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

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

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

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

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

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

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

The cause of all the mayhem

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

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

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

Firms would wither in this age of individualism.

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

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

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

Today:

Re: Consequences of losing firm: true or false ?

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

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

GP list sizes in England can be found here. 

Standards are falling in most areas because of the pressure of work both in Hospital and General Practice. Occasional well respected and popular training practices are the least under pressure. In social care standards are also falling, and one inspector (Greg Hurst reports in the Times 13th June 2019) has quit citing a toxic culture in the Care Quality Commission. He should be listened to, as there is a toxic culture, and disengagement everywhere in Health and Social Care. Of course there will always be examples of individuals who break the mould, but in general NHSreality says it as it is. The Times report is below..

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Mary MacCarthy in Pulse December 2018: Cappling GP lists would make GPs and patients safer: 

Nick Bostock in GPonline 12th December 2018 reports that since 2004, there has been a 50% increase in GP list sizes.

and earlier that year, he reported with Teni Oluwunmi  that the number of GP practices had declined by 263!!

and last year, according to the Mail by 138

Emma Bower for GPonline 5th June 2019 also suggests that Scotland needs a new target for the GP workforce. With increasingly elderly population with multiple pathologies and complexity, 15 minute appointments are also needed. (BBC News)

Anal Carcinoma needs prevention with HPV vaccine? A nurse comments on her own illness…in Healthonline

Research in the US has discovered what the drug manufacturers should have found: drugs for shrinking enlarged prostates cause delay in the diagnosis if the prostate goes malignant. Another case of Big Pharma and overtreatment.

Barry Stanley-Wilkinson gives his exit interview from the CQC. (Greg Hurst reports in the Times 13th June 2019) has quit citing a toxic culture in the Care Quality Commission.

Waiting lists are getting longer, even for cancer diagnosis and treatment. Nick MacDermott in the Sun12th June 2019 so keep up the private insurance payments as long as you can, especially if you live in Wales.

An inspector whose report highlighting failings at a scandal-hit hospital was never published resigned from the regulator, protesting that some of its staff were too close to the private company that ran the hospital.

Barry Stanley-Wilkinson also complained of a “toxic” culture at the Care Quality Commission and said many of its inspectors felt that they worked in a “bullying, hostile environment”.

Mr Stanley-Wilkinson resigned six months after he led an inspection in 2015 of Whorlton Hall, a private hospital in Co Durham for adults with learning disabilities or autism. Police arrested ten carers at the hospital last month after Panorama on the BBC broadcast footage of staff appearing to mock and intimidate patients.

The inspector reported in 2015 that some patients had accused staff of bullying and inappropriate behaviour. He said patients did not know how to protect themselves from abuse and recommended that the hospital should be given a rating of “requires improvement”.

His report was never published and a new CQC team that inspected Whorlton Hall in 2016 gave it a “good” rating. Mr Stanley-Wilkinson’s resignation email, sent to the CQC in January 2016, was published yesterday by parliament’s joint committee on human rights, which took evidence from two CQC executives. He expressed frustration that his report on Whorlton Hall had not been published “despite significant findings that compromised the safety, care and welfare of patients”.

He referred to a complaint about his report by the hospital, which was then run by the healthcare company Danshell, and pointed out that it had previously been run by Castlebeck, which ran Winterbourne View, a care home where there had been an abuse scandal in 2011. Whorlton Hall was taken over by Cygnet Health Care this year.

“I am concerned about the relationship managers have had with the service,” Mr Stanley-Wilkinson wrote. “Discussions had taken place without my involvement despite me being the inspector.”

Paul Lelliott, deputy chief executive of the CQC, said the 2015 report had had inconsistencies and lacked evidence. Ian Trenholm, its chief executive, said the CQC planned to develop a new way to monitor institutions.

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What is the cure for depressed doctors? Adam Kay

The BMA tries to look after the wellbeing of doctors. We all know however, that a union is far removed from an employee! Adam Kay, author of “This is going to hurt” explains his views on solutions. He asks the question, in the Sunday Times 19th May 2019, “What is the cure for depressed doctors? NHSreality agrees with his suggestions, but adds more. In addition to being treated properly, and cared for by our employers, we need meaningful exit interviews, and we need to feel that the edifice of our particular health service is founded on a financial rock, is fair and equitable, so that across the nation those paying the same taxes get access to the same quality of care for serious problems. This is NOT the case. Wales in particular, of all the UK Health Services misses out on choice, quality and waiting times. 

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In the BMA website the wellbeing of doctors is addressed.

The support services are explained clearly.

The BMA purports to support the wellbeing of doctors and medical students. it includes:

  1. Report: ‘Caring for the mental health of the medical workforce’
  2. Principles to improving the health and wellbeing of doctors and medical students
  3. Report: ‘Personal stories of doctors in training with experience of mental illness’ 

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Melting down….We are all getting what we deserve. Without honesty to ration overtly the system will only get worse.

