Category Archives: Professionals

Midwives are right to revisit received wisdom on what counts as a ‘normal’ birth

Mothers are having fewer children later. This makes them more high risk, and most sensible ones will have whatever form of delivery gives the best chance of a normal child. 

Born Free. Times leader 12th August 2017: Midwives are right to revisit received wisdom on what counts as a ‘normal’ birth

For an event so natural that none of us can avoid it, the business of childbirth has become an unfortunately ideological battleground. Since the 1960s advocates of “natural” birth have been pitted against defenders of medical intervention. The assumption, driven in part by advice from midwives, has been that a natural birth is somehow superior. In an interview with The Times today Cathy Warwick, chief executive of the Royal College of Midwives (RCM), acknowledges that her profession has got the emphasis wrong. There are great benefits to birth without interventions, but they should be pursued in a way that is sensitive to every woman’s situation, not as an article of faith.
For 12 years the RCM, midwives’ professional and representative body, has campaigned, as a matter of policy, for births where the mother enters and completes labour without medical intervention. Avoiding epidurals, forceps, artificially induced labour or a Caesarean section, the RCM argued, was better for mother and child. Yet that orthodoxy has been criticised, on two grounds. First, it can take a psychological toll on mothers. Those who ask for medical intervention because of their own anxieties or past experiences, are often left feeling as if they have failed. The RCM has sensibly decided to scale back the use of value-laden terms such as “normal birth” in favour of more neutral phrases like “physiological birth”.
The second, and more trenchant criticism of old habits is that they risk putting patients in danger. There is some evidence to support this charge. In 2015 an inquiry into a catalogue of unnecessary deaths in a Morecambe Bay hospital found that midwives’ pursuit of normal childbirth “at any cost” was, in part, behind the failures.
James Titcombe, who brought the scandal to national attention after the death of his son, has warned that the pressure for a delivery without medical intervention is rooted not in concern for patient safety, but in ideology. There have been concerns, too, about the role that midwives’ prejudices may have played in a string of deaths at Shrewsbury and Telford Trust.
None of this means that more intervention is always better, or even that it often is. There is value in a physiologically natural birth — the touch of a mother’s skin to her child’s in the moments after delivery helps to build a bond; a profusion of tubes, doctors and medical instruments does not. Caesarean sections come with well established risks. Mothers are vulnerable to the complications of any major surgery, and researchers have found some evidence that babies born this way are more likely to suffer from asthma and obesity in later life.

However, parents are well able to understand these risks and come to a considered view on what is best for them. The dangers are greatest, in any event, when interventions are emergency measures, taken after the failure of a “normal” birth. Better that midwives speak openly and neutrally about the benefits and risks of epidurals, inductions and Caesarean sections, well in advance, to avoid eleventh-hour panics.
Healthcare in Britain mostly compares favourably to that in other countries. Childbirth, however, is the exception. Britain has among the highest infant mortality rates in western Europe. That is all the more reason for midwives to eschew ideology and focus instead on what will work best for mothers and babies.

Mums, you have a 1:200 risk of stillbirth – what can you do about it?

The long term results of rationing midwives and doctors in training…

Rationed to dangerously low levels – “..Nine in 10 of the biggest NHS trusts are below safe staffing levels”.

The collusion of denial of rationing by politicians and administrators continues. Caroline Wheeler reports in The Sunday Times 13th August 2017: Nurse numbers dangerously low – Nine in 10 of the biggest NHS trusts are below safe staffing levels

This is the result of rationing places in nursing to save costs over a short time horizon (4 years or one term of office). The longer term loss of money due to inefficiencies and diminishing standards does not concern today’s politicians. In my own constituency the MP won by a few hundred votes, and is likely to lose the seat next time. An “honest debate” is what the public wants, but all parties are denying them… It does not help that Nurses are “graduates” as the caring side of personal care is excluded from their jobs as they get more senior. And now we are threatened with fewer immigrant nurses…So, it’s going to get worse.

