Category Archives: Consultants

Consultants are at the highest point of their profession – or are they? What ambitions do they have and are they able to do research easily?
How does sub-specialisation fit in with keeping ones skills as a generic doctor? If those generic skills are lost, does it matter?
Should all consultants be in teams run by tertiary centres and with opportunities to go to the centre for updating?
Are the consultants in your local hospital happy they are there? Would they have preferred to be elsewhere? And how do they see management and professional standards changing?

The Hacking reveals a collusion of anonymity for responsibility for rationing…

Update 13th May 2017: Mark Bridge May 13th in the Times: Outdated technology offers easy pickings

As readers know NHSreality says there is no NHS, but a regional system. The rationing of services, and this includes IT, is the responsibility of the Trust Boards, and commissioning groups in England. An inability to provide the requisite upgrades to computer systems is a decision made at a higher level. IT managers, paid much less than those in the private world, are rewarded by job security (never get sacked), but they have failed to use their leverage and knowledge to force the changes needed. The debate would have been puerile, if it ever happened at all. On December 8th NHSreality posted: Hackers get easy route to patient data – still on Windows XP but we have no sense of sangfroid, only sadness. The Hacking reveals a collusion of anonymity for responsibility for rationing…

“The first duty of government is to keep the nation safe”. (Amber Rudd on Radio 4 this am) The Health Services are part of this safety, but the net has been holed in so many places, and the responsibility for errors leading to potential disasters such as this is missing. NHSreality predicts that no heads will roll, and the media will fail to find a scapegoat.

The good that may arise is that computer systems may be updated. GPs in Wales were in charge of their own systems and backup until 5 years ago. The Welsh Government took over the computers, put all the data in one central server, and connected to the periphery by BT lines . ( Virtual Private Networks ) I recommended to my own practice that we had our own independent back up system which would ensure that, if the government server failed, or the lines were sabotaged, that we could perform our daily work. My recommendation was rejected but the idea needs re-visiting, even though Wales was unaffected on this occasion.

There is so much evidence for rationing, not prioritisation when it is “all or none” as in IT. Here are some articles/news from the last 24 hours:

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Laura Donelly in the Telegraph: Thousands of children and teenagers with anorexia forced to wait months for help

Chris Smyth in the Times: Hospital backlog is worst for decade – A&E units had their worst year since 2003, with one in ten patients not being seen within four hours and Patients wait longer as GP jobs lie vacant and, initially reported in the Shropshire Star: Nurses ‘forced to buy pillows for patients’

and because of the rising anger even a cancer sufferer is standing against the Minister for Health: The Deathbed Candidate. Getting nearer and nearer to “posthumous voting” isn’t it?

Paul Gallagher opines in the Independent: General election 2017: what role will the NHS play among voters? and implies Theresa May is more trusted than the others…. but this was written before the latest Hacking.

NHSreality trusts none of the parties. They are all lying. It is only going to get worse. Patients are going to wait longer. (Personnel Today) More and more, those who can afford it, will go privately.

Health Reform – Rationing for rare and complex conditions is wrong, and against the concept of a “mutual”.

The debate is puerile. There is no addressing the real issues..

NHSreality on IT systems

Hackers get easy route to patient data – still on Windows XP December 8th 2016

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The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

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You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

Speaking up – Whistleblowing in the NHS – file on four. The profession needs a scapegoat – Mr Hunt.

Nothing has substantially changed since the Francis report – indeed the leadership of politicians was not referred to in the debate, making out that the lack of a proper lead in cultural change was needed from Management, when actually it is needed from Politicians. The only way to find out if Jamie Grierson is correct is to do exit interviews on all staff (like those in file on four), and have these done by an independent Human Recourses body. SOSR means “some other serious reason” and all whistle-blowers need to consider whether this might be attached to their file after spilling the beans. The admirable ideology of whistle-blowers contrasts strongly with the ideology of HR departments described in File on Four today. If 66% of doctors are under “serious stress” then the profession, and the public, need a scapegoat….. Mr Hunt will do as a sub for all the successive ministers of health. Civil unrest is likely without honesty. The current winter “murmurings” of starlings will become a riot of protest and discontent. One of the major reasons for a state to exist ;”keeping it’s citizens safe”, is failing…

Speaking up – Whistleblowing in th NHS – file on four and part of the report is from BBC Liverpool (Staffing ‘inadequate’ at Chester baby death hospital)

Dave Simonds 12/02/2017

This is reinforced by Jamie Grierson in the Guardian: NHS hasn’t improved enough since Mid Staffs, says inquiry lawyer

Robert Francis, whose report uncovered poor care in hospital trust, says pressures on health service generally are ‘pretty bad’

Current conditions in the NHS ”sound familiar” to those that existed during the Mid Staffordshire scandal, according to the lawyer who chaired the inquiry into the hospital trust.