The profession has been warning the different UK governments and Health Administrators for decades that there would not be enough trained doctors, nurses and attached staff. Now that this is actually happening, what are the thoughts of NHSreality? You get what you deserve in a first past the post short time horizon system? You get what you deserve if you don’t do exit interviews, and destroy teams? You get what you deserve if the access is so poor that citizens are pushed into private care? But even if we had trained too many doctors etc, we would still have a system with unlimited demand, limited resources, and no disincentive to make a claim (other than prescription charges, travel and parking). We need exit interviews urgently, and in West Wales the threat of Hospital closure and of poor Out of Hours coverage is so bad that many people may choose to leave the area…..

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The Nuffield Trust gives some background and insight into how we have got to this point, but without referencing rationing. The trust reports the worst April on record…

The paediatricians in Wales are over-working, but this is partly because of the shortage of GPs. They find that it is easier to refer many problems than to see them again and support in the community.

The radiologists are worried that their vast workload leads to mistakes (mainly of omission).

Nick Triggle for the BBC reports: GP pressure: Numbers show first sustained drop for 50 years

Its not just patients who are charged: Trainee doctors on call at night are often charged for sleeping!

In a world market the Irish Times reports that there are plenty of opportunities in the UK, but you will have to work “HARD”.

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Perhaps Pembrokeshire will be the first area to “go private” and abandon the health service?

Do we need an Aspberger’s Teenager to tell it as it is…?

A GP in Bristol explains for Gulf News

A GP in Pembroke explains for those who don’t know that “the hours stink”.

 

The revolving door of health service managers….. mismanagement is nothiong less than neglect.

The mismanagement of the 4 health services that used to be the “National Health Service” amounts to nothing less than neglect.

We medics all know managers who move on quickly. Being fast on your feet is essential in a  service where nothing is addressed long term. Recruitment is a nightmare of under capacity, female bias, and the resultant manpower disaster means we need to recruit from overseas for decades. NHS looks abroad for thousands of nurses – Health chiefs admit failing to plan for elderly care

We jaundiced GPs and Consultants can only assume that these managers have no exit interviews, and that nobody wants to hear what they have to say any more than the professionals.

Chris Smyth reports 7th May 2019 in the Times: NHS register to stop ‘revolving door’

A professional register of NHS managers and a values test for senior leaders are being planned to stop a “revolving door” for failed bosses.

A health service scarred by bullying and stress “needs to be a better place to work”, an interim workforce plan concedes. Although the NHS acknowledges that unexpected pension tax bills are forcing doctors to retire early and work fewer shifts, plans to tackle that issue have been removed from a final version.

The NHS interim people plan makes the starkest acknowledgement yet that staff are leaving the health service because they are overworked, with increases in bullying, harassment and abuse all reported recently.

The plan promises staff that they can expect support on work-life balance, whistleblowing protection and equal opportunities. Specific details are yet to be decided but the plan pledges that more jobs should be part-time or term-time only.

The plan lays out how the management culture of the NHS had to change to “root out bullying and harassment” with an admission that all staff will have experienced a dysfunctional working environment at some point.

“It cannot be right that there are no agreed competencies for holding senior positions in the NHS or that we hold so little information about the skills, qualification or career history of our leaders,” the plan states.

“A series of reports over the last decade have all highlighted a ‘revolving door’ culture where leaders are quietly moved elsewhere in the NHS, facilitated by ‘vanilla’ references,” the plan continues. “These practices must end.”

A government-ordered review has previously recommended a set of core skills for managers. The NHS has now pledged to draw up “an explicit set of competencies, values and behaviours required in different senior leadership roles”. This could include, for example, honesty and protecting patient safety.

Ministers have previously promised a central database of directors’ qualifications. The NHS has now pledged to “develop options to create a registration scheme for NHS managers similar to those used in other healthcare professions and in finance”. It is unclear whether such registration would be compulsory. The plan concedes: “The lack of a transparent, fair and consistent process for the appraisal of senior leaders has contributed substantially to the challenges we face today.”

The plans do not address higher pension taxes for top earners, which are forcing many consultants to retire early or turn down extra shifts to avoid bills for tens of thousands of pounds.

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

This mismanagement of the NHS amounts to neglect

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Sign the Brexit petition – and have more wealth for better health

The Stop Brexit petition

The 4 UK health services need more staff: not less. The 4 UK health services need more money and new infrastructure, not less. Health is so closely related to wealth that in population terms they are virtually indistinguishable. There are only a few poor countries whose life expectancy has exceeded the richer countries, but this is mainly due to politics, warmongering, and subject populations in the richer ones. (Nepal has a better life expectancy than Russia, Venezuela and Zimbabwe, despite no natural resources, and with only tourism to bring in foreign currency). The threat from Brexit is closing fast, and the indicative voting from most recent polls is that there could well be a majority for remaining in the EU now. We will have fewer people, especially carers, less money, and poorer health after Brexit.

Informed consent is better than uninformed consent. The opinions of rich, self employed businessmen, and media owning magnates, are not important except that they have informed the first vote with false assertions. People are wiser now and more informed, which makes the peoples vote petition that much more important. This may be our last chance….