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Nearly all England’s 50 biggest hospital trusts are failing to hire enough nurses to ensure patients are safe.
Nine in 10 of the trusts, which oversee 150 hospital sites, are not meeting their own safe staffing targets, according to analysis by the Royal College of Nursing (RCN).
The data also suggest nurses are being increasingly replaced by cheaper, unqualified healthcare assistants.
To cope with the shortage of nurses, more than half the largest hospitals (55%) brought more unregistered support staff onto shifts, the figures show. The situation is worse at night, with two thirds (67%) of hospitals using unregistered support staff — which critics claim will lead to higher patient mortality rates.
Janet Davies, chief executive and general secretary of the RCN, said patients can pay the “very highest price when the government encourages nursing on the cheap”.

She added: “Nurses have degrees and expert training and, to be blunt, the evidence shows patients stand a better chance of survival and recovery when there are more of them on the ward.”
A separate study of staffing in NHS hospitals, published in the online journal BMJ Open, found that in trusts where registered nurses had six or fewer patients to care for, the death rate was 20% lower than where they had more than 10.
Hospitals have had to publish staffing levels since April 2014 in response to the scandal at Stafford Hospital, where hundreds died from neglect.
The RCN analysis, which calculates the average fill-rate across the month, reveals the worst affected site was the Royal Blackburn Hospital, which had on duty only three quarters of the nurses needed.
According to the RCN there are 40,000 nurse vacancies. Brexit, low morale, the end of bursaries for tuition fees, and the public sector pay freeze have all been blamed.

The Department of Health said: “Just this month we announced an extra 10,000 places for nurses, midwives and allied health professionals by 2020, and there are over 12,500 more nurses on our wards since 2010.”

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Comments are legion at the Sunday Times. Here is one..

Stephen G Spencer letter by e-mail

With the culture of bullying so prevalent, pay held so that salaries today are worth less but nurses expenses like others have gone up, and a plainly mad Secretary of State and Department of Health that thought doing away with nurses training bursaries was a good idea, together with all those nurses from EU countries worried about the implications of Brexit for them and their families. No surprise at all. But quite worrying if you do have to go into hospital.

A nation choosing to have fewer children, and to import fewer workers for the health and social care services. It does not stack up.

We are a nation choosing to have fewer children, and to import fewer workers for running the health and social care services. It does not stack up.

Things have to get worse unless we export our elderly for warehousing abroad, or they are managed by robots.Image result for nuclear family cartoon

Fay Schopen reports in the Guardian that “IVF was stressful enough even before this new post code lottery. (NHSreality points out it’s not new and is only getting worse and more unfair as predicted)

Fay is paying for private care and pints out the two tier system which is the national effect of current policy.

Ironically, the Economist points out that fewer women in the west are choosing fertility. More and more have either one or no children. Is society getting compassion fatigue for those who choose to have large ffamilies?

The Rise in Childlessness is available in the Economist 27th July but also below.

Childlessness – Economist

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Change the Rationing of Infertility treatments from covert to overt: Schools should tell girls to try for a baby before 30, says fertility expert – and prospective professional be warned..

Patients suffer in GP funding lottery. Anger and civil unrest to follow?

You never knew it was “unavailable” until you needed it.. and then it’s too late

Women denied IVF as 80 per cent of NHS trusts ration fertility treatment

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NHS must cut waste if it wants more cash and NHS “must put it’s house in order before demanding more cash”.

It’s going to get worse though, despite this report. When the professor writes a report without mentioning rationing we know what will happen to it… Writing a report from the provider side will only emphasise that it is not “patient centred”, but government centred. The bureaucracy is unable to change without the rules of the game being changed.. Mental health is a case in point, where desperation has led to a promise of more money, but what will suffer as a result?