Sir Robert Francis QC said the health service was being hit by a combination of financial pressures and high demand.

The barrister whose 2013 report uncovered poor care in Mid Staffordshire said the pressures the health service was under were “pretty bad”.

His remarks came after a week of scrutiny of the NHS, with performance figures showing a raft of missed targets and record waiting times, leading health secretary Jeremy Hunt to say conditions were “completely unacceptable”.

Francis told the BBC’s The Andrew Marr Show on Sunday: “I think they are pretty bad. We’ve got a virtual storm of financial pressures, increased demand, difficulties finding staffing, and pressure on the service to continue delivering. And some of that sounds quite familiar, as it was those were the conditions pertaining at the time of Mid Staffordshire.

“Things have changed since then, so the very fact that we’re talking about this today the way that we are, the very fact that the secretary of state says things are unacceptable, shows that there’s a greater level of transparency.

“So people are talking about the problems in a way that they weren’t before. But the system is running extremely hot at the moment and it’s only working at all because of the almost superhuman efforts of the staff of the NHS, and it can’t carry on like that indefinitely without something badly going, or risking going badly wrong.”….

NHS Surgeons kicking their heels as thousands of operations delayed.

Michele Hanson opines: We are a rich country that can afford to pay for proper care – so why don’t we?  and Why are GPs having to beg for appointments to get their patients treated in hospitals?

Matthew Weaver reports: A&E in England had worst delays ever in January, leak suggests – Provisional data shows an unprecedented number of patients spending longer than four hours waiting to be seen

Dennis Cambell reports: Two-thirds of young hospital doctors (Anaesthetists) under serious stress, survey reveals -Trainee anaesthetists complain of fatigue, disillusionment, ‘burnout’ and fears for patients’ safety as pressure mounts on NHS

Undercapacity leads to undersupply. When skills are valuable and in short supply they demand high payment, especially if working “overtime”. Which party believes in market forces? All parties have failed to control the supply in a market it commands completely?

NHS ‘pays £7.5m a year for 20 most expensive agency doctors’ – Watchdog says health service could save £300m a year if locums charged within set price cap, after data found some are paid £375,000 a year

Jeremy Hunt: NHS problems completely unacceptable – Health secretary says there is no excuse for some of health service’s shortcomings after figures show record delays for patients

One in six A&E departments at risk of closure or downgrade- As many as 33 casualty departments across the UK could be lost by 2021 in an attempt to save £22bn from the NHS’s budget

Alexandra Topping reports: Woman, 89, trapped in hospital for six months despite being fit to leave – University Hospitals Bristol NHS trust launches inquiry after lack of social care led to stay that cost health service £80,000

BBC News: 2000 NHS doctors call on prime minister to increase spending

Robert Pigott for BBC news reports: NHS Health Check: ‘Most staff have been attacked’, doctor says

Nick Triggle reports for BBC News: 10 charts that show why the NHS is in trouble

An “existential crisis”? – as civil unrest gets closer… 

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The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

A Times leading article alludes (correctly) that undergraduates are less value to the state than graduates who enter medical school. But Zawad Iqbal in “Doctors’ training needs streamlining before it’s too late” does highlight the problem of declining standards, and lowest common denominator medicine. The problem with the new GMC suggestion is that too low a standard may be deemed acceptable in order for us to have enough doctors in the short term. The fact that NHSreality would never have chosen to start from here is omitted. Long term rationing of medical school places, as well as too many undergraduates and too few graduates is to blame. A ten year program of capacity management may be undermined if we admit too many overseas doctors suddenly.. On the other hand, if the bar is set high enough… OK, I forget, nurses can do the job of a GP can’t they? NHSreality feels it is already too late, and it’s going to get worse… (Katie Gibbons reports from Kent: NHS operations postponed to save cash). Decommissioning is going to get worse still.

