This is a sad day. There has been a way found to create a two tier system in General Practice in Londonderry. Northern ireland doctors and their health service have been let down badly by their politics in the past few years, but now that two leading ladies have got the willpower and ability to find compromise and a pragmatic way forward there is hope. Unfortunately it may be too late for family doctors and the start of the privatisation of General Practice. What compromises have been reached there could open up and operate elsewhere in the disunited kingdom. The preverse incentive to by pass the rules of the game (registration with a practice) are at the expense of the poorer people, regressive and unfair. Nevertheless, like in the Dental world, they herald a two tier system. The Belfast Telegraph says that the system is only for patients not registerd at the practice, whereas the recent BMJ article implies this restriction has been “got around”. NHSreality can see that if a patient resigns from the partnership, asks for a computer printout, and then sees his usual Doctor that he could be seen privbately: all within a few minutes. Then, or leaving the consultation the patient could re-register with the practice, and the GP can then update the notes based on the record he made of the previous private consultation. In view of the national situation NHSreality would nto expect health trust boards to challenge this way of working. The “regulatory hurdles” the Londonderry practice has overcome might not have been in another of the dispensations that we pretend makes up our NHS.
The Belfast Telegraph editorial 21st December 2023: Self-sufficiency may be only way for GPs to survive ….Abbey Medical in Londonderry is at risk of closure. It says the underfunding from Stormont means it will not be able to continue offering the same level of service to the community. But rather than close, the surgery has come up with a different plan — and it has signalled an intention to open a private GP practice in the New Year, specifically for patients who are not registered with Abbey Medical. It will, the practice says, run along similar lines to dental surgeries, where NHS patients and private patients mix appointments. The additional income will be used to help maintain the services on the NHS side. It is, of course, not exactly what anyone wants to happen. And it’s far from an ideal solution in a country where we have come to expect the NHS to be there ‘from the cradle to the grave’, not ‘from the cradle to the grave if you can afford to pay for it’. In the April BMJ Doctor magasine Jennifer Trueland reports: Survival plan – Tom Black’s GP practice in a deprived area was losing thousands of pounds a month, so the partners took an unexpected step to try and save it. Tom Black loves Derry, the Northern Ireland city where he has lived and worked since he was a child. As we drive towards his practice in the Bogside – an area high in deprivation and redolent with political history – he proudly gestures towards a building which used to house his widowed mother’s clothes shop. As a boy during the Troubles he would be on duty, he says, making sure there were no bombs. ‘There were none on my watch,’ he adds. The family shop – latterly run by his wife – has changed recently. COVID was hard on retail with so much going online, so now his daughter runs a beautician’s business from the premises; it has flexed to survive. It’s a similar story at Dr Black’s surgery. From the start of the year, Abbey Medical Practice has moved to a hybrid model, continuing to care for HSC (Health and Social Care service, essentially similar to the NHS) patients on its list as usual, but also seeing private patients after hours. Patients pay £75 for a 15-minute consultation with one of the practice’s GPs. The doctors themselves are not paid for this extra work – all the money is ploughed into keeping the practice doors open and lights on for its own patients.
No choice
Nobody could sound more surprised by this turn of events than Dr Black himself – private healthcare is not normally the go-to solution for GPs who chose to make a career among deprived communities – but he says the practice had no choice: it was either take this radical step or go bankrupt. ‘To be blunt, the contract was going back in June this year at the latest,’ he says. ‘We were losing thousands of pounds a month – it simply wasn’t sustainable.’ When The Doctor visited Dr Black’s surgery in February, the Northern Ireland Assembly had just started sitting again after a gap of two years. The suspension of devolution has had a huge effect on healthcare in Northern Ireland, and many, Dr Black among them, fear the restoration of government has happened too late to save public services. General practice is no exception. The lack of a health minister has had practical consequences which have hastened the demise of many practices (see box on p9), not least because even the below-inflation 6 per cent financial uplift recommended by the Review Body on Doctors’ and Dentists’ Remuneration had still to be paid, almost a year after it was agreed. ‘To give you an insight into the impact that has had, in my own practice we didn’t get the 6 per cent and we were already overdrawn. ‘We then lost three reception staff in six months – because our pay was lower than Lidl’s. We took a second overdraft from the bank and we gave all our staff an 8 per cent pay rise, because we need someone to answer the phones. ‘At the same time, our heating and lighting costs had doubled in the last 12 months, and our workload is phenomenal, partly because of the huge problem we have with long waiting lists in Northern Ireland. One of the reasons we need this is that the health service has collapsed – we had to do something. The private patients are paying for the convenience of an appointment without waiting, and for extra time – there are no fancy consulting rooms with comfy sofas at the practice. ‘They get a 15-minute appointment – they’re getting the appointment I used to be able to give them 10 years ago,’ he says. ‘You know, I’m really annoyed I’m having to do this, because I never thought I would. But all confidence and hope and trust has gone out of the system.’
Debt relief
Regulations mean they can only offer the service to patients from other practices, not their own, and it remains a small part of the overall workload. Nevertheless, it’s making a financial difference, and the practice is now paying off its debts. Patients appreciate the private service, says Dr Black, who ends his six-year term as chair of BMA Northern Ireland council this summer. He describes one man, an IT consultant with an upper-respiratory tract infection. ‘It would have cost him an awful lot of work time to sit on the phone, talk to the receptionist, make his case [for an appointment], wait for the GP to call back, then go down for an appointment at the convenience of the practice. He said: “I’m self-employed, I make £85 per hour, and you saw me at 5.30pm – you’ve saved me a fortune today.”’ Another typical patient was someone who attended with three or four small problems which were worrying them, but they felt they were not worth ‘bothering their GP’ with. ‘We gradually worked through her non-urgent problems – it did take longer than 15 minutes – but the patient was really delighted.’ Setting up the service has been challenging with many regulatory hurdles to cross, says Dr Black. But patients in his own practice have been very understanding. ‘There have been so many practice closures in Northern Ireland and they worried that we would be next in line. ‘So, I said to them: “I’ll work harder, I’ll maintain your service, and I’ll use this private money to keep the practice going.” They believe me – after 35 years, there’s a relationship of real trust.
‘Extreme pressure’
Dire warnings on workforce and financial pressures in audit report General practice in Northern Ireland is under extreme pressure, with one in three practices seeking crisis-support services in the last four years, according to a public-services watchdog. A report from the Northern Ireland Audit Office on access to general practice, published last month, warns extreme pressure continues to build on primary care, with challenges including funding and workforce. Auditor General Dorinnia Carville called for the development of ‘sustainable long-term plans’ to address the situation. The report shows that, between March 2022 and March 2023, 13 practices either handed back or gave notice to hand back their contracts. The need to attract locums to these practices has led to trusts (who took over five of the contracts) paying rates of up to £1,000 per day. Workforce issues, including a shortage of GPs, and the failure to roll out multidisciplinary teams are also challenges, as is demand resulting from growing waiting lists in secondary care, the report warns. BMA Northern Ireland GPs committee chair Alan Stout says the report reiterated and validated what the BMA has been warning about for some time. ‘Escalating workload, workforce and financial pressures, coupled with a failure to tackle these issues with sustainable long-term and properly funded solutions, has brought general practice to the state it is in today. ‘This is the latest in a long line of reports published over the past decade which have outlined what needs to happen to save general practice. We can only hope its recommendations do not also fall on deaf ears and that properly funded, long-term, sustainable interventions to save primary care are actioned before it is too late.’