(Judge warns of ‘blood on our hands’ if suicidal girl is forced out of secure care

 

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Chris Smyth in the Times 4th August reports: NHS must cut waste if it wants more cash

The NHS does not deserve more money because it wastes so much on poor care, according to the senior surgeon who has the job of driving up standards.
The health service must put its house in order before asking for extra taxpayers’ cash, said Tim Briggs, who is conducting the most comprehensive clinical efficiency audit of the NHS yet undertaken.
His review found huge variations in the cost and quality of common treatments, with low-performing hospitals routinely ignorant about superior methods adopted elsewhere.
The NHS could save hundreds of millions, if not billions, a year if the best and most efficient practices were applied across the country, Professor Briggs concluded.
His programme is backed by the health secretary, Jeremy Hunt, who urged hospitals yesterday to act on the findings, as well as Simon Stevens, the head of NHS England……

Specialists in each area gather data from hospitals then sit down and discuss individual results with clinical staff in each unit, learning from the best and helping poor performers improve. “Just putting it in a drawer and forgetting about it is no longer an option,” he said.

Profile: Tim Briggs
After a long and distinguished career as a hip and knee surgeon, Tim Briggs admits that he is out of his comfort zone as a crusader for NHS clinical efficiency (Chris Smyth writes).

Yet the former Blackheath rugby forward does not flinch from tackling colleagues.

A consultant at the Royal National Orthopaedic Hospital since 1992, Professor Briggs grew used to seeing patients with complications caused by botched surgery. It was obvious not everywhere was doing as well as they could.

In 2012 as the president-elect of the British Orthopaedic Association, he gathered data on all orthopaedic units, visiting them to discuss their results. It is this, he insists, that makes the “getting it right first time” programme different from the plethora of audits the NHS has seen come and go.

Times leader: Healing the healers.

The British love the National Health Service, but it is in a mess. It was built in the 1940s for a different kind of country. Now it largely looks after a bulging population of the old and chronically ill, and is constantly short of cash. Reform is urgently needed but it has been too slow to arrive. A troubling new report is likely to drive this point home to doctors and health officials. It was overseen by a respected and straight-talking orthopaedic surgeon, Tim Briggs, and was backed by the health secretary, Jeremy Hunt. The report, on general surgery, part of a much broader review led by Professor Briggs, finds the NHS is wasting a great deal of money.

It says that 300,000 patients a year are needlessly admitted for emergency operations, and £23 million wasted on patients staying too long in hospital after bowel surgery. Some hospitals are paying much more than others for surgical supplies, and varying infection rates for hip replacements (between 0.2 per cent and 5 per cent, depending on where people go) cost the heath service £300 million. Hospitals tend to have no idea what others are doing and are surprised when told that they are behind their peers. In sum, Professor Briggs told The Times: “I do not think at the moment we deserve more money until we put our house in order.”

This argument has some merit. Professor Briggs’s report is the latest in a line of government reviews which have pointed out that there is money down the back of the sofa. In 2014 the NHS England chief’s Five Year Forward View found room in the health service for £22 billion in efficiency savings by 2020. In his 2015 report the former Marks and Spencer boss Lord Rose of Monewden concluded that the health service was “drowning in bureaucracy”. And last year a report by Lord Carter of Coles said that hospitals were wasting £5 billion on paying too much for supplies.

The NHS response has been glacial or nonexistent. But its problems are not unsolvable and it has a number of correctable design flaws. There is political pressure not to run deficits but little to invest in innovations, which means that smart new ideas do not often travel from one hospital to another. Hospitals are paid per operation so they are not inclined to cut back. Separate budgets and commissioners for different sections of the NHS (such as preventive healthcare and specialist hospital care) mean ideas that might move money from one to another are often resisted. No single person holds responsibility for smoothing out variations across the health service. The matter can therefore slip under the radar.

