as far as I am aware. It must be acknowledged that NHS in UK is under financial constraints and its repercussion as reflected by the reduced number of staffs (doctors and nurses) has significant implications on the workload of doctors, particularly the consultants, and the quality of training. It is important to assess issues surrounding the current training scheme and address them commensurate with the rapidly advancing science and technology in medicine.