It takes a non woke, retired consultant expert to give an unofficial exit interview to change the abuse of gender reassignment after short term dysphoria (NHS on gender dysphoria). We need to be asking why so late, and why no exit interviews, and if we do them, who should undertake them. The gagging and bullying extend into the whole workforce, and the litigation anxiety of the Trust Boards means that short term issues dominate, along with bullying and denial for both patients and staff.No wonder the service has been decommissioned!We have not heard one minister yet commenting on the Cass report, and certainly my party, the Liberal Democrats have made no sensible statement as yet.. (Although LibDem voice has..) Sajid Javid: NHS let gender ideology replace children’s best interest The Times April 10th 2024. Former health secretary praises findings of the Cass report and calls on all political parties to work together to close puberty blockers loophole. When I was briefed on the NHS’s Tavistock Gender Identity Development Service (Gids) for the first time, I knew this was not just another policy area but a child protection issue and huge medical scandal in the making. As Secretary of State for Health and Social Care at the time, I instructed officials to provide all available support to Dr Hilary Cass, the chair of the Independent Review into Gids. I introduced legislation to support her investigation, and months later, backed the recommendations of the interim report. She has demonstrated exceptional courage throughout and today, her final report is published. Whilst the findings are not surprising, they are no less sickening. Quite simply, ideology replaced the best interests of children, thousands of whom have now been failed in this modern-day scandal. At every opportunity, and in each department I served in, I tried to advance the cause of child protection. In this case, the source of lessons lies within both the clinical practice, and political culture which enabled it to persist for so long. Unless each is resolved, more children will be harmed. In any other setting it is hard to imagine a patient meeting a doctor and the patient telling them what their diagnosis is. Yet the approach of self-diagnoses was the medical pathway adopted at Gids. This resulted in clinicians not showing enough interest in other potential factors, including trauma, social influence, sexual abuse or different conditions. Take the example of autism, which we know about 2 per cent of children in the UK are thought to have. At Gids, a review found that about 35 per cent had moderate or severe autistic traits. Compounding this was the widespread prescription of puberty blockers. Thankfully, that practice in the NHS is changing, but huge loopholes remain in the system. Both private clinics and prescriptions ordered from abroad remain significant problems. In the case of prescriptions, someone could simply order them online to any pharmacy in the country. The government must close this loophole without delay. But this is only one area and many more exist. Despite the specific data legislation I brought forward at Dr Cass’ request, parts of the NHS continue to block access and frustrate the express will of parliament. The common thread between all of these is an extreme gender ideology, which enables them to persist. Across political parties, we need to reassess how effective the commitment is to protecting children and keeping this militant gender lobby at bay; otherwise, this review will be wasted. Only the courage of whistleblowers and activists on this issue was able to provide the beginning of much-needed accountability. Without political support, advocates of the existing system will continue to dominate, as they have in other countries. The same theme of being afraid to tackle “uncomfortable” issues has existed in other areas before, to the detriment of children. Whether it is race, sex, gender or other identity characteristics, politicians cannot let a culture of silence prevail because of political sensitivities. As the introduction of the hate crime law in Scotland demonstrates, the consequence of compliance now risks people being forcibly silenced. party, will need to be tempered. The debate always risks descending into one where far more heat than light is offered, and one where serious policy recommendations fall by the wayside, in favour of stronger words of condemnation. That is why the NHS process was so important. It had the time and power to consider these issues and recommend meaningful change. In a changing society, where many more of these challenges will arise, only substantive processes and firm decisions will effectively manage these complex matters. I experienced first-hand that making policy in this area will never be straightforward. But as a father of four, I know how important securing a positive future on these issues is. All of us will have to navigate a changing society. But as this report today makes clear, never again should that come at the expense of our children.
In 2009 the NHS’s gender identity development service (Gids) saw fewer than 50 children a year. Since then demand has increased a hundredfold, with more than 5,000 seeking help in 2021-22. The sudden increase has gone hand in hand with the adoption of a model of “gender-affirming” care, which puts children on a life-altering path of hormone treatment. Services have been left overwhelmed, with vulnerable young people clamouring for medical interventions to help them change gender — despite a lack of evidence over the long-term effects. It was against this backdrop that Dr Hilary Cass was commissioned in 2020 to examine the state of NHS services for children identifying as trans. Her final report, published on Wednesday, delivers a damning verdict on the medical path thousands of children have been sent down. It marks a turning point in years of bitter debate over how to help this distressed group of young people, confirming a shift towards a holistic model that takes into account the wider social and mental health problems driving the rise in demand.
Gen Z and online porn
The Cass report shines a light on the biggest unanswered question over transgender healthcare: why are so many Gen Z women suddenly wanting to change gender? Cass paints an alarming picture of an anxious and distressed generation of digitally savvy young women and girls, who not only are more exposed to online pornography and the wider problems of the world than any previous generation but also consume more social media and have lower self-esteem and more body hang-ups than their male peers. When Gids opened in 1989, it treated fewer than ten people each year, mostly males with a long history of gender distress. In 2009 it treated 15 adolescent girls. By 2016 that figure had shot up to 1,071.
Cass concludes that such a sudden rise in such a short time cannot be explained alone by greater acceptance of trans identities, which “does not adequately explain” the switch in patient profiles from predominantly male to female. She also says greater investigation of the “consumption of online pornography and gender dysphoria is needed”, pointing to youngsters’ increasingly early exposure to “frequently violent” online material that can have a harmful impact on their self-esteem and body image. Gen Z is defined as those born between 1995 and 2009. Rather than focusing on the issue of gender in isolation, Cass looked at the context in which adolescents today, who have “grown up with unprecedented online access”, are experiencing such a disproportionate crisis over their gender. “Generation Z is the generation in which the numbers seeking support from the NHS around their gender identity have increased, so it is important to have some understanding of their experiences and influences,” she writes. “In terms of broader context, Generation Z and Generation Alpha (those born since 2010) have grown up through a global recession, concerns about climate change and most recently the Covid-19 pandemic. Global connectivity has meant that as well as the advantages of international peer networks, they are much more exposed to worries about global threats.” The report also focuses on 2014, when female referrals to Gids accelerated. Although this is not mentioned, 2014 was the year that CBBC, for example, broadcast I Am Leo, a video-diary-style documentary, to an audience of to 6 to 12-year-olds, showing the positive personal journey of a child who transitioned from female to male. Throughout almost 400 pages, Cass argues that the gender-related issues of young patients should be treated in the same context as the wider mental health issues facing their entire generation. “The striking increase in young people presenting with gender incongruence/dysphoria needs to be considered within the context of poor mental health and emotional distress among the broader adolescent population, particularly given their high rates of co-existing mental health problems and neurodiversity.” Cass calls for more research into the “complex interplay” between these issues and a teenager’s sudden desire to change gender.
Lack of evidence for medical pathway
Rather than affirming children’s gender identity with medical treatment, the report calls for a holistic approach that examines the causes of their distress. It finds that, despite being incorporated into medical guidelines around the world, the use of “gender-affirming” medical treatment such as puberty blockers is based on “wholly inadequate” evidence. Doctors are cautious when adopting new treatments, but Cass says “quite the reverse happened in the field of gender care for children”, with thousands of children put on an unproven medical pathway. Cass says gender care is “an area of remarkably weak evidence” and that results of studies “are exaggerated or misrepresented by people on all sides of the debate”. She adds: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” The report finds that treatment on the NHS since 2011 has largely been informed by two sets of international guidelines, drawn up by the Endocrine Society and the World Professional Association of Transgender Healthcare (WPATH), but that these lack scientific rigour. The WPATH has been “highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency”, Cass says.