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In a letter to The Times 3rd Feb 2017 Prof Derrick Wilmot of Sheffield writes: on DOCTORS’ TRAINING..

Sir, A medical licensing assessment for doctors is long overdue (“Doctors face tough new test on basic skills”, Feb 1). There is a similar situation for dentists. A third of the dentists entered each year on the General Dental Council’s register qualified at an overseas university. UK graduates are not tested by a common examination but by the individual university dental schools, which do try, mostly with success, to maintain sufficient quality and commonality. Many of the overseas new dentists entering the UK come from EU countries and cannot be tested. Brexit is the ideal opportunity to introduce a new robust common assessment for all doctors and dentists registering in the UK.

Recent years have seen a frightening increase in medical and dental litigation. Evidence for an association is weak but if a basic clinical education is lacking problems surely lie ahead both for the practitioner and, more worryingly, for the patient.

Emeritus Professor Derrick Willmot of Sheffield University, and past dean, Faculty of Dental Surgery, Royal College of Surgeons: Doctors’ training needs streamlining before it’s too late

The news that thousands of newly qualified doctors aren’t confident enough to perform basic tasks such as taking blood is a real canary in the coal mine moment — a warning sign that the way we teach doctors urgently needs to change.

Part of the problem is that the basic structure of medical training hasn’t changed in more than a hundred years. The General Medical Council sets the standards for undergraduate medical education and supervises the training and education of students. But the content and length of a medical degree varies widely, depending on which institution you attend, and the different medical schools are allowed to set their own criteria for licensing doctors.

There is no common standard to practise in the UK. Doctors from the European Union can work here if they’ve passed relevant exams in their own country. Doctors from other parts of the world are given a separate test, resulting in a confusing system with no overall benchmark.

So it’s a relief that medical regulators now want to introduce a standard test. But that’s still some years away and frankly it’s not enough. We should seize the opportunity to conduct a bigger and more wholesale review of how we train our doctors and whether these decades-old methods are up to scratch.

What doctors needed to know ten years ago is often a world away from what they need to know today. Basic science and clinical science remain the core modules on medical courses but healthcare delivery is becoming ever more important. As well as introducing a common approach to basics such as taking blood samples and performing lumbar punctures, areas such as data analysis, IT skills and interpersonal ability must play a bigger role in medical training.

One of the biggest opportunities being missed is in postgraduate medical education. This is because postgraduate training falls under the NHS rather than a university or medical school. Our doctors need to keep learning new skills if they’re going to give their increasingly well-informed patients the best treatments. The doctor of the future will not necessarily carry a stethoscope around his or her neck but will more likely be one of a specialist team working alongside health technicians, pharmacists and nurses.

Rather than introduce a new standard test for doctors after they have qualified, they and their patients would be better served if medical schools standardised the courses they begin at 18.

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We must think the unpalatable to stop death of NHS, say doctors

Somehow the doctors say the truth without mentioning the “R “word. The problems are well outlined, but there is no  analysis of the short termism inherent in the system which underlies the crisis,  the political collusion of denial, and lack of courage: it is going to get worse.

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Sarah Kate Templeton reports 20th November 2016 in The Sunday Times: We must think the unpalatable to stop death of NHS, say doctors

More than 60 NHS consultants call today for a royal commission to consider every option, including “even the most unpalatable”, to boost funding for the health service.

The doctors say radical funding measures must be debated because standards of care are “increasingly poor by international standards”.

While they do not say where the additional funding should come from, they argue that all potential sources should be considered. These would include increased taxation, an obligation on patients to have a form of social insurance or charging for some treatments and services.

Almost all the signatories of the letter, which is published in today’s Sunday Times and in full online, are consultants working in the NHS.

The letter says: “Outcomes for many conditions are becoming increasingly poor by international standards. This means many unnecessary deaths for British patients from treatable conditions. It means higher infant mortality. It means more human suffering as medicines and treatments routinely available in most developed countries are withheld in the NHS. Waiting times for treatment in emergency departments, for the diagnosis and treatment of cancer and for surgery are lengthening.”

The letter demands “an honest and transparent debate that considers all options for increasing health spending” and calls on parliament to “establish a royal commission . . . to look at all the options, even the most unpalatable”.

Professor Karol Sikora, a cancer consultant and one of the signatories, said increased funding could come from taxation, patients having a form of social health insurance or a charge for some medicines and treatments.

