Category Archives: General Practitioners

NHS 111 is a disgrace… How to get rid of it?

I have personal experience of the inefficiency and risks attached to incorrect advice from NHS 111. One of my relatives was ill after a delivery, with fever and I wanted to ring 999. I was stopped by the relative who demanded I ring NHS111. The advice for a post partum sepsis was to ring her GP, and was not to attend hospital. There are too few full time GPs to run a proper out of hours service…. There are so many part timers that any form of continuity of care, particularly when we are terminally ill, has virtually disappeared. Experimental technology is being used in reality. There is a real need to bring experienced diagnosticians closer to the initial presentation, whether it is by phone, in GP or in A&E (or whatever it is named). How do we get rid of NHS 111?

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So it is no surprise to read about the problems reported by Jon Ungoed-Thomas and Jack Taylor in the Sunday Times 5th Jan 2020: Toddlers died after NHS 111 helpline said they were not in danger – The urgent medical care service faces calls for an independent investigation after a number of child fatalities

The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.

Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.

Professor Carrie MacEwen, chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”

Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.

The latest coroner’s report issued to prevent further deaths was published in November. It concerned Myla Deviren, 2, from Peterborough, who died from an intestinal blockage in August 2015….

,,,Researchers examined 2,191 patient safety incidents involving children receiving NHS care between January 1, 2005 and December 1, 2013. The majority of the 659 incidents involving diagnosis, assessment and referrals — including 10 child deaths — occurred during calls to NHS 111.

The report stated: “The safety of software used to triage children over the telephone is unclear, particularly its sensitivity to detect signs of serious illness in children.”

The NHS Pathways triage system, used by NHS 111 and in about half of ambulance services, is one focus of the inquest into the death of Shante Turay-Thomas, 18, from north London, who suffered a suspected allergic reaction.

Leigh Day, the legal firm representing Shante’s family, said she was assigned an ambulance with a response time of two hours (category 3), but a 999 call to the London ambulance service with suspected anaphylaxis would trigger an ambulance with a target response time of seven minutes (category 1).

NHS 111 is operated by various providers, and NHS Digital supports the NHS Pathways triaging software. The 24-hour service is free to use.

Professor Jonathan Benger, acting interim chief medical officer at NHS Digital, said: “NHS Pathways supports the remote assessment of more than 17m calls each year and is a safe and robust system.”

NHS Digital said that since 2016 there had been changes to improve identification of patients at risk of critical illness; where a clinical safety issue is raised, an assessment is made within 24 hours.

NHS England said serious safety incidents involving NHS 111 were “thankfully rare” and more than half of callers received advice from qualified clinicians.

Professor Martin Marshall, chairman of the Royal College of General Practitioners, said: “Patients need to be reassured that valuable lessons have been learnt if we are to maintain public trust and confidence in NHS triage systems.”

Dr Chaand Nagpaul, chairman of the British Medical Association (BMA) council, said: “There is clearly much more to do be done to ensure there is adequate assessment, expertise and support on hand for those who contact the service.”

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Rationing over Christmas. Just part of the routine now… in a toxic culture of denial.

Over Christmas we hate to hear about the hard truths of peoples lives. Dying alone is not something I look forward to, and I suspect I will not know the medical person who comes to see me in the last days. Continuity of care has disappeared, and in its place is part time working of both nurses and doctors. These professionals have not necessarily been trained to deal with the variety of conditions which the ageing community and General Practice demands of them, Many miss out on Paediatrics or Gynaecology or Dermatology as well. Most miss out on orthopaedics… The “hard truths” which Mr Stevens wishes to discuss (since 2014!), facing politicians and their electorate about health, are present all the year round. And its too toxic a subject for all politicians..

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So it is no surprise that diagnoses are late, especially for conditions with rather unspecific symptoms such as early leukaemia ( Susan Oneill in the Times 27th December: A quarter of cancer patients go to GP three times before a diagnosis ). Doctors are taught to use time as a diagnostic tool, and if all patients had all possible tests on presentation the service would surely implode. Sepsis on the other hand is severe and should be recognised by every doctor.. It is still “causing more deaths than expected” in Wigan.

Dennis Campbell reports 10th December in the Guardian: Thousands die waiting for Hospital Beds – study.

Shaun Lantern in the Independent 27th December reports that the nursing profession don’t think Boris Johnson’s NHS plan is deliverable.

Laura Donnelly in the Telegraph: Hip Rationing

The Daily Mail reports that the Scots are to get three rounds of IVF compared to the one offered by most English Trusts.

Andrew Proctor for the Dermatologists reports on the rationing of emollients (which are almost all very cheap)

It features National Eczema Society’s Chief Executive Andrew Proctor discussing the important issue of emollient rationing for people with eczema.