Mental health
Mental health issues could be presenting as gender-related distress. Children and young people referred to specialist gender services have higher rates of mental health difficulties than the general population. This includes rates of depression, anxiety and eating disorders. Some research studies have suggested transgender people are three to six times more likely to be autistic than the general population, with age and educational attainment taken into account. Therefore, the report says that the striking increase in young people presenting with gender dysphoria needs to be considered within the context of rising levels of poor mental health. The increase in gender clinic patients “has to some degree paralleled” the deterioration in child and adolescent mental health, it finds. Mental distress, the report says, can present through physical manifestations, such as eating disorders or body dysmorphic disorders. Clinicians were often reluctant to explore or address co-occurring mental health issues in those presenting with gender distress, the report finds. This was because gender dysphoria was not considered to be a mental health condition. The report finds that, compared with the general population, young people referred to gender services had higher rates of neglect; physical, sexual or emotional abuse; parental mental illness or substance abuse; exposure to domestic violence; and loss of a parent through death or abandonment. The report says there was “no evidence” puberty blockers allowed young people “time to think” by delaying the onset of puberty — which was the original rationale for their use. It finds the vast majority of those who start puberty suppression continued on to cross-sex hormones, particularly if they started earlier in puberty. There was insufficient and inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health, it says, and some young females had a worsening of problems like depression and anxiety. Cass says there is “some concern” that puberty blockers may actually change “the trajectory of psychosexual and gender identity development”. Her report warns that blocking the chronological age and sex hormones released during puberty “could have a range of unintended and as yet unidentified consequences”. It describes adolescence as a time of “identity development, sexual development, sexual fluidity and experimentation”. The report says “blocking” this meant young people had to understand identity and sexuality based only on their discomfort about puberty and an early sense of their gender. Therefore, it adds, there is “no way of knowing” whether the normal trajectory of someone’s sexual and gender identity “may be permanently altered”. Brain maturation may also be “temporarily or permanently disrupted” by the use of puberty blockers, it says. This could have a significant impact on a young person’s ability to make “complex risk-laden decisions”, as well as possible long-term neuropsychological consequences. The report highlights the “concern” of young people remaining on puberty blockers into adulthood — sometimes into their mid-twenties. This is partly because some “wish to continue as non-binary” and partly because of ongoing gender indecision, the report says. Cass adds: “Puberty suppression was never intended to continue for extended periods.” The report finds young adults who had been discharged from Gids “remained on puberty blockers into their early to mid twenties”. A review of audit data suggested 177 patients were discharged while on puberty blockers. Cass says the review “raised this with NHS England and Gids”, citing the unknown impact of use over an extended period. “The detrimental impact to bone density alone makes this concerning”, the report adds.
A Dutch study originally suggested that puberty blockers might improve psychological wellbeing for a narrow group of children with gender issues. Following this, the practice “spread at pace to other countries” and in 2011 the UK trialled the use of puberty blockers in an early intervention study. The results were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes. It also found that 98 per cent of people had proceeded to take cross-sex hormones. Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice. “The rationale for this is unclear,” the report says. Puberty blockers were then given to a wider range of adolescents, it says, including patients with no history of gender issues before puberty and those with neurodiversity and complex mental health issues. Clinical practice, Cass found, appeared to have “deviated” from the parameters originally set. Overall, the report concludes there was a “very narrow indication” for the use of puberty blockers in males to stop irreversible pubertal changes, while other benefits remained unproven. It says there were “clearly lessons to be learnt by everyone”.
Social transition
The report concludes it was “possible” that social transition, including the changing of a child’s name and pronouns, may change the trajectory of their gender development. It finds “no clear evidence” social transitioning in childhood has any positive or negative mental health effects, but that children who socially transitioned at an earlier age were more likely to proceed to medical treatment. A more cautious approach to social transition needs to be taken for children than for adolescents, it concludes. The review also heard concerns from “many parents” about their child being socially transitioned and affirmed in their expressed gender without their involvement. Draft government guidance, published in December, stated that schools should not accept all requests for social transition and should involve parents in any decision that is made. Despite this, there has been evidence of schools ignoring ministers and allowing children to change gender behind their parents’ backs. The report makes clear that “parents should be actively involved in decision making” unless there are strong grounds to believe that it may put the child at risk. It also finds that social debates on trans issues led to fear among doctors and parents, with some concerned about being accused of transphobia. The interim report, from 2022, had classed social transition as “not a neutral act”. The full report explains that it is an “active intervention”, because it may have significant effects on a young person’s psychological functioning and longer-term outcomes. In a strong warning to schools, the report describes the need for “clinical involvement” in the decision-making process on social transitioning. It adds: “This is not a role that can be taken by staff without appropriate clinical training.” The report concludes that maintaining flexibility is key among those going down a social transition route and says a “partial transition”, rather than a full one, could help. In decisions about whether to transition prepubescent children, families should be seen “as early as possible by a clinical professional”.
Rogue private clinics
Long waiting lists for NHS care mean distressed children are turning to private clinics or resorting to “obtaining unregulated and potentially dangerous hormone supplies over the internet”, the report says. Some NHS GPs have then felt “pressurised to prescribe hormones after these have been initiated by private providers”, and Cass says this should not happen. The report also urges the Department of Health to consider new legislation to “prevent inappropriate overseas prescribing”. This is intended to tackle a loophole which means that, despite the NHS banning the use of puberty blockers last month, children can still access them from online clinics such as GenderGP, which is registered in Singapore.
Detransitioning
Cass says some of those who have been through medical transitions “deeply regret their earlier decisions”. Her report says the NHS should consider a new specialist service for people who wish to “detransition” and come off hormone treatments. She says people who are detransitioning may be reluctant to return to the service they had previously used.
NHS numbers
The report recommends that the NHS and Department of Health review current practice of issuing new NHS numbers to people who change gender. Cass suggests that handing out new NHS numbers to trans people means they risk getting lost in the system — making it harder to track their health histories and long-term outcomes. The review says that this has had “implications for safeguarding and clinical management of these children”, — for example, the type of screening that they are offered.
Toxic debate
Cass has called for an end to the “exceptionally toxic” debates over transgender healthcare after she was vilified online while compiling her review. In a foreword to her 388-page report, the paediatrician said that navigating a culture war over trans rights has made her task over the past four years significantly harder. She warned that the “stormy social discourse” does little to help young people, who are being let down by a lack of research and evidence. Cass added: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop. “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.” Cass said: “Finally, I am aware that this report will generate much discussion and that strongly held views will be expressed. While open and constructive debate is needed, I would urge everybody to remember the children and young people trying to live their lives and the families/ carers and clinicians doing their best to support them. All should be treated with compassion and respect.”
The recommendations
Data collection Gender identity clinics should offer their data to NHS England for review, and more research should be conducted on the impact of psychosocial intervention — such as therapy — and the use of masculinising and feminising hormones, such as testosterone and oestrogen. Cass recommended that the NHS should also consider data from private clinics.
Puberty blockers and hormone treatment Cass recommended research to establish the long-term impact of puberty blockers, which is expected to start by December.
Assessment of other conditions Cass said that children arriving at gender identity services should be screened for conditions such as autism and other neurodevelopmental conditions.
Criteria for medical treatment When treating children with gender dysphoria, only those who have experienced “longstanding gender incongruence” will be able to get medical treatment. Even then, this will only be available — with “extreme caution” — for over 16s.
A holistic approach Before any medical intervention, Cass recommends that children should be offered fertility counselling and “preservation” by specialist services. This formed part of a more “holistic” approach to gender identity services. Cass suggested the creation and implementation of a national framework and infrastructure for gender-related care.
Growing into adulthood The review advised that follow-through services for 17 to 25-year-olds should be established to ensure a continuity of care and support when children grow into adulthood.
Detransitioners The report proposed that NHS England should “ensure there is provision for people considering detransition”, while recognising that they may not wish to attend services that assisted in their initial gender transition.