“There are lots of models [of social insurance] in Europe. They are all different but they guarantee that everyone will have insurance cover to pay for what we would call basic NHS services,” he said. “It could be that you pay for certain services, co-payment.”

Sikora said many forms of co-payment existed or had existed in the NHS, including paying an NHS hospital for extra nursing care.

Social insurance would be a form of health insurance that individuals would be obliged to contribute towards, based on their earnings, to cover basic health services. Usually, the government would cover the contributions of the unemployed and elderly.

Co-payment involves NHS patients paying for treatments or services not available on the health service. In 2008 the government ended the ban on co-payment after this newspaper exposed how NHS treatment for cancer patients had been withdrawn after they paid privately for drugs that it did not fund.

The consultants’ letter follows a report last month by Owen Paterson, a former minister and founder of the UK2020 think tank, which found that 46,000 people died unnecessarily each year because the NHS failed to match the best international health outcomes.

A Department of Health spokeswoman said: “The NHS already has its own plan, designed by NHS leaders, which set out how we can transform services and improve standards of care . . . We are investing an extra £10bn per year in the NHS by 2020-21 . . . to do just that.”

The letter 20th November 2016:

ROYAL COMMISSION CAN CURE NHS
The NHS is in crisis! Doctors, by their nature and training, are not prone to exaggeration. But every day we see more evidence of crisis. We are not politicians but professionals trained to act in the interests of our patients. And we care.

The UK medical profession itself is in crisis. Young doctors are leaving the NHS in droves, either to practice abroad or to leave medicine completely. The recent junior doctor’s strike was born from the deep discontent that drives some of the brightest young people in the country to abandon years of study and commitment. And, at the other end of the profession, senior doctors are now retiring at the earliest opportunity. In some towns there are virtually no general practitioner partners over 55 and similarly, consultants are increasingly leaving the NHS. This is an appalling waste of talent, skill and experience and of the clinical leaders that the NHS needs. Just one generation ago these events would have been unthinkable. Doctors’ morale has deteriorated because of the appalling decline of the quality of patient care.

Outcomes for many conditions are becoming increasingly poor by international standards. This means many unnecessary deaths for British patients from treatable conditions. It means higher infant mortality. It means more human suffering as medicines and treatments routinely available in most developed countries are withheld in the NHS. Waiting times for treatment in emergency departments, for the diagnosis and treatment of cancer and for surgery are lengthening. Our hospitals are increasingly full of people who should be cared for elsewhere, either at home or in nursing homes. They occupy expensive facilities meant for acute care. These failures affect every family in the country.

We understand and accept that the NHS has to reform and use its resources as effectively as possible but while no healthcare system is perfect ours is increasingly failing the people who need it most. Outcome evidence suggests that it is increasingly failing by comparison with other similar countries. But while the reasons for this failure are complex, we believe fundamentally it comes down to money and use of resources. We now spend just 7% of the wealth the nation produces each year on healthcare. Most similar countries spend nearly half as much again and many far more. This amounts to tens of billions of pounds each year. While we applaud the optimism of the Five Year Forward View we worry that it will not deliver the £22billion of savings it promises and that it will necessitate cuts to local services that the public will find unacceptable and risk the quality of clinical care.

Virtually every healthcare expert in the country knows that the funding gap between demand and supply must be closed if we are to have the quality of healthcare we all want and if we are to retain the confidence of the medical profession and of the public. These funds can be raised from only three sources – taxation, insurance and cash. All healthcare systems use a combination of these sources. The deteriorating situation facing the NHS now necessitates that all of us, professionals, politicians and the public have an honest and transparent debate that considers all options for increasing health spending.

We call on Parliament to demonstrate the leadership required in a crisis and to establish a Royal Commission. Its remit would be to look at all the options, even the most unpalatable, for raising spending on healthcare in the NHS to levels that will restore it to once again become the envy of the world. Without this debate we will inevitably condemn the nation to increasingly poor healthcare. Without radical change the NHS will wither and die.

The NHS is in crisis. The first step is to acknowledge that this is the case. Failure to do so demonstrates a failure of leadership. Failure to hold the debate we ask for and indeed demand would amount to the same. All of us, senior members of the UK medical profession, ask you to display the leadership that is expected of you as our elected representatives and insist on the establishment of a Royal Commission to consider how to adequately fund and reform the NHS.