Any changes will require considerable political clout. The Department of Health has yet to recover fully after the botched reforms under Andrew Lansley, Mr Hunt’s predecessor. While other public services such as the police have spruced up their technology and adapted to changing needs, the NHS has remained in deep freeze. It should summon the confidence to drive through the reforms that a modern health service urgently needs.Professor Briggs’s project suggests that matters may be moving in the right direction. It is not just a data-gathering exercise — his team take their results from hospital to hospital, talking through how each health centre compares with its peers. Professor Briggs claims that a similar initiative from 2012, on orthopaedics, is now yielding good results.
The health service is not alone in its problems. It shares them with most of the world’s healthcare systems. This year’s Commonwealth Fund survey found Britain’s health service to be the best, safest and most affordable of the 11 countries that it analysed. The NHS is also one of the biggest organisations on the planet. The pace of change, however, need not be so languid. Certainly it will continue to require more cash, but first it must show that it can spend that cash wisely and efficiently.

Changing the rules of the game

Who will be the “last man standing” in your practice? Changing the rules of the game

NHS funding advice: GDP worth debating… Showers of money will not work..

When will public anger over the NHS reach a political tipping point? More NHS mental health patients treated privately…

in 1983 another eminent Orthopaedic Professor reported: His advice was taken at first, fond to be more expensive and then ignored. Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres The difference between Hospital Infection rates is nothing when private hospitals are added to the mix. Instead of a 50 fold difference in infection there is a 500 fold difference in risk of infection.

 

A first city GP service implodes. Being a GP is too stressful to do full time, say trainees

When I started work as a GP I did 9 sessions working Monday to Friday in routine surgeries with one half day exchanged with my partner. We also covered our own patients in the evenings and at weekends. and we delivered 50-60 babies per annum. After a few years the doctors combined in an Out of Hours rota (OOH) as a co-operative which was run from the local hospital. This was the high point of my on call career, with cooperation and teamwork three doctors could cover 120,000 people when formerly there had been 30 doing personal on call. The OOH system was demobbed, and the new “Blair” contract allowed us to opt out of OOH. By now many of the newer GPs had young families, and the benefits of no OOH were obvious. The cost of running OOH with locums became too much and salaried posts were created. Nowadays we have too few doctors and paramedics covering vast numbers of patients and in the rural locations vast areas. 

Meanwhile, since Mr Blair’s new contract, the working day has become more intense. GPs often don’t stop for lunch, or coffee breaks, and engineering time for their own health or families is hard. A 12 hour working day is commonplace. More than this, the shape of the job has changed. Where I had flexibility in 1979 and could do other things at times during the day, there is now no time flexibility, and 10 hours fixed to a computer screen is unhealthy, and leads to sarcastic patients who expect and complain more….

Rationing places in Medical School means 9 out of 11 have been disappointed for years. Now Portsmouth is the first city to implode, and its going to get worse.. It takes 10 years to train a GP…

 

Chris Smyth reports in the Times 3rd July 2017: Being a GP is too stressful to do full time, say trainees

Only one in ten trainee GPs wants to work full time, according to a survey that raises fresh fears of a shortage of doctors. The average family doctor-in-training wants to work three days a week, saying the job is too intense to do a full five days.

Waiting times are already lengthening and health chiefs fear that a national GP shortage will be worsened as younger adults shun the long-hours culture of previous generations.

One in five junior doctors training to be GPs also says they do not expect still to be working in the NHS in five years, according to a survey by Pulse magazine of 310 trainees. Doctors are planning either to move abroad or to change career, according to figures that cast further doubt on government pledges to recruit 5,000 extra GPs by 2020.

Officials are trying to recruit 2,000 doctors from abroad after numbers in the NHS dipped despite rising demand from an older, sicker population.

Simon Stevens, head of NHS England, has pointed to an increase in GP trainees as an encouraging sign, but only one in ten surveyed wanted to work the eight half-day sessions considered full time, with a further tenth willing to work seven sessions.

All GPs should be signed off work for stress, argue GP leaders | News …

NHS has the west’s most stressed GPs, survey reveals | Society | The …

GPs get £20m scheme to help them cope with stress | Society | The …

Nine in 10 GP practice staff find work life stressful, poll finds | Society …

Inquiry into the GP workforce in Wales | National Assembly for Wales

£20,000 trainee GP offer to boost doctor recruitment – BBC News

22,000-patient practice forced to close over GP shortage – Carolyn Wickware  in Pulse 2nd August 2017

Neil Roberts in GPonLIne: Entire city’s GP services almost ‘unviable’ as 22,000-patient provider quits

Patients in same street get different NHS care. Neighbouring surgeries provide sick with different levels of care.