We all know that many elderly people are not “on line” and will not write. We all know the petition is self selecting for those with e ability. BUT this does not negate the need for another vote. Those of us who voted to remain will be much more accepting of another Brexit vote and the country will unite whatever the result. If Brexiteers ask for a third, fourth and fifth referendum, then this is the price we have to pay for Mr Cameron’s idiotic decision to replace representative democracy with a peoples democracy for a single issue. We can all make mistakes…

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The Stop Brexit petition is at

https://petition.parliament.uk/petitions/226509

27th November 2018: Seeking informed consent on Brexit

26 Jan 2019 On the Brexit slipway…. There is a problem: there may be too many to save, all at once.

23 December 2018: The Brexit deadline and the Health Services planning – standards and services are going to get worse..

8th December 2018: BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

August 2018: Patients should not be looking forward to a “hard” Brexit. Make sure you have a good stock of medications..

and Successive increases in the health budgets in Wales have not helped….. Brexit will make it worse… We all seem agreed, so why not change direction?

and Doctors warn “Brexit bad for health”, as calls grow for new EU vote.

Beware the tyranny of the mob. Brexit will harm those suffering from rare diseases.

The Commonwealth Fund compares health systems. Unreality of MPs. ..

Health is closely correlated to Wealth – If you are poor you get no choice (Wales), and live a shorter life, but if you are rich, or born abroad, you live longer and you do get choice! So much for equity…

Just for Health – “MPs must be brave and tell us we were wrong” December 29 2018

This made me laugh, but its sick.

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NHS plan ‘ends public right to choose hospital’ – A form of rationing well known to Wales

The Welsh did not complain about lack of choice when it was begun a decade ago, and the weak BMA in Wales made comment, but no hue and cry resulted in this “lowest common denominator” medicine. Choice is a fundamental plank of a liberal society, and its loss is justified in war, famine, civil war and national emergencies. But rarely has choice been threatened in an advanced democracy/ Standards really are falling, and the right to choice may only be available to those who can afford it. A two tier society once again, and exactly what Aneurin Bevan wanted to avoid when he started the original health service. The Welsh health service has excluded choice because the money moves with the patient. The English will be less accepting of this form of rationing…… Losing choice does work for commissioners in saving money; but it does not work in saving lives. In rural and poorer areas where there are under resourced and under staffed hospitals it may actually do harm. 

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Oliver Wright reports in the Times 22nd Feb 2019: NHS plan ‘ends public right to choose hospital’

Patients’ right to choose where they are treated is being threatened by radical plans to scrap competition in the NHS, ministers have been warned in leaked documents.

Plans to abolish the health service’s internal market are being resisted by Whitehall officials who have told Matt Hancock, the health secretary, that they would quietly reverse 30 years of policy, according to a Department of Health briefing seen by The Times.

Mr Hancock is understood to be ruling out any changes that would prevent patients selecting the NHS hospital or private provider where they are sent for treatment. But he has been told that if he blocks new laws the NHS could blame the government for the failure of a £20 billion reform plan that was expected to save 80,000 lives a year.

The confidential briefing reveals for the first time the scale of changes proposed by health chiefs, which officials believe amount to another major reorganisation of the NHS.

Last month Simon Stevens, the chief executive of NHS England, asked Theresa May to reverse market-based reforms introduced in 2012 by Andrew Lansley, then the health secretary. Mr Stevens wants to make hospitals, GPs and local services work together.

His proposals were presented as a tidying-up exercise, but a briefing for Mr Hancock privately warned that NHS England’s unpublished plans went much further and would undo the internal market introduced by Kenneth Clarke when he was health secretary in 1991. Since then NHS managers have bought services from self-governing hospitals and companies, which were encouraged to compete for business.

The briefing warns Mr Hancock that he must be comfortable with this before signing off, adding: “Removing the internal market will entail undoing some 30 or so years’ worth of policy and legislation in the English NHS, including some of the checks and balances that a market-type approach allows and could have broader implications, for example, how choice works in the NHS.”

Mr Hancock has backed ending enforced competition but he supports patient choice and has little appetite for a Commons battle to reform the NHS.

The briefing warns that Mr Stevens’s position “implies that primary legislation is essential” to implementing the long-term plan, published last month. “This presents a future risk that, in the event that the long-term plan is not delivered, the NHS blames the government if there is no bill. We don’t think you should accept this shift in emphasis.”

Department of Health sources played down a split with NHS England, suggesting a compromise would be found that made clear that legislation was not essential, and which minimised upheaval and protected choice.

NHS England said Mr Stevens did not want to remove patients’ choice on where they are treated. A spokesman said new laws would not be needed. But, he said, as requested by the Commons health and social care committee and the prime minister, “carefully targeted” legislative changes had been drawn up that would provide better services.

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Heath and Safety Executive news 22nd Feb 2019: Patients’ 30-year right to choose where they are treated under threat as part of NHS England reshuffle

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