Charles Akle, Consultant Endoscopist; Jonathan Appleby, Consultant Anaesthetist; Georg Auzinger, Consultant in Intensive Care Medicine; Simon Bailey, Consultant Surgeon; Ian Beckingham, Consultant Surgeon; Jenny Bird, Consultant Haematologist; Mark Bower, Professor for HIV Malignancy; Nick Boyle, Consultant Surgeon; Jane Brown, Consultant Oncologist; Jacqueline Butler, Consultant in Emergency Medicine & Major Trauma; Jonathan Byrne, Clinical Director of Cardiovascular Services; Santiago Catania, Consultant in Neurophysiology; Shan Chetiyawardana, Consultant Oncologist; RN Clayton, Professor of Endocrinology; Chi Davies, Consultant Anaesthetist; Ann Drury, Consultant Clinical Oncologist; Albert Edwards, Consultant Oncologist; Mark Farrar, Orthopaedic Surgeon/Consultant Anaesthetist; Roshan Fernando, Consultant in Anaesthesia, Graham Fleming, Consultant in Trauma and Emergency Medicine; Andrew Gaya, Consultant Clinical Oncologist; Tom Geldart, Consultant Medical Oncologist; Ashley Grossman, Emeritus Professor of Endocrinology; Matthew Hacking, Lead Consultant Anaesthetist; Marcus Harbord, Consultant Physician & Gastroenterologist; Jamal Harisha, Consultant Surgeon; Clive Harmer, Clinical Oncologist; Catherine Harper-Wynne, Consultant Medical Oncologist; Adam Harris, Consultant Physician & Gastroenterologist; Michael Harvey, Consultant Upper GI Surgeon; Ian Holloway, Orthopaedic Surgeon ; Maxim Horwitz, Consultant Hand and Orthopaedic Surgeon; Tom Hurst , Consultant in Intensive Care, Major Trauma and Pre-hospital Care; Alberto Isla, Consultant Upper GI Surgeon; Cara Jennings, Consultant in Emergency Medicine; Sritharan Kadirkamanathan, Consultant Upper GI Surgeon; Scott Kemp, Consultant Anaesthetist; Hemant Kocher, Consultant in General Liver and Pancreas Surgery; Pardeep Kumar, Consultant Urologist; Michael Kuo, Consultant ENT Surgeon; Mark Lawler, Chair in Translational Cancer Genomics; Sara Leonard, Intensive Care Consultant; Nick Linton, Consultant Cardiologist & Electrophysiologist; Charles Lowdell, Consultant Clinical Oncologist; Gitta Madani, Consultant Radiologist; Katie McLeod, EM Consultant; Nigel Mendoza, Consultant Neurosurgeon; Julian Money-Kyrle, Consultant Oncologist; Amir Montazeri, Consultant Clinical Oncologist; Tariq Mughal, Professor of Haematology/Oncology; Ramesh Nair, Consultant Neurosurgeon; Asif Qasim, Consultant Cardiologist; Victoria Rose, Consultant Plastic Surgeon; Neil Rowson, Consultant Opthalmic Surgeon; Karol Sikora, Professor of Cancer Medicine; Matthew Solan, Foot and ankle surgeon; Margaret Spittle, General Specialist Oncology Consultant; Justin Stebbing, Professor of Cancer Medicine; Henry Taylor, Consultant Clinical Oncologist; John Timperley, Consultant Orthopaedic Surgeon; Sancho Villar, Consultant in Critical Care; Oliver Warren, Consultant Colorectal Surgeon; Mark Wilcox, Professor of Medical Microbiology; Ana Wilson, Consultant Gastroenterologist; Jonathan Wilson, Consultant Colorectal Surgeon; Crellin Perric, Consultant Oncologist, Andre Vercueil, Consultant in Intensive Care

PMI or private cover? Should GPs ask patients if they have private health insurance? Putting the patient in front of you at the centre of your concern – includes asking about attitudes to non state options..

“Would you like to discuss non state provided options?” This, or a similar question SHOULD occur more frequently in many doctor consultations.. in Hospital or the Community. It is only in emergency care that the private provision is lacking, and in cities this is changing..