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

The politics of health.. The Lemmings of the left leave a vacuum where Mr Stevens’ debate will not happen… Are we all lemmings as far as our health system is concerned?

The Election Horror Show, and denial… The political spin doctors are leading us into a health-less “black hole”. The Health services are too toxic for honesty…

NHS Rationing & Finances | A King’s Fund Report‎ March 2017. Understand the NHS financial pressures. How are they affecting patient care?

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A curse on all their houses. Banal debates omit the really important questions. Entertainment has come before long term politics and unity..

For anyone who has watches the banal ITV debate (Boris v Jeremy)  and BBC question time leaders special I can only sympathise with the shallow nature of the questions, and the replies. They have omitted the really important questions. Entertainment has come before long term politics and unity. What a pity for those who gave their time to watch this display of denial. A curse on all their houses. They have all conspired to put patients and doctors lives at risk….

Here are some of the questions that NHSreality would like to have asked:

Brexit.

Do you feel that the Union of Great Britain and N Ireland is more or less likely to survive if we leave the EU?

Do you feel that continuing peace is more or less likely to continue if we leave the EU?

Do you feel that varied opportunities for work, particularly for younger people, are more or less likely if we leave the EU?

Do you believe the reports of the Economist, Governor of the Bank of England, World Bank, EU economists, all UK economists (bar one) and most politicians before the first referendum, when they indicate that prosperity and influence will diminish after leaving the EU?

Proportional Representation.

Please can you give your parties’ arguments against PR? Do these still apply?

If Proportional Representation is good enough for the devolved dispensations, why is it not good enough for the UK?

What form of PR would you advocate if we changed our system?

Do you think the vote should be extended to all those over 16, as in Scotland?

Identity

Since we have a virtual identity system with face recognition and other methods connected to central databases, and since we have a problem with identifying those eligible for state benefits, including health, would you support ID cards?

Could these ID cards lead to means related co-payments or taxes?

Tax

Would you support Land Rental Tax?

Do you think it could be at a level that allowed replacement of Estate Duty, Stamp Tax and reduction of Council Tax?

Health.

Do you feel that the 4 health services are sustainable under their present rules? Do you think that the pace of technological advance is faster than any government’s ability to pay? Given the demographics how would you change the rules?

If social care is means tested, then why not medical care? Or would you advocate the Scottish model of social care for England?

Is health care rationed covertly, so that nobody knows what is unavailable to them until they are denied it?

As far as health is concerned, has devolution worked in Wales and N Ireland?

Bearing in mind the excess of able applicants, for decades: Why are there so few doctors and nurses to meet the nations’ needs? Do you think this has anything to do with our political system and FPTP time horizons?

Usually when trying to fill the bath you put the plug in rather than turn the taps on more. We are now training more doctors, nurses and allied professionals than ever before. What are you going to do to change the culture  in the health service to stop the loss of the workforce soon after these individuals  qualify .

Bearing in mind that most purchases of equipment for the 4 health services are in dollars, and the costs have gone up 20% since the referendum, and this without trade barriers, do you believe leaving the EU will make our health as a nation better?

Education.

Bearing in mind job applications and competition for places at university, and interviews: Do you feel that all education is divisive? Is it more important to aim for excellence, or to reduce inequalities, when there is competition for resources and people? Do parents have the right to choose how to educate their children, and whether to spend their money on private tuition, sports activities, music etc?

Spin doctors – what the economist thinks about the conservatives health manifesto promises.

Northern Ireland health collapses. It would be kinder to bring in co-payments than to let more suffer.

Cloud cuckoo land….. The poor will remain slaves in a GIG economy.

Disgraceful leadership, and a longstanding culture of fear. Successive PMs of all colours are to blame. Spending money on bribing the electorate will bring only short term gains..

What the GP did best: used time as a diagnostic tool. The “failiing fiasco” of health care in the UK.

 

In the BMJs subsidiary magazine “Doctor” on 16th November the headline article is “On the cusp of collapse”. Overcrowding and Underfunding have left patients and doctors at risk……

New Registrations: More non-UK graduates than home grown clinicians…. in 2018

After failing to provide the 5000 extra GPs promised 4 years ago, the numbers have actually fallen by 1600, and of those remaining a far larger proportion are part time. The complete failure of forward planning is due to rationing of med school places, and the First Past the Post electoral system. It will happen again, and repeatedly. If the conservatives win an outright victory the money will dry up quickly. If Labour wins they wont be able to borrow, and they will have to print more money. Both outcomes are likely to lead to a fall in the value of the pound. We still have 11 applicants for every place. Increasing the numbers by a small % is not enough…. We now need locality based virtual training for medicine. It can be run by the local medical scghool, and exams and assessments can be centralised, but the training should be local, and graduate based. Traditional medical schools just dont have the capacity. …

Doctors‘ early retirement triples in a decade BMJ 21st June 2019

Rowena Mason reports in the Guardian 8th November 2019: Boris Johnson promises preferential immigration for NHS staff

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

PM proposes half-price visas and quick decisions for doctors and nurses as part of points-based system

Jonathan Paige reports in the Times 8th November 2019: Hospitals told to pay doctors cash over fears of winter crisis

Andrew Gregory in the Times 9th November 2019 reports: Will Tory promises help to clear your GP’s waiting room? 500 more GPs in training per annum promised……

The Conservatives today promised to create an extra 50m more GP appointments a year if they win the election.

