Category Archives: General Practitioners

So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

Mrs May’s money will make no difference and will not create trained staff. If she admitted there would be no dividend for at least 10 years she would be more honest. 

What if she buys more scanners – where are the radiologists to report and where are the radiographers to provide, and the oncologists to define the treatment, and radiotherapists to treat?

Where is the plant to provide the projected radiotherapy needs?

So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

….”to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

Without this no administration can win the hearts and minds of the professionals who man the system. They know the truth, which is that there has to be rationing; by exclusion, restriction, exception, reduction, prioritisation, etc. What we don’t like is unpredictable post-code rationing which differs for different people with the same condition.

Robert Colvile opines in the Times 18th June: Let’s talk about how NHS spends our money – An obsessive focus on funding ignores the importance of improving efficiency and results

Weeks — months — of furious speculation, and it all boiled down to a simple set of numbers. Would the settlement be closer to 3 per cent or 4 per cent? For five years or ten? Could Theresa May hit the magic figure of £350 million a week? Would Philip Hammond even let her?

Finally, we have some clarity. The NHS will receive, as its 70th birthday present, a real-terms annual funding increase of roughly 3.4 per cent. Not as much as some wanted, but more than many feared. And though it is being billed as a “Brexit dividend”, the prime minister ominously admits that “as a country” — by which she means as individual taxpayers, present and future — “we need to contribute a bit more”.

What has been almost completely buried in the coverage of this story, and was certainly overshadowed in her interview on The Andrew Marr Show yesterday, is an equally important aspect of the prime minister’s announcement: her insistence that the money must be spent wisely.

It’s often said that analysts at the Commonwealth Fund consider the NHS the world’s best healthcare system. It’s less often said that it actually came 10th out of 11 nations in terms of “healthcare outcomes” — in other words, the most important bit. Compared with its rivals, the NHS has far too many deaths from strokes and heart attacks, and our closest peers in terms of survival after a cancer diagnosis are Chile and Poland.

As the debate over the funding settlement reached its height, we at the Centre for Policy Studies carried out some simple analysis. It showed that as NHS funding goes up, productivity tends to go down: in other words, it does more with less, and less with more. The most notorious example of this was the great Blair/Brown splurge, which was, as the prime minister points out, misspent to a quite scandalous degree.

It’s not just about the headline figures. Talk to anyone in the NHS and you will come away with a laundry list of complaints about how the service works: the profusion of quangos; the targets and funding mechanisms that often incentivise, or force, people to act in the wrong ways; the fact that it is still far too hard to reward and replicate good performance, both by trusts and individuals, and punish bad.

This is why Mrs May was right to insist that the new five-year budget settlement — itself a welcome injection of certainty — be accompanied by performance improvements. That NHS leaders will be held to account for how it is spent, that the health service will have to become more efficient. That structural issues such as slow adoption of new technology and the disconnect between health and social care must be addressed.

But there is still a limit to what this government, or any government, can do. That is why the prime minister, as the NHS turns 70, should appoint a cross-party royal commission: taking NHS England’s current plan as its starting point, but going beyond that to deliver a full examination of the health service and how it can improve.

The difference between an NHS that matches its best productivity performance over the coming decade, and one that lives down to its worst, is vastly greater — in terms of patients seen, operations carried out and lives saved — than between the prospective funding settlements.

In other words, to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

We will not know until the budget how the new cash will be found (though freezes to tax thresholds are rumoured). But economic growth of 1.5 per cent and NHS spending growth of 3.4 per cent is not a circle that can be squared for ever, unless we either want the state to amputate many of its other functions or to end up paying far more tax: approximately £1,000 extra per individual taxpayer by the end of the decade. (Remember: just as voters complain about the NHS, they complain equally bitterly about the pressure on their pockets.)

Yet if you suggest that part of the answer could be to find ways to deliver extra funding to the NHS outside of general taxation — from charging for missed appointments to introducing top-up payments to get more money from richer patients — you are castigated as a heretic. This, again, is an area where a royal commission could make progress, without the usual party-political brickbats.

The humbug that often surrounds the NHS has a real cost because it stops the health service working as well as it could or should. A few days ago, for example, the head of a left-wing think tank grandly tweeted that “the #NHS is as much a social movement as it is a health system”.

But the NHS is a health system, one that all of us rely on. Yes, it’s packed with dedicated staff, many doing impossibly difficult jobs for little money. But sinking into a sepia-tinted, Danny Boyle reverie about #OurNHS and the #TirelessAngels within it is not the way to make it better. Nor is thinking of all of its problems in terms of how much cheapskate politicians put in, rather than what the rest of us get out.