It is concerning if a colleague rejects to offer or to even discuss or offer options outside of the Health Service locally. The first duty of a doctor (GMC) is to “put the patient at the centre of your concern”, and this makes no reference to the state provided health services. Your duty is not primarily to the state, and where the interests of the state and the patient differ, a doctors duty is to their patient. It may be a GP aware of long waiting lists, or an oncologist aware of treatment exclusions – and covert rationing.

And the patient has also got the choice to pay directly. Monthly payments of £300 amounts to nearly £12,000 over 3 years, which covers most joint replacements and a lot of physiotherapy. Just because somebody looks poor, or lives in an impoverished area, does not mean their doctor should assume that they have no savings or insurance. Increasing their options with an honest discussion could be good for their health. Telling the truth is a virtue – even if it includes saying a patient is obese.

Putting the patient in front of you at the centre of your concern includes asking about PMI  (Private Medical Insurance) or direct payment if the local service puts them at risk. It does not imply that the doctor makes the choice as to whether to use said insurance (what is the excess? )or to pay directly.

What is shameful is that for 60 years only 10% of the population chose to have PMI, but in the years ahead it may rise well above this, and a two tier system will become de facto.

If patients ask you for recommendations that is another matter. You might refer them to a broker, or to Benenden which promises to cover everyone (but with important exclusions including heart disease and cancer). Benenden advertises at £8.71 per month per person!

There is no harm in asking. The decision to pay is different to asking the question, and being honest about ALL the options is part of the duty of a doctor. You might also wish to point out the difference in the Perverse Incentives: to undertreat in the one system, and over treat in the other.

Fortunately, as yet, different Post Codes are not being charged different premiums, but they may be. Where there is less choice there should be more demand for private services (Wales) and premiums here may rise.

As communities realise the deficit in their potential care, they could group together. PMI is much cheaper for groups and communities. Perhaps a whole town may decide to have a policy. Once again this will favour the richer suburbs., and increase the health divide. But at least they would all know what was excluded, unlike todays covertly rationed health services.

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Charlotte Alexander asks in Pulse 27th October : Should GPs ask patients if they have private health insurance?

YES

I do not see anything wrong with asking patients whether they have private insurance if it helps to create some much-needed slack in the NHS. A recent scheme in Mid-Essex has seen private referrals increase by 6% since the start of the year, which suggests that health insurance is being underused. It may be that people forget to use it or have a ‘no-claims bonus’ attitude towards it, resulting in a pick-and-mix approach to the NHS. Whatever the reason, I do not think most would object if they were gently reminded that they could see the most senior person available more quickly if they did use their cover.

I know some people think this is an inappropriate way to try to save money, but with a dwindling pot can we afford to be so high-minded? Which is worse, trying to increase uptake of health insurance with those fortunate enough to have it, or having to save money by banning non-urgent procedures such as vasectomies, sterilisations and ear syringing?

Some people have said it puts unfair pressure on patients to refrain from using NHS services that are within their rights, but GPs could exercise judgment about who to ask. For example, for those who have used private healthcare before, it is not a huge leap to ask them whether they would like to again. Premiums may go up as a result, but the person will choose to pay it or not. It is not denying them care they are entitled to, it is offering them a choice to use NHS or other services, like the choice between a state or a private school for their children.

Some say that asking patients about their private healthcare insurance compromises the impartiality of the consultation. Actually, we already do that with the QOF, prescribing certain medications because they are cheap and having personal stakes in private companies providing NHS services.

People will also say that this approach lets the Government off the hook as it will continue underfunding the national system. This may be true, but what is the alternative when there is no extra money? While we are living in this time of unfettered corporatism and very high societal inequality I see nothing wrong with redressing this slightly by asking people to use their insurance if they can. The NHS is staggering under the weight of demand and cost cutting. Unless we do everything we can to preserve the cash flow, it won’t get up again, even after multiple infusions.

Dr Charlotte Alexander is a GP in Addlestone, Surrey

NO

On the surface, asking patients about private healthcare insurance may appear to be a positive move; I am sure I’m not the only GP who finds themselves apologising for ever-increasing waiting times for outpatient clinics and elective operations. However, not only are GPs constantly apologising for problems that are beyond our control, we are now being put in the difficult position of asking patients to forfeit the NHS care they deserve as much as the next person. This could potentially put the patient-doctor relationship at risk, and could even jeopardise a doctor’s ethical or moral standing if the patient disagrees with the principle.