In this early stage of the campaign, the NHS has dominated the agenda….

Adrian O’Dowd reports in the BMJ: More non-UK graduates than home grown clinicians joined medical register in past year (BMJ 2019;367:l6203 )

Where are the UK’s doctors from?

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Of the 251 319 doctors on the UK medical register in 2019:

  • 164 525 trained in the UK (65.5% of the total, and a 2.2% rise from the number in 2018)

  • 22 280 trained in European Economic Area countries (8.8%, and a 2.2% rise from 2018)

  • 64 514 trained outside the EEA (25.6%, and an 8.3% rise from 2018)

There was an especially large increase in the number of medical graduates from Africa and the Middle East, but most non-EEA joiners still come from South Asia.

The trend of increasing numbers of doctors joining from Central and Eastern Europe and the Baltic countries continued in 2019. The number joining from northwest Europe remained the same in 2019, after a prolonged period of steady decline. Southern European doctors have joined in slightly greater numbers in 2019, a contrast to decreases since 2014.

Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

 

Health Services might be designed wrongly: In praise of dissenters.. Currently there is little ability to speak out, “without fear of sanction”.

The Different health services in the UK are not open to the suggestion that they might be designed wrongly. They are failing more quickly than anyone imagined (other than those in the profession, and NHSreality). An interview with Helen Stokes-Lampard (RCGP chair) In “You and Yours” on Radio 4 17th October 2019 tells it straight: its going to take at least 12 years to remedy the failure in forward and manpower planning. (The interview is at the end of the recording) The culture of fear means that opportunities to learn constructively are being lost, educational standard are falling, and engagement with the politics of health is minimal. One route to honesty is the exit interview, and these collated together could give messages that lead to the changes needed. Meanwhile……  “Winter is coming”. We will all be hearing how they will listen (See Jill Patterson in Walesonline below), but NHSreality can tell you that even if they hear, they don’t have the human resources to act. 

In Bartleby in The Economist 12th October 2019 “In praise of dissenters – It pays companies to encourage a variety of opinions “

The ability to speak up within an organisation, without fear of sanction, is known as “psychological safety” and was described by Amy Edmondson of the Harvard Business School in a book on the issue. Mr Syed cites a study of teams at Google, which found that self-reported psychological safety was by far the most important factor behind successful teamwork at the technology giant. ….“In praise of dissenters

As many practices disintegrate, I give a link to a local practice in the news.

Eleanor Philpotts in Pulse 12th October 2019 reports on Ferryside practice.: Practice set to close after 3 years without a GP

In Walesonline Sandra Hembury on 14th October reports: The GP surgery that hasn’t had a GP for over 3 years..

A doctors’ surgery hasn’t had a GP working there for three years and is now being threatened with closure.

The Mariners Surgery in Ferryside has only had nurse sessions since 2016, because there were no GPs available to operate from it.

Now plans have been unveiled to close the surgery and relocate services to other practices, forcing patients to have to travel for miles to receive treatment.

A public drop-in session is being held to consult with patients at the Three Rivers Hotel in Ferryside between 2pm and 7pm tomorrow (Tuesday, October 15).

But there are fears those less mobile patients will struggle to get to the next nearest surgeries in the Meddygfa Minafon practice – in Kidwelly or Trimsaran.

Cllr Mair Stephens is ward councillor for St Ishmael and deputy leader of Carmarthenshire County Council.

She said the Carmarthen Road practice had been there for a number of years.

“There’s traditionally been a dispensing surgery, which is exactly what we do need,” she said.

“The majority of people who live in the area are older, and the surgery has been on the decline in recent years, but it still has such things as foot clinics and heart clinics.

“They are now going to close it, which is out of all proportion.”

She said the nearest surgery in the group was Minafon in Kidwelly, which was about four miles away. But it was difficult to get to if patients needed public transport. The nearest bus route to the Kidwelly surgery dropped passengers off at least 10 minutes away from the practice, which wasn’t suitable for the less mobile, she added.

She suggested the practice could set up a bus route taking passengers without suitable transport from the Ferryside surgery to Kidwelly.

Cllr Stephens added: “This is about moving services from their locality.

