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?

Why won’t anyone in power talk about rationing? “We need to talk about NHS rationing”…

The downside of honesty must be greater than the upside – what an indictment of our media led society. Why are our leaders and administrators, trust chairmen and CEOs so afraid to speak out?

In Pulse 10th October 2017 David Turner opines: We need to talk about NHS rationing

A woman requesting breast reduction.

A child with severe behavioural problems in need of psychological assessment

A seventy year old brought to tears daily with knee pain, waiting for physiotherapy.

A new cancer drug costing thousands per month that has just received NICE approval.

What have these patients got in common? They all have a legitimate claim on the NHS pot of money for funding.

The recent announcement that NICE has approved nivolumab for treating patients with certain types of advanced lung cancer is fantastic news for those patients and will add valuable months to their lives.

There is, though, a rather large pachyderm in the room, which sooner or later needs to be faced. I’m afraid all of us – doctors, patients, managers and politicians – seem reluctant to address the rather obvious reality that NHS coffers are not infinite. Funds for healthcare are always going to be finite and even with the best political will in the world (and we certainly don’t have that at the moment) we cannot pay for everything.

Funding an expensive cancer treatment to give someone extra time on earth will impact on other aspects of healthcare. Increase funding to one area and others will suffer with reduced services and longer waiting lists.

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Do we say only disorders that can be fatal go to the front of the queue?

Many will say we should prioritise the most serious illnesses which can kill quickly such as heart disease or cancer. Nobody dies from osteoarthritis, but thousands suffers tremendous pain every day while waiting joint replacement surgery. It’s also not unheard of for people with mental illness to kill themselves while waiting to see a psychiatrist.

Name virtually any condition or disease and there will be individual sufferers and support groups making their case as to why more taxpayers’ money should be spent researching into or treating their disorder.

The reality is everyone’s health matters to them more than anything else and few people will be altruistic enough to say public money should be spent treating others before themselves and their loved ones.

I don’t claim to have the answers, but unless we start to talk more openly about the very real issue of rationing in the NHS we are just postponing some very serious questions for the future and they are not going to get any easier to answer.

Dr David Turner is a GP in west London

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Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

If commissioning groups insisted that oncology clinics had a GP present, and that he was involved in decision making with the patient, and especially the decision to move from oncology cancer care to palliative  or terminal care, there would be far less wastage. There is an issue: there are not enough GPs. Undercapacaity means the most pragmatic way would be a phone call to the GP BEFORE any decision on treatment is taken. The savings involved, the quality of life gained, and the honesty of such teamwork seems to be unimportant… 

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Chris Smyth in the Times reports 5th October 2017: Cancer patients given new drugs that won’t help them

Most new cancer drugs are given to patients without any evidence that they extend or improve lives, an overview of data has concluded.
Only half show they have any real benefit, according to researchers who say regulators must make it harder for medicines to be approved. Other care for patients is being rationed to pay for drugs that are often useless, they add.
Regulatory approval, however, does not mean the NHS will pay for the drugs. Health chiefs will see the study as vindication of a tougher line which has seen them rejecting many new medicines as poor value for money.
NHS England yesterday defeated a legal challenge to its decision to add an extra layer of rationing to new medicines. Even cost-effective treatments can now be delayed or restricted if the total cost to the NHS exceeds £20 million a year, after a High Court judge refused the Association of the British Pharmaceutical Industry (ABPI) permission to take the plans to judicial review.
In an effort to assess the effectiveness of new medicines, scientists looked at data on all 68 cancer treatments approved for routine use by the European Medicines Agency between 2009 and 2013. They found that only 35 per cent had been shown at the time to lengthen patients’ lives.

A further 7 per cent could show they improved patients’ quality of life, according to data published in The BMJ. Instead, drugs were approved on the basis of studies that looked only at interim measures, such as how many patients responded, or how long the disease went without worsening. However, these turned out to be poor markers that patients would live longer, with just 7 per cent of drugs without a survival advantage when they were approved going on to demonstrate one over the next five years.