It could be suggested that encouraging patients to use their private insurance will take pressure off NHS waiting lists by filtering some patients out. But in reality, it creates a two-tier system, further broadening the gap between the rich and poor and exaggerating health inequalities. While those who can afford either private care or health insurance will find themselves being seen and treated quickly, others who rely on the NHS may be at risk of their health conditions deteriorating while they wait ever-increasing amounts of time.

Asking about private health insurance would also produce geographical health inequalities. Affluent areas will benefit more, not only from a larger number of the population accessing private care, but from the higher number of patients filtered out of NHS waiting lists, freeing up more appointments and improving services in the area. But conversely, in deprived areas, where fewer people have access to private healthcare, NHS waiting times will continue to remain above what is acceptable, further widening regional differences in care.

A final issue is that schemes such as this free the Government from the responsibility for their funding cuts. The NHS is currently in dire straits, and the solutions lie with our Government and the way it funds the NHS, not with alternative solutions such as pushing patients towards the private system. This merely patches up the system while the Government continues to slash funding to public services. It would be more prudent for local health boards or CCGs to fight for more enduring, appropriate solutions, rather than taking us one step closer to an unfair insurance-based healthcare system.

Dr Rebecca Jones is a GP in Hastings, East Sussex

Putting the patient in front of you at the centre of your concern – includes asking about PMI

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There is no plan – only inactivity and statemate. Gradual decline in state standards seems inevitable, in contrast to private…

The general public will not be aware of how difficult it will have been for the reporter to persuade doctors to talk, and e named, but over the last few years their natural reluctance to “let their Health Service” down has been eroded. The “truth” needs to be heard and they appreciate this, but there are still far too few of them willing to speak out. If only the directors, CEOs and Chairmen would have the same courage and honesty.. It is most unfortunate that there is no plan… and for the new consultants contract: inactivity and stalemate. A gradual decline in state standards seems inevitable, in contrast to private .. And of course we are going to Reduce NHS reliance on migrants.

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Emma Thelwell reports for BBC news on the views of 5 doctors questioning their professional direction and altruism.

‘I can’t imagine being a doctor for five more years’

Should patients be worried that poor morale among doctors is putting them at risk?

The General Medical Council has taken unprecedented steps to warn there was “a state of unease within the medical profession across the UK that risks affecting patients as well as doctors”.

Five doctors speak about their experiences.

Worried I’ll miss something: London GP Dr Eloise Elphinstone, 31, says she feels “very demoralised and pressured in the current climate”.

“I work incredibly long hours to ensure patients get the treatment they deserve, but sometimes to the detriment of my own health.

“I worry that I may miss something, being so tired by the end of a 12 hour day. I feel it’s such a shame as it is an incredibly rewarding job on a good day.

“However, even over the last year the pressures are getting greater and greater and I feel we can provide a less good service.

“It has even got to the point that I have private health insurance for myself and my family as I worry that the NHS can not provide a timely service anymore with the pressures.

“I’ve also started looking to work in other environments – with the military or privately – where you get longer appointments with patients and the pressure is less…

“I also feel ashamed to say that a relative is thinking of training as a doctor, and I have been very reluctant to encourage this.”

Extremely Disheartening: Dr Kalpa de Silva, 35, a final year cardiology registrar from London, says the “unstinting” belief in the NHS he had when he left medical school “has been whittled away”.

A slew of government interventions have seen the training system “eroded”, and most proposals under Health Secretary Jeremy Hunt – leading to recent strikes by junior doctors in England – have “degraded morale even further,” he said.

“The way the whole saga has been portrayed by the government and, more worryingly by the media, has been extremely disheartening,” he said.

“I work days, and nights, seven days a week, on a rota, as do all of my colleagues, and many hospital specialties do the same…

“Whilst I do not ask for a pay rise, I am frustrated that I will be financially less secure despite the number of years I have worked and trained for.”

He added: “As cliched as it sounds, I work for my patients… no matter what happens I will do my utmost to deliver the best care that is possible.”

“I do however, think that overtime, a workforce that is disenchanted and disillusioned will inevitably be less inclined to work the extra hours, and go the extra mile…which would be a sad thing to see.”

Taking Breaks from Work: Dr Andrew Bull, from Bristol who qualified nine years ago, says he has had to take breaks from work due to low morale.