 We need to go back to Aneurin Bevan and re-examine the fundamental reasons for the UK health services. We all pay under the same tax regime and should have universal fair and equal access, but this does not mean rationing out some services is impossible.
Rationing by post-code exclusion, covertly, and in a way that means patients are unaware of the lack of cover until they need it is morally wrong.
The only fair way is overt rationing. Since technology will continue to outstrip the states ability to pay there will also be some low volume high cost treatments we have to ration or exclude. Our system needs to be good enough, and with short waiting lists, so that these conditions are as few as possible.
Identity cards giving access to health care, and at the same time tax codes, could be used to create differential co-payments. These might be accepted if the standards were high, there was meaningful choice, and if waiting times were low. The opposite is true at present, and the under capacity looks to be getting worse.
The result of training too few of our own, and importing form abroad is disillusion. Short termism in political thinking has led to a crisis which will get worse and result in two tiers of health: state and private and the dishonesty has disengaged the professions. This is exactly what Aneurin Bevan wished to avoid.

Kat Lay and Tom Wills, Times Data Team report in the Times 3rd July 2017: Patients in same

street get different NHS care

Patients are facing a lottery of services from GP surgeries even within the same postcode, a Times investigation has found.

People attending different GP practices in the same building face huge variations in waiting times for the same procedures, the analysis shows.

Choosing one practice over another could influence whether it is possible to have a baby after fertility treatment, or mean waiting five weeks longer for knee surgery, according to the study.

The Times data team analysed the addresses of all English GP surgeries and found 120 pairs within 500 metres of each other that were governed by separate clinical commissioning groups (CCGs), the GP-led bodies that decide what the NHS will pay for locally.

Many had identical postcodes and all are thought to accept patients from the same or overlapping areas, but provision varied wildly within the pairs.

Some of the starkest variations occurred in fertility treatment. At the Museum Practice in Camden, north London, patients can have three cycles of IVF. However, 327 metres away, patients at Covent Garden Medical Centre would be offered only one. The discrepancy occurs because of different policies followed by Camden and Central London CCGs.

Infertile patients at Bawtry Health Centre, near Doncaster, will be offered three cycles of IVF, but patients at Mayflower Medical Practice in the same building will be offered two.

Waiting times for treatment can also vary, in some cases by months. In Birmingham, Modality Attwood Green is on the second floor of the same building as Bath Row Medical Practice, which is one floor down.

Bath Row comes under Birmingham South and Central CCG, where patients requiring general surgery face an average wait of 12.4 weeks. Modality Attwood Green is governed by Sandwell and West Birmingham CCG, where the waiting time for general surgery is 7.4 weeks.

On Stroud Green Road, in Finsbury Park, north London, the Stroud Green Medical Centre and the 157 Medical Practice are a few doors apart. The former comes under Islington CCG, with an average 11.8-week wait for general surgery, the latter under Harringey CCG, where the general surgery wait is 7.4 weeks.

A spokesman for the Royal College of Surgeons said: “It will no doubt surprise and anger people to discover that patients visiting GP practices in the same building, or indeed very near by, could have different access for surgery . . . Commissioning groups must investigate why their waiting times are so much longer than their neighbours.

John Kell, head of policy at the Patients Association, said: “Expecting patients to have the understanding of the system needed to navigate these complexities, for instance by choosing a GP practice based on the CCG it sits under, is obviously ridiculous.”

Chaand Nagpaul, chairman of the BMA’s GP committee, said that the “arbitrary drawing of lines on a map” to create CCGs had led to “a serious and unfair postcode lottery”.

Under the Health and Social Care Act 2012, CCGs are responsible for paying for the NHS care of any patient registered at any of their member GP surgeries, but can set their own policies on what they will fund.