“What older people want to do is to see a GP. They don’t necessarily want to see a nurse.

“Once they have seen the doctor they are quite happy to meet a nurse or practitioner. That’s where the whole system seems to be falling down.”

She felt the consultation was not being spread out enough to the wider community, including nearby Llandyfaelog.

A petition has been set up to maintain the surgery in Ferryside.

Started by Ute Eden, it says: “We feel very strongly that it is essential to maintain a surgery in Ferryside.

“We need a doctor, a nurse and a dispensary to provide the vital services required by a village where most residents are over the age of 50.

“It is an integral part of Calon y Fferi Community Centre, which is very accessible.”

The petition, which has been signed by 44 people, said it would be a backward step to oblige all residents to leave the village for treatment.

Jill Paterson, director of primary care at Hywel Dda University Health Board, said: “As a health board we are committed to listening to and engaging with local populations around our proposals to relocate our primary care services from Mariners Surgery to neighbouring surgeries.

“We would therefore like to invite residents to come along and get involved in the conversation.

“Following a review of how services are used by patients at the surgery, it is becoming clear that these services are limited and not fully utilised and could be relocated to Minafon and Trimsaran Surgeries.”

The best and worst places to have your hip operation (In England. No global comparisons)

All hail the honesty of the Health Services Journal. Unfortunately they are not allowed to advocate rationing and freedom of speech is limited. But the stories they expose and the issues they address are relevant to  us all. There are many problems, which include poor staff hygiene, poor hospital cleaning, inadequate training, and above all, the failure to separate cold orthopaedics from “dirty” hospital cases where infected wounds and guts are operated on in the same building. The old fashioned DGH has served its time for hips and knees. But why are there no comparable figures for the Scottish, Welsh and Irish Hospitals? Because there is no “National” health service, I as a taxpaying citizen in Wales cannot find out how my service performs compared to England. Indeed, I would like to know comparisons with other countries, and with the private sector. Only with such data can patients be properly advised, and of course they also need to be “led” ask the right questions! Rationing by lack of choice, restriction to a local DGH, and long waiting lists, can only lead to more infections and complications (increased obesity and heart attacks from immobility). Should your GP air these issues when you choose to be referred? Of course he should even if it means telling the truth about your local services.

In the Times Monday 14th October a short report ( not in the on line edition) reads:

Repeat Offenders

The hospitals with the worst records for having to repeat knee and hip surgery on patients are revealed in a report in the Health Services Journal. The sick/ Six NHS hospitals are Southampton General, Milton Keynes, Chichester, Wansbeck, (Northumbria), Weston General, Somerset, and Ormskirk DGH Lancashire. Overweight patients, high infection levels and shortcomings in supervising trainees are blamed for poor performance.

In the Telegraph they report: “Revealed: the best and the worst places to have your hip operation”.

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

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?

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

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites

 

Ambulances use unproven scoring system to ration their service…

As a recent sufferer from sepsis, and having had much pain as a result, and from a hand operation (for which I am most grateful) I am interested in this new form of rationing. Since ambulances are “free” and since many calls are for relatively trivial issues, triage has to occur. However, when a GP rings, rather like when a doctor appears in A&E, lights should alert the telephonist that this needs to be taken seriously. A&E, and Emergency, and Urgent Care centres, have sepsis warnings all over their walls…  It made little difference to my care..

The ambulance service regards being in a GP practice as a place of safety, with medical care to hand, although GPs are being systematically deskilled in emergency care. This reduces their “points” score and the perverse action of the GP whose surgery has been “arrested” by this, is to send the patient outside and ask them to ring the ambulance!

Yes, the ambulance service is underfunded, especially if it remains free for all. The Air Ambulance is a charity, and like many others it too has to prioritise its service. Waiting times for ambulance calls are generally getting worse, and it wont be long before private contractors compete. But in West Wales it would be very expensive as the journey to a competent hospital is 1.25 hours at Swansea, or 2 hours to Cardiff.

Hiba Mohamadi reports for Pulse 27th September 2019: GPs requesting ambulance will have to provide a score for level of emergency.

In the BMJ Elizabeth Mahase reports: GPs warn against use of scoring system.  BMJ 2019;367:l5814

…..The system is based on six physiological measures: respiratory rate, temperature, oxygen saturation, systolic blood pressure, pulse rate, and level of consciousness. Despite not being validated for primary care, NHS England has “encouraged” its use. Last year its was made mandatory in ambulance trusts. NHS England said the score should be used “for all pre-hospital patients who are ill or at risk of deteriorating” and to “support colleagues to identify deterioration early and prioritise resources in times of surge.”…..

Dr Rachel Marsden RCGP Clinical Support Fellow for Sepsis, is on the RGP website: The updated National Early Warning Score and its use with suspected Sepsis

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