Update 12th April 2024Times letters: Cass review and the use of puberty blockers Sir, The recommendations in the report of the NHS review chaired by Dr Hilary Cass (“NHS rejects use of puberty blockers”, news, Apr 10) are excellent: I support all of them. What is missing from the report is an explanation for the unsatisfactory clinical service provided at the Tavistock Clinic. This must begin with an account of the development of gender identity, which normally occurs between two and four years. Rarely, the identity is opposite to that of the biological sex and this gives rise to gender dysphoria (discomfort). Sound research findings from the 1990s onwards suggest medical treatment (including puberty blockers) for this tiny group is indicated after in-depth assessment and counselling. From about 2005 all over the developed world, a different group — teenagers — presented to clinics with gender dysphoria. These were mainly biological girls who had a male identity. In all probability these were drawn from that minority (about 10 per cent) of adolescents who suffer from identity confusion and who were further confused by what they read on social media. These probably accounted for the bulk of referrals to the Tavistock Clinic which, sadly, sometimes failed them diagnostically. Philip Graham Emeritus professor of child psychiatry, UCL; London NW5 Sir, I wonder how history will judge the appalling use of puberty blockers in children with gender dysphoria. The lack of evidence is totally at odds with other branches of medical care, where evidence-based medicine is the gold standard. Doctors who raised concerns as long ago as 2005 were criticised, ignored or even sacked. As GPs, we can be asked to prescribe by gender clinics, including the Gender Identity Development Service. The only position to take is to follow NHS guidelines, which allow puberty- blocking hormones. To decline on personal grounds leaves one open to complaints or a claim of discrimination. The Cass report is a welcome breakthrough. Doctors must have the freedom to express doubts about unproven, experimental treatments without the risk of attracting personal criticism and bullying. This degree of mass child abuse must not be allowed to happen again. However uncomfortable or politically sensitive an issue is, to prevent a future scandal we need open debate and evidence- based medicine. Dr Fiona Cornish, GP Cambridge Sir, In light of the publication of the Cass report, I am concerned that the licensed use of puberty blockers for the treatment of precocious puberty in children — when puberty starts at an unusually early age, sometimes as young as two — may be misunderstood. These highly targeted drugs have been available for decades, have an excellent safety profile and are of huge benefit to the affected children and to their families. They revolutionised treatment and there is extensive published follow-up data. These children may have serious brain problems such as tumours or severe learning disability. After treatment, children with precocious puberty can continue into puberty at an appropriate age. It is important that we distinguish between the safety of the drugs and their unlicensed use in a situation where the long-term effect of puberty blockers and the use of transgender hormones are poorly understood. To regard this group of drugs as dangerous, as your leading article (Apr 10) appears to do, is misleading — it is the reason for using them that is the point. Dr Tony Hulse Former consultant paediatric endocrinologist, Evelina London Children’s Hospital; Hadlow, Kent Sir, In my 40 years in senior positions in secondary and comprehensive schools I was closely involved in the pastoral care of thousands of young girls and boys. Not once did I encounter a pupil who wished to change their gender. Noel Simpson Midhurst, W Sussex
Sir, The rise in children and adolescents referred to the NHS Gender Identity Development Service in the UK from 2009 to 2016 firmly aligns with the rise in popularity of smartphones and social media from 2010. With 88 per cent of those aged 16 to 24 owning a smartphone in 2014 and social media networks almost tripling their user base in the past decade, 2014 is identified by the Cass report as the point at which referrals to gender identity youth services in the UK spiked for teenage girls. In light of the Cass report, the question to ask is whether social media accessed omnipresently on smartphones by our children has been a contributory factor. Children approaching puberty and a difficult phase of adolescence may find themselves being exploited rather than supported via social media, smartphones and the network of influencers that inhabit such a space. The government should regulate such devices and content to protect children from online coercion and harm. Arabella Skinner, Safe Screens Miranda Wilson, Teched Off
Sir, This disaster has echos of the child abuse scandal of the late 1980s. Then “diagnostic signs” of abuse were used to falsely convict hundreds of innocent people. Whenever clinicians use diagnostic signs in new and radical ways they must submit to rigorous research before applying these practices on vulnerable patients. Few patients are more vulnerable than children. Those of us with years of experience have been trying to point out that a desire to be the opposite sex and to feel strongly attracted to members of the same sex are normal phases of development that children pass through. They require sympathy and reassurance, not labelling and treatment with life-changing drugs. It is the one clear obligation of parenthood that children require guidance. The present idea that every preference of the child should be indulged is nonsense. The algorithms of the internet reinforce user preference; this dangerous and perverse trait should be removed to ensure that all information is balanced. That way, misguided parents would not put pressure on clinicians (who should know better) to provide seriously harmful treatments. Just because it is possible to do something does not mean it should be done. This simple advice is normally part of medical education and needs to be clearly understood. Dr John Orchard FRCGP Retired GP and associate dean of postgraduate medical education; Youlgrave, Derbyshire
Multiple reforms of the Health Services have failed. No wonder the public feels disillusioned. The long term opportunity to tell the truth is lost because politicians know that if they implement what is needed they wont be elected again. A scapegoat government is needed. Mr Streeting talks about the NHS, but he means England.On this he knows he is “gagged” by his own party. The letter below about staffing for surgery is easily addressed by the current administration: just let “medical assistants” operate instead of real doctors! The Times letters April 10th 2024 following Wes Streeting trying to make Labour think seriously about reform: “Reform of the NHS”. Sir I am not sure if Wes Streeting is correct in identifying “middle-class lefties” as those who seek to prevent him from using private hospitals to reduce waiting lists, but I applaud his intention to take them on (“ ‘Middle-class lefties’ won’t hold me back, says Streeting”, Apr 9). That vocal group insist all services must be provided by direct employees of the NHS. Do they not appreciate that a large proportion of NHS services are already provided by private enterprise? Medicines, drugs, operating equipment (scalpels, lights, gases, etc) and prostheses are all provided by private industry. Perhaps they are referring only to staff? One of the largest contributory sectors of the NHS, GPs, are not employees of the NHS but are private contractors. The critical element in Mr Streeting’s objective is that, whoever provides the service, it is free to the patient, ie the cost is borne by the taxpayer. All strength to Mr Streeting’s elbow. John Evans Wingerworth, Derbyshire
Sir, Wes Streeting is right to question the shortcomings in our health system but his contention that “everyone should be able to have timely access to healthcare but not have to worry about the bill” seems an aspiration too far. While users of healthcare services may not have to worry about post-treatment costs, they will certainly have to contribute through better advance funding mechanisms. He may consider the difference in waiting times between the NHS and private healthcare to be “a disgrace” but those going private have paid twice (once to the NHS through tax and national insurance contributions and again to their insurer), whereas many NHS users have paid very little or nothing. Stuart Southall East Horsley, Surrey
Sir, It is not “inexcusable” that NHS operating theatres lie empty in the evening and at weekends, it is inevitable (“Sacred Cow”, leading article, Apr 9). There are too few staff to safely man the service during the week, so how will any government find the additional trained staff to provide a full weekend service? This is political magical thinking. Dr Bob Bury Leeds
The Sun April 7th 2024: THE Shadow Health Secretary warns the NHS today that there will be no additional funding without the “major surgery” of reform under Labour. – Wes Streeting asks for Sun readers’ backing for a massive overhaul of our troubled healthcare system. Wes Streeting warns the NHS that there’ll be no additional funding without ‘major surgery’ under Labour. Wes Streeting and Sir Keir Starmer unveil plans to digitise massive amounts of NHS paperwork with an overhaul of the NHS app. It would include bringing in the private sector to help cut waiting times. Mr Streeting says an extra £1.1billon of funding will only come with agreement to get the NHS operating throughout the weekend to slash lists. He also vows that “spare capacity in the private sector” will be used to help. Pitching himself against healthcare unions and Labour supporters, he says “middle-class lefties cry ‘betrayal’”, but he is “up for the fight”. And he warns the entire conversation about our creaking system must move from money to results. Writing below, he says: “The NHS is a service, not a shrine. “It is judged by how well it serves the public, not how heavy a price we’re paying for failure.” The fiery words come as he and Labour leader Sir Keir Starmer unveil plans to digitise massive amounts of NHS paperwork with an overhaul of the NHS app — giving notifications of scans, GP availability and direct access to medical records. And children’s health records will be available to their parents via the app to allow mums and dads to easily see if little ones are behind on jabs or check-ups. It is hoped that the changes will turn around falling numbers in vaccines for measles.