Overall, no more than 51 per cent of the treatments approved have shown any benefit in terms of life expectancy or quality, they say.

Courtney Davis, of King’s College London, who led the study, said patients often did not realise that the drugs they were offered had not been shown to extend life. “What people often don’t realise is that it’s not just resources taken away from other disease areas, they are also being taken from other cancer treatments that are actually more effective than drugs.”

Many of the best-known treatments approved during the study have been shown to extend life, including abiraterone and enzalutamide for prostate cancer, and Herceptin and Kadcyla for breast cancer.

Paul Catchpole, of the ABPI, said: “It can take many years to gather overall survival data on new medicines, which is why meaningful surrogate outcomes are used by regulators so that promising new medicines can be provided to patients whilst further evidence is collected. These cancer patients often have no other remaining options.”

Hearing loss and dementia: more research is needed. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us …

More research is needed into the relationship between hearing loss and dementia. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us … The rationing of hearing aids is patently perverse, and the outcome could be more long term dementia care demand on the state. And of course the politicians making the decisions today will not be those addressing the future problem.

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A letter from Dr Ted Leverton in the JRCGP October 2017 reads: 

Iliffe and Manthorpe’s editorial in the August issue1 is apposite in view of the publication in July of the Lancet Commissions’ report Dementia prevention, intervention, and care, which expands on several of the themes raised.2 In particular, the editorial’s focus on the role of general practice in prevention and research is to be welcomed. However they do not mention hearing loss, to which the Lancet report devotes considerable space and ascribes a significant potential preventive role. Hearing loss is independently associated with developing dementia in about one-third of cases.

Recent research has suggested that use of hearing aids may reduce or prevent the increased prevalence of dementia seen in adults with hearing loss.3,4 This needs confirmation, as current evidence is weak due to the large number of confounding factors. General practice is ideally suited to carry out this research thanks to our large-scale and long-duration databases. In the meanwhile, GPs are likely to see increasing numbers of patients asking for referral for hearing aids, as some in the commercial sector are stating this benefit of hearing aids as fact. Such referral should be expedited; GPs are sometimes accused of minimising hearing loss and delaying referral, but early users of hearing aids are more likely to use aids successfully over a longer timescale as they can be difficult to use. Hearing loss is associated with depression and social isolation;5 denial of the disability is common, as is irritability and interference with relationships. By the age of 70 years, 70% of GP patients have hearing loss. If in doubt, or if the patient is reluctant, a simple validated screening test is available over the phone or online.6

REFERENCES

  1. (2013) Hearing loss and cognitive decline in older adults. JAMA Intern Med 173(4):293299. Lin FR, Yaffe K, Xia J,et al.
  2. (2015) Hearing loss and cognition: the role of hearing aids, social isolation and depression. PLoS One 10(3):e0119616, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356542/ (accessed 5 Sep 2017). Dawes P, Emsley R, Cruickshanks KJ, et al.
  3. Action on Hearing Loss. Check your hearing. https://www.actiononhearingloss.org.uk/your-hearing/look-after-your-hearing/check-your-hearing/take-the-check.aspx (accessed 5 Sep 2017).

£500 each citizen, man, woman and child, paid for “negligence” annually by 2010. Why no “no fault” compensation?

Kat Lay reports in the Times September 7th 2017: Negligence payout bill for NHS to hit £3.2bn in 2020

There is a built in inflation in medical negligence claims. GP insurance is rising rapidly, and some years ago the removal of unlimited cover occurred. Some GPs are paying well over £1500 per month, and the average is £1000 per month. This comes back over the years in the pay review package, but there is built in delay. £3.2 billion (£3,200,000) represents a bill for £500 for each citizen, man, woman and child, paid for “negligence” annually by 2010. If we exclude the people who pay no tax, the burden will fall on a small number – say 25% of the population, which means £2000 each. Why are the politicians ignoring the idea of “no fault” compensation? The escalating scale is reported in the Mirror in July, and that’s just for this year..