Susan Seenan, chief executive of the Fertility Network UK charity, said: “This highlights how utterly unfair access to NHS fertility treatment is in England. An individual’s choice of GP practice should not determine the medical help they will receive and yet, this is what is happening: if you register with one GP you will have a chance to have a baby with IVF, but if you’re unlucky enough to choose another practice you will not.

“Sadly, not all patients realise that their choice of GP practice can determine whether they receive fertility treatment or not, or how much clinical care they receive.”

Under a “capped expenditure process”, local NHS leaders have been told to consider further cuts. Measures could include extending IVF limits or increasing waiting times for elective surgery.

Julie Wood, chief executive of NHS Clinical Commissioners, said that commissioners had to take into account the needs of the local population and their finite funding so it was “right and inevitable” that there would be variation in provision. She added: “We appreciate this can be difficult for some patients, and particularly sharply felt when relating to neighbouring areas.”

Behind the story
Most patients choose their nearest GP but few realise that this can influence which treatments the NHS might offer (Chris Smyth writes).

When people use an NHS hospital, the bill is sent to their GP’s clinical commissioning group. The groups control £77 billion of NHS cash, deciding what care they will pay for.

Created by Andrew Lansley’s reforms in 2012, GP-led commissioning groups were meant to allow doctors to use this clout to tailor services to their patients’ needs. Yet an NHS squeeze has meant that cost control has become an ever-bigger part of decisions. Stories abound of CCGs cutting back on fertility treatment, curbing surgery or restricting care for the obese and smokers.

Few patients shop around for a group with a favourable approach to fertility treatment, for example, but they have that right. They are entitled to register with any GP, providing the surgery is willing to accept them. Treatment decisions would then be taken by that practice’s CCG. The right to choose a GP for reasons other than proximity is not widely exercised, but some may soon feel it is worth their while.

Everything for everyone for ever for free?

The Reality on recruitment: we need more of whoever, whenever, wherever …..

The “reality” in the current position for staff shortages in health is summarised by “we need more of whoever, whenever, wherever …..” It is interesting that the BBC reports questions its feasibility.. Language issues in Wales do not help, especially related to schooling. We are reaping the harvest of long term covert rationing of medical school places. All students with the required grades and abilities should be allowed to do Medicine..

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Kat Lay in the Times reports 31st July 2017: NHS drive to recruit 21,000 mental health staff ‘not realistic’

The NHS will create 21,000 mental-health posts by 2021 in an effort to ensure that psychological conditions are treated as seriously as physical health problems.
The drive will tackle a “historic imbalance” in workforce capacity, the government said. The new staff will include nurses, therapists, psychiatrists and support workers.
Medical schools will be asked to treat psychology A levels as of equal merit to “pure” science subjects, in an attempt to boost recruitment of young people with an interest in mental health.
Ministers have promised £1 billion of investment to provide round-the-clock care every day of the week, treating an extra million patients by 2020-21.
Doctors’ and nurses’ representatives questioned whether 21,000 extra staff was a realistic target, with NHS vacancies growing…..

…Analysis
Promising an extra 21,000 staff in any area is a big ask for the NHS (Kat Lay writes). Last week figures revealed at least 86,000 vacancies had been advertised across the NHS in the first three months of the year, up 10 per cent from the year before.

Jeremy Hunt admits the figure is “ambitious”. However, a deadline of four years’ time is difficult. As Janet Davies, of the RCN, points out: “If these nurses were going to be ready in time, they’d start training next month.”

A lot of the factors that have driven staff away have not changed. There is the 1 per cent pay cap, but also an increasing workload. Brexit is making Britain less attractive for EU doctors and nurses and visa restrictions are hampering efforts to recruit from elsewhere. Parts of government beyond the Department of Health will need to co-operate.

The BBC reports: Reality Check: More mental health staff for the NHS? and the following day

From Tuesday 1 August, most new students of areas such as nursing, midwifery and physiotherapy will no longer be able to apply for grants, and will have access instead to the student loans system