‘ONLY WE CAN CURE THIS’
By Wes Streeting, Shadow Health Secretary JUST one in every four people say they are satisfied with the NHS today. Who can blame them? Record numbers of people are waiting for treatment, and they are waiting longer than ever before. 24 Hours In A&E isn’t just a TV programme, it’s reality for thousands. Patients are literally queuing around the block to see a dentist. Rishi Sunak responds that he is putting in record amounts of funding. But the NHS is a service, not a shrine. It is judged by how well it serves the public, not how heavy a price we’re paying for failure. The problems with the NHS are clear. It’s a 20th century service that hasn’t changed with the times and isn’t fit for the modern era. It catches illness too late, which means worse care for patients at greater cost to the taxpayer. It costs the NHS about £40 to provide a GP appointment. But if patients can’t get an appointment, they end up in A&E, which costs around £400. We’re paying more but getting less. This can’t go on. If the NHS doesn’t change, it will die. For the Conservatives, the NHS is covered in flashing signs warning, “Danger: Do Not Touch”. They know the public don’t trust them with it, so they daren’t change it. Only Labour can reform the NHS. It won’t happen overnight. It will take a decade of change and modernisation to make the NHS fit for the future. But if we marry Britain’s greatest scientific minds and tech entrepreneurs with the NHS, this country will go to the front of the queue for the revolution in medical treatments coming over the horizon. That’s how the NHS rolled out the fastest vaccine in history. If we did it to defeat Covid, why not to cure cancer and dementia? Cutting waiting lists will be our top priority and Labour has a plan to do it. Operating theatres lie empty on weekends while millions of patients wait. Labour will get the NHS working around the clock, with an extra two million appointments on evenings and weekends a year. That’s the reform. It will come with investment of £1.1billion, to pay staff for the extra shifts. With Labour, investment will always be linked to reform. Pouring more money in without reform would be like pouring water into a leaky bucket. We will also use spare capacity in the private sector to cut the waiting lists. Middle-class lefties cry “betrayal”. The real betrayal is the two-tier system that sees people like them treated faster — while working families like mine are left waiting for longer. Hours of doctors’ and nurses’ time is wasted by outdated equipment. Labour will bring our analogue service into the digital age. As a first step, we will put artificial intelligence technology in every hospital, and make proper use of the NHS app to give patients real choice and control. GPs are currently measured by 55 targets. Too much time is spent filling in forms and ticking boxes. Labour will fix the front door of the NHS so more people get care in their own neighbourhood, starting by cutting the red tape that ties up GPs’ time to bring back the family doctor. I don’t pretend reform will be easy. There will always be vested interests who resist change, but I’m up for the fight. The NHS saved my life when I had kidney cancer and now I’m determined to save our NHS. That is why I’m asking Sun readers to vote for change, and give Labour the mandate we need to fundamentally reform the NHS. Sticking plasters won’t do — the NHS needs major surgery and only Labour can deliver.
On Radio 4 today Dr Adrian Boyle from the Royal College of Emergency Medicine ( 07.13) opines on the perverse outcomes in A&E. Some prople wait a very long time indeed. The low threshold for performance means that all the attention is made on people who can return home. There is a financial incentive for hospitals to deal with those who are less unwell faster! The perverse outcomes are exposed by Dr Boyle. He is not against a target (or two) but he points out that the strokes and heart attacks dont get the speedy attention they deserve. At @ 06.40 Hugh Pym describes the claim for “improved” waiting, but the “long waits” have got worse. At 07.21 Philip Hammond describes the “three Ds” meaning: The Demographic challenge, Decarbonisation, and Defence. “The challenge with a more honest conversation in a democracy is, as all politicians know, voters don’t want to hear this: they want politicians to resolve it for them. They want politicians to find a way round it, and so politicians either focus on an economic solution, which is a productivity revolution, or they focus on improving the efficiency of public serv ices at the margin, or collecting a bit more tax from people who are perhaps not paying as much tax as they should be. I think the real issue here is to get the public to engage with the opportunity of technological innovation across the economy being a way of raising our productivity game, but the truth is we have not done well on productivity, certainly since the 2008 global financial crisis. The formidable problem is for our democratic politics …. despite the polls rejecting the conservatives the labour party has no magic bullet. The Luxemburg Prime Minister, Xavier Bettel said “We all know how to reform our countries, but we then dont know how to get elected afterwards”.
NHSreality supports My Life My decision. The fact is that we are not in a celestial world where palliative and terminal care is given by a family doctor who has known the household for years. This trusted person is nearly extinct. I will never get the standard of care that my generation of GPs gave to their patients. A lack of continuity, too few but part time and inadequately trained professionals, and a post code rationed system where 80-90% of the money has to be raised by charitable methods, means that we will be dying in a “war zone”. In a war we are happy to have anyone sew up our wounds, and give first aid. This is where we are going in palliative care in the UK. Standards will vary remendously from the asset rich suberban shires, to the impoverised and left behind coastal towns. So we need to have a choice when our time comes. If we want the system to be “cheaper” we need to maximise those dying at home. Hospices are expensive, but diamorpine is cheap. In Which countries are these practices permitted?Assisteddying: What does the law in different countries say?
The Netherlands, Belgium and Luxembourg permit euthanasia and assisted suicide
Switzerland permits assisted suicide if the person assisting acts unselfishly
Colombia permits euthanasia
California has just joined the US states of Oregon, Washington, Vermont and Montana in permitting assisted dying
It seems quite normal to me that there should be an increase if something is new and in demand. Eventually NHSreality expects the Canadian numbers to settle down to a small fraction of the population. Those who exercise choice and autonomy in this way should not be derided or discouraged provided there is informed consent. The percentages of eligable deaths in each country might be more helpful in future. Hanna Geissler for the Express today 4th March opines “Britain ‘behind the curve’ of public opinion on assisted dying, MP says” and Times letters below 16th Feb 2024 agree.
Back in July 2021 when the health services were beginning to implode (The Minister was Matt Hancock!) in covid, the Scottish edition printed this letter: We already have what we need to die with dignity Sir, Assisted suicide is being suggested to the Scottish people as a lawful way to end some people’s lives. The Sunday Times and a cross-party group of Scottish MSPs have decided to dress up assisted suicide as “dignity in dying”, a clever euphemism that suggests many people do not have dignity in death. I have been a witness to six deaths within my family in the 61 years of my life, and all my family members had deaths that were eased with painkillers — ie, morphine — and a benzodiazepine such as diazepam to ease anxiety. They all died with dignity without resorting to suicide. I would strongly advise the Scottish people to fight any change in the law related to assisted suicide. There are enough effective drugs, palliative care teams and good hospice facilities to assist the dying without resorting to suicide. In my opinion it would rip many families apart, with some members agreeing with the decision to assist suicide and others disagreeing with it. John Smith, Falkirk
Assessing value of life
Michael Veitch (“MSPs must listen on assisted dying”, Letters, last week) presents the inherent value of human life as a coup de grâce against the argument for assisted dying. One can believe in the value of life but also in the idea that ultimately it is up to the individual to decide whether their life still has value to them. In which case, is there not an inherent value in a good death for those individuals with a terminal illness facing a difficult end? Allison Wroe, Edinburgh
Letters on End of life strategy 2nd March 2024: Sir, The health and social care committee is to be commended for its thorough and even-handed addressing of the complex issues involved in assisted suicide and euthanasia (“We need a national assisted dying strategy, say MPs”, Feb 29). The committee wisely decided not to recommend action towards a change in the law. As HL Mencken once observed: “For every complex problem, there’s a solution that is simple, neat and wrong.” Everyone who thinks that the case for legalising assisted suicide is self-evident should read this report. Baroness Finlay of Llandaff Professor of palliative medicine
Sir, Both sides want the same outcome: a dignified and peaceful death, preferably at home. But for many disabled people, the unintended consequences of change loom large. I am not convinced that legislators can safeguard against human nature. With quality domiciliary care for the sick and disabled ruinously expensive and house prices temptingly distorted, mission creep seems inevitable. Anthony Stone London SW19