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Clinical negligence claims are likely to cost the NHS £3.2 billion a year by 2020, and could worsen patient care, the National Audit Office has warned.
Action to control costs will require co-operation across government departments, it has said in a report but the government has no coherent strategy.
Amyas Morse, head of the NAO, said: “The cost of clinical negligence in trusts is significant and rising fast, placing increasing financial pressure on an already stretched system. NHS Resolution and the Department [of Health] propose measures to tackle this, but the expected savings are small compared with the predicted rise in overall costs.”
Spending on the clinical negligence scheme for health service trusts has quadrupled, from £400 million in 2006-07 to £1.6 billion in 2016-17. In the same ten years the number of successful clinical negligence claims where damages were awarded rose from 2,800 to 7,300. Last year 590 claims were settled with an award of more than £250,000, while NHS Resolution, which handles claims for the health service, spent £602 million on legal costs. In 61 per cent of successful claims last year the claimant’s legal costs exceeded the damages awarded.
The report said that trusts spending a higher proportion of their income on clinical negligence were significantly more likely to be in deficit. In 2015-16, all 14 trusts that spent 4 per cent or more on clinical negligence had deficits.“There are indications that financial stress faced by trusts has an impact on patients’ access to services and quality of care,” the report said.
A rising number of claims accounted for 45 per cent of the overall increase in costs but rising payments for damages and claimant legal costs accounted for 33 per cent and 21 per cent respectively.
The Department of Health and NHS Resolution have put forward measures aimed at reducing costs, including fixed recoverable legal costs for low-value cases and a voluntary alternative compensation scheme for birth injury cases.
But the NAO report said that some of the biggest factors were outside their control, including changes in the way courts calculated lump sum payments.
A government spokesman said that clinical negligence costs were too high and that it was taking action.

Keir Mudie in the Mirror 23rd July 2017: NHS sets aside £56 BILLION for compensation claims as payouts for medical blunders soar

Experts say the NHS is sitting on a ‘timebomb’ of future claims and legal reform is needed to tackle the problem

Cancer sufferer urges patients to stop suing NHS – No fault compensation is the answer.

Patient complaints hit a ‘wall of silence’ from NHS – No fault compensation would help change the culture…

Litigation – The rising tsunami is swamping us all.. NHSreality lists all the posts on litigation in the two years of existence. NFC (No fault compensation) is essential.

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The facts, What doctors earn – except that GPs are self employed and you wont know their overhead/expenses/debts which will vary by GP and by practice.

BMJ has helpfully published the latest data on GPs (BMJ Aug 30th article by Tom Moberly

Data chart: what doctors earn

Authors: Tom Moberly

Publication date:  30 Aug 2017


In 2016, the mean annual pay for all doctors working full time in the UK was £78 386, according to figures published by the Office for National Statistics (ONS).

The ONS data show that 78% of doctors work full time. For the remaining 22% who work part time, the mean annual pay was £46 277. Across all doctors, working full time or part time, the mean pay was £71 455.

Separate figures on doctors’ earnings are published by NHS Digital, and these figures provide data on the earnings of different sections of the workforce.

These figures show that, in 2014-15 (the latest period for which these data are available), the mean earnings for GPs was £101 500. This figure is for income before tax, but after expenses, for salaried GPs and partners working under either general medical services or personal medical services contracts.

For consultants and other hospital doctors, NHS Digital has published data on earnings in the year up to March 2017. These show that the mean earnings for consultants were £111 563. For specialty and associate specialist doctors they were £69 336, and for all doctors in training, mean earnings were £49 318 (£55 629 for those in higher specialty training, £47 420 for those in core training, and £36 122 for those on the foundation programme).

The ONS data show that, between 1997 and 2016, mean pay across all doctors increased from £36 849 to £71 455.This equates to an average annual increase of 3.5% over that period.

What doctors earn

Consultants £111 563
GPs £101 500
Specialty and associate specialist doctors £69 336
Trainees (higher specialty training) £55 629
Trainees (core training) £47 420
Trainees (foundation programme) £36 122

Source: NHS Digital. Note: GP data are for 2014/15; other data are for 2016/7.

Tom Moberly UK editor BMJ

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..