A GP for just two years, he says: “Gradually I am enjoying my career less and less. I originally thought I would be a doctor for 40 years but now I struggle to imagine being a doctor beyond five more years.

“The low morale has complex causes but most doctors chose this job for the satisfaction it gives rather than for the money. Take away the satisfaction and we are not left with much from our career.

“I’ve had a couple of breaks from work to help get my enthusiasm back. It worked – it’s useful to have a break, some people have enough and retire early.

“I’ve worked in Australia – it’s another health system, you realise the NHS isn’t as bad as everyone makes out. Outside the UK, many countries are jealous of the NHS. There are so many things it can do that the rest of the world can’t.

“I’m thinking of working abroad again, maybe next year as things can get a bit stale. It’ll be short term to begin with – maybe a year, like I did in Australia. I’m not planning on leaving forever. My plan would be to come back.”

The Last Straw: Dr Stefan Cembrowicz, 69, former Senior Partner at Montpelier Health Centre in Bristol, said that the current generation of doctors face fresh challenges.

In the mid-1990s, he interviewed 20 of his registrars at Montpelier about a number of staff conditions, including morale.

He said: “They all had surprisingly high morale – they nearly all said their morale was eight out of 10. Why? Well they were a capable, high calibre bunch, but it was because they were looking forward to a good career.”

Twenty years later, there is “a state of unease within the medical profession”, the GMC has warned.

Dr Cembrowicz said: “As I understand it, the junior doctors’ problem isn’t money, it’s the rota. What you have is a very hard pressed workforce already filling in the cracks, and being asked to fill in even more gaps on the rota is the last straw.

He added: “We must cherish them because they are the brightest and motivated people in the country.”

Dr Cembrowicz pointed out that his generations of doctors were almost entirely male and did not have the shared childcare duties that they face today.

“If you change have to ask people to change their child care for rotas all the time, the sky will fall – it costs money and what’s worse is all the organising”.

An Exhausting Privilage: Dr Matt Piccaver, 38, a GP from Suffolk, maintains doctors will take the pressure first, before it hits the patients.

“Doctors just put more hours in – there aren’t really corners you can cut. You can tell them to keep their coat and shoes on to save time, that’s about it. To do the job properly you have to do all the right checks and you can’t cut corners with those.

“You keep on absorbing until you personally suffer. I’ve been a GP for 11 years and it’s an exhausting privilege – I’m knackered but I love the job”.

With morale remaining low in the aftermath of the junior doctors’ strikes, he said: “I think patients are still on our side, but in the media it’s like we are the bad guys. We seem to be vilified in the press – it’s reduced the perception of it being an attractive career.

“No one wants to be a GP anymore, no one wants to work – unbelievably – in paediatrics, or A&E.

He said the NHS was being “set up to fail” by the government, which is not giving it enough money in the face of rising patient numbers.

“The government needs to shape society around a world where one in three of us is elderly. They need to invest in social and community care – and give us adequate funding for the job, we need to attract people to it and get away from this toxic, awful feeling”.

Andy Cowper reports – A view to a plan?  ( BMJ 2016;355:i5583 )

The Care Quality Commission has warned that the NHS is on the verge of a “tipping point.” But one of the key rescue plans for providers may be undeliverable, finds Andy Cowper

For almost all the wrong reasons, NHS performance is scarcely out of national news headlines. The State of Care report just published by the Care Quality Commission (CQC) outlines a system having to deal with a record 23 million emergency department attendances and six million hospital admissions in 2015-16. 1

The CQC chief executive, David Behan, identifies falling and failing social care provision and pressures in primary care as key contributors to problems with NHS performance. “[They] are now beginning to impact both on the people who rely on these services and on the performance of secondary care. The evidence suggests we may be approaching a tipping point,” he said……

Hugh Pym reports for BBC 27th October 2016: Doctors, the BMA and ministers – the state of play

The Evening Standard: Harley Street gets a new proton beam cancer unit splitting investors

Reduce NHS reliance on migrants, HEE told – Abi Rimmer in  BMJ Careers 14th October 2016 but Wales has differing ideas. They began in 2002, and have continued to fail. In 2006 – Rhodri: There’s no GP crisis looming – Wales Online – and now “financial Incentives” are needed despite refusing 9 out of 11 applicants to medical school for decades…

The Guardian 28th October: We mustn’t stop doctors in the UK giving us a dose of the truth

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