Gordon Macdonald, of Care Not Killing, misses the point about assisted dying (Letters, last week). He notes that MPs have voted against it, but our representatives are badly out of touch with the electorate on this subject. Politicians are providing what they feel is right for the population rather than what we want. Glyn Edmunds, Hayling Island, Hampshire
Wrong arm of the law Let me get this straight: the police no longer have time even to attend the scene of many burglaries, let alone investigate them; they do, though, have time to investigate the terminally ill seeking assisted dying, and their distressed relatives, at what are possibly the worst moments of their lives. Burglary laws have public support; harrying the dying does not. The police should simply refuse to investigate the latter — if necessary, citing the same lack of resources that they use in the former. Rita Johns, Bramley, Surrey
Concerning statistics Macdonald says in Oregon “a majority of those ending their lives cite fear of becoming a burden as a reason”. Without context, this is misleading. Oregon’s statistics show the three most frequent end-of-life concerns are loss of autonomy (91.7%), decreasing ability to participate in activities that made life enjoyable (90.5%) and loss of dignity (66.7%). This is why such claims need the proper scrutiny of an independent inquiry. Trevor Moore, chairman, My Death, My Decision
The poaching of our own expensively trained docs by Canada and Ireland is in the medical news. NHSreality would not blame any doctor or nurse in todays bullying and gagging and uncaring dispensation within the 4 UK systems, for leaving the UK. We poached from all over the world for decades, and now the boot is on the other foot. West Wales BMA passed resolution in debate to “ration overtly” and to “have an honest debate” on the options in health – and that was over 10 years ago. The sustainability of the current politisised system is impossible when the pace of technological advance is faster than any government can fund. NHSreality has pointed out that few GPs do post registration jobs in Psychiaty or Paediatrics, and that many male doctors are unable to examine women internally..No solution is in sight for all these problems until we have Proportional Representation (PR).Once we have PR we can change the system, ration overtly, and charge in some way that encourages self care for all. BMJ Letters: We’ve failed our Generation Next of doctors – Listen to the voices of the next generation of doctors BMJ 2024;384:q347 Harshit Kondapally, foundation year 3 doctor, Ellie Jackson, foundation year 2 doctor As members of “generation next,” we know that there are several reasons contributing to a sense of being failed.1 Throughout history, a career in medicine was thought to have great job security. Doctors today, however, find themselves in an increasingly competitive job market with tightening bottlenecks at every stage of training. There has been an admirable, but perhaps shortsighted, drive towards increasing medical school places in recent years with less thought given to increasing specialty training positions. Internal medical training, for example, has increased its vacancies from 1550 to 1633 over the past eight years, but the number of applications in the same timeframe rose from 2631 to 4406, with this year’s number of applications at 6174, an increase of 43% compared with last year.2 It seems an increasingly bleak prospect for current medical students. We agree with Kar that the rise in anonymous accounts on social media is a symptom of the current system of raising workplace concerns. But if doctors felt that raising concerns through the traditional chain of command led to tangible improvements, we wouldn’t see social media being used as a substitute. This problem is compounded by the rotational training model, which is receiving renewed scrutiny by BMA members.3 Is a four to six month rotation long enough to make meaningful improvements in departmental systems? Are rotations too short to foster a culture of teamworking where concerns can be raised openly? Given the range of causes for increasing dissatisfaction and rates of burnout,4 it is no surprise the current generation of doctors seems more vocal than ever. We hope the near future brings about a change in our culture so we can have more open conversations about these matters, whether it is with our trusts, royal colleges, or our regulator. Until then, we must listen to the voices of our next generation of doctors, even if they come from behind a keyboard.
We seem to give plenty of money to research, cancer, but not enough to treat all our citizens, and the elderly in particular. The fact is that all lives are not equally valuable (vertical equity) and if care is rationed then it is appropriate to put a 24 year old before a 74 year old. It might be acceptable that those in work are operated on before those who are retired. After all it is workers taxes that are funding the system. Lack of foresight, planning and political denial have conspired together to create the anarchic, unfair, post coded, covert maelstrom of medical care that is the UK. Civil unreast is a risk, and it is essential to balance up life’s chances across the nation if we are to avoid it. If its going to get worse, at least make it fair! I suspect many elderly people have a better death by not having the most aggressive therapies, but this should be their choice rather than that of their consultant. Perhaps this explains the differences in survival and we have sensible rationing of oncological treatments. Informed consent only comes when there are alternatives, and oncologists are not consulting patients along with with GPs &/or Palliative Care consultants yet. We just don’t have the staff! Laura Donelly in the Telegraph reports 27th Feb: UK cancer survival rates lag 15 years behind other major countries – Patients in Britain more likely to be denied chemotherapy or radiotherapy than those in Australia, Canada or Norway UK cancer survival rates are lagging 15 years behind other major countries because of a lack of chemotherapy and radiotherapy, research shows. For the first time, experts at University College London examined the differences in treatment for eight cancer types across three continents. They found cancer patients in the UK were much less likely than people in other countries to receive chemotherapy or radiotherapy. Those who did receive it were forced to endure longer waits, while the disease was spreading. The differences were most stark among older patients, with those in Canada seven times as likely to receive chemotherapy, compared with those in Britain. Researchers said the lower rates of treatment in the UK helped explain why Britain’s cancer survival rates were 15 years behind those of comparable nations. Across the countries examined, the UK was worst for cancer of the stomach, lung, colon and ovaries. The UK five-year-survival rate for stomach cancer was just 20.8 per cent in 2010-14. This is lower than figures other countries achieved 15 years earlier. In 1995 to 1999, Australia had survival rates of 25.7 per cent, while Canada had 21.5 per cent, with 21.3 per cent in Norway. Experts said NHS shortages of both staff and equipment meant patients were too often being denied treatment or waiting so long that it could no longer benefit them. The studies, funded by Cancer Research UK and the International Cancer Benchmarking Partnership, published in the Lancet Oncology examined data from more than 780,000 patients in Australia, Canada, Norway and the UK diagnosed between 2012 and 2017. In total, just 31.5 per cent of cancer patients in the UK received chemotherapy, compared with 42.1 per cent in Australia, 38.5 per cent in Canada, and 39.1 per cent in Norway. For radiotherapy, the UK figure was just 19.8 per cent, compared with 25.7 per cent in Canada, 23.9 per cent in Australia and 22.5 per cent in Norway.
Older patients fared particularly badly in the UK. Just 2.4 per cent of UK patients aged 85 and over received chemotherapy, compared with 8.1 per cent in Australia and 14 per cent in parts of Canada. Experts have also warned of “fatalistic” attitudes – especially towards older patients, and those with other health problems – with rushed consultations meaning that there was not enough time to explore treatment options. Dr John Butler, clinical lead for the International Cancer Benchmarking Partnership and an ovarian cancer surgeon, said: “For many aggressive cancers – such as ovarian, lung and pancreatic cancer, it’s vital that people are diagnosed and start treatment as soon as possible. “Lower use of chemotherapy and radiotherapy in the UK could impact people’s chances of survival, especially for older patients. “Although we have made progress, the last benchmark showed that cancer survival in the UK is still around 10 to 15 years behind leading countries. “This study captures missed opportunities for patients in the UK to receive life-prolonging treatment.” Dr Butler said there were a number of likely factors behind the trend. “In some cases, it’s about patients being so unwell by the time they are diagnosed that they are not well enough to receive chemotherapy. And furthermore, if there are long delays in the diagnostic pathway then that is more likely.” He said the low rates could also reflect “nihilism” from some doctors, in assuming that the side effects of treatment were not worth the potential benefits, particularly in elderly patients. The figures, which used international benchmarking data, tracking survival between 1995 and 2014, found that the UK figures were often on a par with other countries 15 years earlier. For colon cancer, the UK’s rate of 58.9 per cent in 2010-14 was similar to those in Australia and Canada 15 years earlier. Australia now achieves survival rates of 70.8 per cent for colon cancer, while Canada is at 66.8 per cent. UK lung cancer survival, at 14.7 per cent, is similar to the rates in Australia and Canada 15 years ago. Latest benchmarking data has Australia at 21.4 per cent and Canada at 21.7 per cent.
Michelle Mitchell, chief executive of Cancer Research UK, said: “All cancer patients, no matter where they live, deserve to receive the highest quality care. “But this research shows that UK patients are treated with chemotherapy and radiotherapy less often than comparable countries. “When it comes to treating cancer, timing really matters. Behind these statistics are people waiting anxiously to begin treatment that is key to boosting their chances of survival.” Prof Pat Price, a leading oncologist and chairman of the charity Radiotherapy UK, said the study showed “devastatingly” poor levels of access to treatment. The co-founder of the Catch Up With Cancer campaign said: “A shortage of oncologists and front-line staff to deliver treatment, insufficient equipment, lengthy travel times, a negative approach to cancer care, particularly in the elderly, and an acceptance of variable and poor care in some parts of the country have all resulted in patients not receiving the treatment they need. This is simply not good enough for cancer patients and is costing lives.” The study also compared trends within the UK. Take up of chemotherapy and radiotherapy was lowest in Northern Ireland and Scotland. The studies also found the average time to start chemotherapy was 48 days in England, 65 in Scotland, 57 in Northern Ireland and 58 in Wales. In New South Wales, Australia, the wait was lower at 43 days and 39 in Norway. For radiotherapy, the UK fared even worse, with it taking 63 days to start treatment in England, 53 in Northern Ireland, 79 in Scotland and 81 in Wales. In Alberta, Canada, the figure was 48 days and 53 days in British Columbia, while in New South Wales, Australia, it was 43 days. An NHS spokesman said: “More people than ever are being diagnosed at an early stage of cancer and more treatment options are available – and over the last 12 months, nearly three million people received potentially life-saving cancer checks compared to 1.6 million in 2013. “Whilst cancer survival is at an all-time high, it remains crucial for people to come forward and get checked if they have unusual symptoms – finding cancer earlier saves lives.” A Department of Health and Social Care spokesman said: “These figures cover only the period from 2012-2017. “Since then, we have made significant investment in cancer diagnosis and treatment, including £162 million towards radiotherapy equipment and £2.3 billion to launch 160 Community Diagnostic Centres across England, which will help us achieve our aim of catching 75% of all cancers at stage one or two by 2028. “Cutting waiting lists is one of the Government’s top five priorities, and we have treated record numbers of patients over the last year. “Survival rates are also improving across almost all types of cancer, and we will shortly legislate to create the first smoke-free generation – the biggest single public health intervention in decades.”
We have a large proportion of the younger generation feeling disenfranchised in the FPTP (First Past the Post) system we have now, and so being unwilling to waste their time voting. The drivers towards this are lack of housing, lack of reliable altruistic long term politics, fast media distribution of often false news, (Girls Mental Health especiallyis threatened) and a threat that they might be conned by the media… And of course the betting industry will complain! There is the added risk of “spiked drinks” which has happened to Kate McCann (Times Radio) and other celebrities and a brigade of people. The mental health of dying patients is better with continuity of care, but we all know thats a dream now. Choosing how we die is important… The Fench are removing state provision of drugs for new cases of non psychotic depression.and anxiety. The bill for “Big Pharma” should reduce, and the savings made fund the alternative treatments for depression: exercise, gardening, singing, art, hobbies etc. We in the profession know how hard it is to stop these drugs, but also how many side effects and unintended consequences there are. Overuse of Benzodiazepines, intensively marketed over decades, has led to a dependency culture. We fell into the same trap with Opiates and in the USA particularly, fentanyl is the coming plague which is possibly coming here. Gambleing, encouraged by on-line living, is an oncoming tsunami as well.. We need to treat and care for those with psychosis, and with the oncoming drugs epidemic there will be many more of them. The NHS has one of the worst sickness and absentee rates in the world. This is partly because it acts as a working safety net for many low paid workers. It also employs many part timers, and it needs to provide creche and schooling facilities for these workers if they are to work maximally and efficiently with less time away. The “friday afternoon” culture means that hospitals, and recently, schools are now much less efficient than they used to be. In my neglected town centre children appear at friday lunchtimes with noone at home. They are free to do as they wish, and often the health and social care services are at low staff levels concurrently. Junior doctors in GP training should all do a session in Psychiatry as this may become the bulk of their work… As a doctor said to me the other day, many patients each day come to see them and say “Its m’e mental Dr”….
in the Spectator 22nd Feb 2024: Why Britain stopped working – there is a 50 minute podcast to explain the differences both before and aftter covid between the UK and the rest of the world. “According to The Spectator’s calculations, had workforce participation stayed at the same rate as in 2019, the economy would be 1.7 per cent larger now and an end-of-year recession could have been avoided. As things stand, joblessness is coexisting with job vacancies in a way that should be economically impossible, writes Kate Andrews in the cover story. She joins the podcast alongside Paul Nowak, general secretary of the Trades Union Congress (TUC), to debate the problems plaguing Britain’s workforce. (03:11)” ….. “One factor seems to be the inability of medical and welfare services to help with mental health problems” “Over 22% of the working age population in Middlesborough is unemployed. In Hartlepool its 24%; in Blackpool 25%. Were watching these people waste away..”…. “Britain is one of only a handful of countries …whose workforce has not bounced back”. “Even in 2019, a year before lockdowns, the number of working age people who were off with long term sickness had already risen to 2 million. Now its almost 3 million”. “The department of work and pensions predicts it to increase by another 1 million in the next 3 years. According to the ONS 53% of those off work with depression.. ” “Workers are disincentivised from increasing theit hours, as their efforts yield diminishing rewards,” “working age disability benefits are expected to rise from £19bn to £29bn in the next partliament, while the bill for working age incpacity will jump from £26bn to £34bn. ” “In april the income tax to be paid by a cleaner working 35 hrs on minimum wage will be almost 50% higher (than in march) due to “fiscal drag”, the stealth tax whereby thresholds are frozen rather than raised in line with inflation. Some of the lowest paid workers will be hit hardest in proportion to their pay, with those on £16000 losing £780 – equivalent to about 5% of their earnings” Meanwhile council tax will also rise… A single parent working 30 hours a week could stand to lose 76p of every £1 they earned in extra work, due to the withdrawal of universal credit and the loss of other benefits.”
Sir, Regarding your report “Anti-psychotic drug reviewed after 400 deaths” (Feb 19), I have met Kate Northcott Spall and it is clear she has an important story to tell. We identified areas where the standard of care for people with schizophrenia and other forms of psychosis could be improved and I am confident that her brother’s experiences will help to drive change. Clozapine is the most effective treatment for schizophrenia and other psychoses. However, it is also associated with side effects that can be life-threatening when not monitored effectively, and there have been cases where it has contributed to deaths that could have been prevented. There also exists longstanding discrimination against people with severe mental illness. Services for them are under-resourced; there is little research around their needs; and they are made to feel ashamed about their condition, so hide it or do not engage in treatment. This can no longer continue. We must create an environment where everyone can thrive and participate in society. Dr Lade Smith President, Royal College of Psychiatrists
27th Feb – What’s going on with girls’ mental health? BBC Claudia Hammond and guests consider the worrying statistics around mental health issues in children and young people – in particular, the long-term trends among teenage girls.
A 5% increase in efficiency is a minimum. Seeing the same GP is a much better service to both the patient and the state. There are advantages in not seeing the same GP as well, and often a new look, perhaps from a colleague in the same practice, will pick up something that the usual GP has missed because the change in the patient can be so insidious. Continuity of care was abandoned when the politicians decided to train too few doctors, and ration training places. (because of the cost, and the perverse temptation to recruit from overseas) Now the boot is on the other foot and Canada and Ireland are recruiting from the UK, just at a time when we have all paid for their training” This is what we have done to India, Pakistan and African countries for decades.There is a cultural and linguistic element to providing continuity, and if mutual understanding occurs there is trust. “Trust is most effective when we can rely on shared knowledge of each others motives . Real trust, real security comes from being able to let down our guard, that we can only do with our allies, those who share our common committments to order without Tyranny, liberty without anarchy.” Ben Ansell, BBC Reith lecture 2 2024. We are all living in a tyrannical health service, which by neglect denial and short termism is now a bsted flush. There is little, and increasingly less, “Trust” in the safety net and the systems therein. The continuity of care is most appreciated in palliativ enad terminal care. Unfortunately I will not recieve the quality and continuity that I as a GP gave for 40 years.Unless private care takes off in a rural area! Continuity is impossible for at least a decade, and probably longer. One method to enhance it would be to give “extra” pay or staff or both to doctors who worked some part of 5 days a week.Would this be seen as “sexist”?A compromise is to share continuity with two doctors agreeing never to be absent on leave together.
The Times letters 26th Feb 2024: Seeing the same GP. Sir, As a GP who worked single-handed in the latter half of the last century, my continuity of care was automatic and satisfying (“Seeing the same GP is good for your health”, Feb 23). A young chap called me at midnight with chest pain. Today that would mean a call to 111, ambulance, A&E and all sorts of investigations.I knew he was shortly to have an operation and that he was terrified of doctors and hospitals. His chest pain was the result of stress. I took the decision and the huge responsibility to keep him at home, which turned out to be correct. No one, of course, knew that I had saved the NHS a huge amount of money because no one apart from the patient knew what had happened. Judith Langfield Bristol
Sir, Considering the obstacles in getting appointments since the pandemic, I think an equally accurate headline might have been, “Seeing any GP is good for your health”. Tom O’Dee
The Times 23rd Feb 2024:Seeing same GP (George Sandeman) ‘boosts health and could ease appointment backlog’ – Research found patients benefited from continuity of care, reducing their need to see general practitioners more often Millions of GP appointments could be freed up if patients routinely saw the same doctor, according to a new study. It found that patients who had a long-term relationship with their GP, known as continuity of care, had appointments less frequently than those who regularly saw different doctors. The findings came after researchers at the University of Cambridge and Insead business school analysed data from more than 10 million appointments in England over 11 years. The anonymised information was collected from 381 GP practices between January 1, 2007 and December 31, 2017. They found that patients who had continuity of care did not need to go to the doctor as frequently, waiting on average 18 per cent longer between visits than those who did not. Older patients and those with chronic illnesses were found to have particularly benefited from regularly seeing the same doctor. Dr Harshita Kajaria-Montag, lead author of the study, which is published in the journal Management Science, said: “The benefits of continuity of care are obvious from a relationship point of view. “If you’re a patient with complex health needs, you don’t want to have to explain your whole health history at every appointment. If you have a regular doctor who’s familiar with your history, it’s a far more efficient use of time, for doctor and patient.” Researchers estimated that the number of appointments could be reduced by 5 per cent if all practices provided the same continuity of care seen in the best 10 per cent of practices. They said: “Importantly, if patients receiving care from their regular doctors have longer intervals between consultations without requiring longer consultations, then continuity of care can potentially allow physicians to expand their patient list without increasing their time commitment.” Dr Victoria Tzortziou-Brown, vice-chairwoman of the Royal College of GPs, said continuity of care was “highly valued by GPs and patients alike”. She said: “Studies such as this one are very important for informing future policy and practice. “Currently, the intense workload and workforce pressures GPs are facing — as well as political agendas prioritising speedy access to GP services above all else — greatly limit the level of continuity we can offer.” Analysis by The Times found that in the first ten months of last year around 14.9 million appointments took place more than 28 days after being booked. The figure for such waits in all of 2022 was 12.8 million.
GPonline magasine headlines:Failure to invest in primary care ‘among greatest NHS policy blunders’ – Governments’ persistent failure to invest in primary care despite plans to shift care out of hospital are among the greatest NHS policy disasters of the past three decades, a report warns. by Kimberley Hackett and Nick Bostock 15th Feb 2024 Anna Colivicci reports in Pulse magasinethe Kings Fund 13th April 2023: Government must invest in primary care to save the NHS, warns influential think tank Priority ‘must be given’ to investing in primary care and community services to stem the decline of the NHS, an influential think tank has warned the Government in a scathing report. In a report for the King’s Fund, Professor Sir Chris Ham pointed out that ‘increases in NHS activity and funding since 2000 have been much greater in hospitals than other services’, particularly singling out primary care as an area desperately needing investment. The report pointed out that ‘the share of NHS expenditure accounted for by hospitals increased from 62.7% to 65.2%, and the share accounted for by primary and community services fell from 20% to 19.4%, between 2015/16 and 2018/19 (NAO 2020a, p 37)’ This unbalance has ‘hindered ambitions to deliver more care in people’s homes or closer to home’, said Professor Ham, who has been one of the UK’s most senior policy influencers for several decades. ‘Priority’ must now be given to ‘investing in primary care and community services’, according to the report ‘in order to anticipate people’s needs, promote independence and offer alternatives to hospitals’. ‘The Government and NHS leaders share responsibility for rebalancing expenditure,’ he added. The report placed the blame on for the decline of the NHS on ‘the coalition Government from 2010 to 2015 and successive Conservative Governments since then’, who were also guilty of ‘neglect of workforce planning’……
Speaking in the opening keynote session on day two of the event at the University of Birmingham, Murray said there has been a steep drop in NHS satisfaction because the health of the population of the UK is under a lot of pressure, with lots of adults off sick, placing stress on the NHS. This has led to a significant drop in basic levels of service and an increase in waiting times, Murray explained, using the example of people experiencing over 12 hour trolley waits. In 2018/19, there were no people experiencing waiting times of this length, but in 2022/23 there were around 50,000…..
The great advantage of being self employed is that you don;t have to do anything you dont want to do. Both Dentists and GPs do not wish to have the contracts they have been given, and which have been imposed on them in the hope that a demoralised majority will accept the terms by working on, It looks as if its not working, but the time span for such professionals to take action is very slow, and responsible, and another political team will likely be in power when the “shit hits the fan”.
This imposition of a contract has occurred in Dentistry since 2006, and the synical demise of the service occurred during the subsequent Conservative adminstration but they ignored it. The “Political Gain” was perversely not enough. Richer people were already paying and the votes of the poor will go to the other parties whatever. Putting citizens was not at the centre of the politicians concern was not their priority, and like the Jewish priest and the Levite, they walked past with heads turned the other way…
The pretence that we have a viable health service which is fair and treats all citizens equally has been dropped. Technological advances, always in tertiary centres first, mean that speedy access to new therapiesa and tests is only available in cities. Thus survival and outcomes are going to be better in these cities. It would be better to be honest about this, and give other services to the rural areas: those that we cannot afford in the secondary centres – but say so!
Self employed doctors and dentists are and always have been a target for a salaried service. The administrators seem to feel they will get better value from salaried staff! The experience of the past proves this is false but the corporate memory in the Elephant and Castle may not stretch that far. When Labour under Tony Blair gave GPs a new contraxct which allowed them to ditch out of hours (OOH) for the loss of £6000 it was seized on by my generation. We were told the local trust could provide the service cheaper, and we could offer to work for the new OOH (but we didn’t) . In Pembrokeshire we were 66 doctors covering OOH for £450,000 (with overhead) but within a year it was costing over £2million. Is the current attitude of the Elephant office staff and advisers part of “revenge” for this gift horse given by their predecessors? OOH certainly changed my life, and i settled into a good and regular sleep pattern at 52 years of age! I was able to accept invitiations to family and friend’s events without a long look at the calender, and arranging swaps with colleagues where possible. In addition I was paid well, and the recruitment of new GPs, especially more women, became much easier. Not doing OOH is much more compatible with children than being a hospital doctor on a rota. So a salaried service will be much less efficient.
All that was needed was to recruit far more doctors (and dentists) in 2002. There were 11 applicants for every 2 places then, and all the other 9 could have done the job. Their careers officers and mentors supported their applications and they had the right grades, but we rationed their places for short term financial gain. To be fair the BMA annual meeting did object to taking on more doctors in training on one occasion, but this was because of insufficient infrastructure and support staff. This alone tells the citizen reader that planning a health service takes a long time. Successive governements have faiked on this.
It is only a new political system of Proportional Representation (almost any type) that can save the health services. They will be very different beasts when this eventually happens, but until then expect more excess deaths, more litigation, more social division and more poverty related diseases. Once the change happens then we must not expect much improvement for at least a decade.
So the two tier system in Dentistry is about to proliferate in General Practice. The profession is voting on strike action, but like the dentists, they know that there is little option other than a two tier system, and they will gain in lifestyle and independence if they opt out of the NHS completely. The current conservative politicians, with access to tertiary hospitals in city centres, are disconnected from their poorer citizens, and know they and their families can afford good, speedy care. As a republican I am aware that our King has the means to ensure he never waits, but would it not have been a great statement to say he would wait the average time across all 4 dispensations for his cancer trweatment? There is good news that we are starting to talk about change. But we are not yet talking about rationing, the pace of technological advance or the unfairness of the current situation.
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