Robert Colvile is director of the Centre for Policy Studies

 

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The desperate state of General Practice. Black swans will not be diagnosed as often, or as quickly.

There is an ennui in the minds of the nations’ GPs. Disengaged and devalued, and with a job they used to enjoy, the older ones are retiring, the younger ones are leaving early, and those who remain to put up with the conditions are going part time. Throwing money at the problem will not help …. I have resigned myself to the fact that, in the Welsh Health service, I may not see a disgnostic doctor in my final illness. I am likely to see a paramedic or a nurse practitioner. Their skills may be many, and they might be experienced, but they are more likely to miss the “black swan”. A colleague (retited anaesthetist) presented elsewhere with atypical chest pain and symptoms and managed to get treated for his aneurysm before he would have died….. It seems incredible to us retired GPs that the most efficient system in the world, 20 years ago, where 90% of the work was done by 10% of the workforce, has been demolished. Yes, it is too late for me, but it can still be saved if we take the unpleasant medicine. What a boost for Private Healthcare….

David Millett for GPonline 27th November 2017 reports: Record GP recruitment not enough to reverse the crisis (and decline )

BBC News 11th June: £8.8 million investment for GP services in Northern Ireland

Nick Bostock reports 29th May 2018: NHS England unveils £10m spend

Jenny Cook reports for GP online 8th June 2018 that 1 in 10 GP practices could close by 2022

ITV News 8th June: The recruitment time bomb in East Anglia

The Scotsman Leading article 2nd June opines: GP burnout is a threat to us all.

The Mirror 10th May  reports that over 2% of the population are “Having to change practices” amidst mass closures.

GP online also reports that the numbers quitting vastly exceed those recruited.

Pulse reports on the £80k pay for EU doctors, refundable if they quit! 

The Mailonline reports thsat 40% of new doctors are quitting within 5 years of qualifying.

.The Soctsman berates the government for new medical school places being “too little and too late.”

June 2017: The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

July 2016: Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

Any GP you want: so long as you’re healthy

See the source image

See the source image

Challenge doctors over your treatment, NHS patients told. Choices need to be made, and a paternalistic doctor might be appropriate for some, but increasingly few.

One of the difficult discussions a GP can have is whether to raise the possibility of the “private” option with a patient. Some doctors leave it up to the patient to raise the issue, and some believe they should raise it if they feel the patient might be best served privately. What is the answer? In NHSreality opinion, all GPs and consultants should discuss the BRAN test… If a doctor’s first duty is to “put the patient at the centre of their concern”, he needs to point out that infections could be lower away from his DGH, and that survival rates are better in centres of excellence.

Should oncologists come out honestly about what is not available, but what they might like to give? Not without consulting with another Dr, preferably the GP.

 

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Kat Lay reports 15th June 2018: Challenge doctors over your treatment, NHS patients told

Patients will be told to challenge their doctors under guidance suggesting they should question the drugs and treatments they are offered.

Doctors and patients should follow what the Academy of Medical Royal Colleges has called the “Bran” test, which asks about the Benefits, Risks and Alternatives to a treatment, and what would happen if they did Nothing.

The academy, which represents 24 medical royal colleges and faculties, issued the guidance as part of a programme designed to reduce over-medication and decrease interventions of little or no value.

“This is all about enfranchising patients and giving them a sense of ownership of the way they are treated,” Professor Dame Sue Bailey, who leads the campaign, said. “Too often patients just accept what a doctor is telling them without question. We want to change that dynamic and make sure the decision about what treatment is taken up is only made when the patient is fully informed of all the consequences.

“Too often there’s pressure on both the patient and the doctor to do something, when doing nothing might often be the best course of action.”

The first part of its programme, published in 2015, encouraged the NHS to stop using 40 tests, treatments and procedures, including plaster for “buckle” wrist fractures in children. The latest tranche comes after NHS England said last year that it would no longer fund certain treatments including some dietary supplements and homeopathy.

The academy has now listed more than 50 further tests, treatments and procedures, which they said “may have little value or could be replaced with a simpler alternative”.

The list includes a recommendation to extend the length of contraceptive pill prescriptions to a year, to reduce visits to the GP, and simplifying advice on vitamin D supplementation to tell everyone to take them during the winter, not just the frail and elderly. It also says that doctors should not use drug treatments to manage behavioural and psychological problems in patients with dementia if they can be avoided, and talk to relatives and carers before a diagnosis, rather than just relying on a basic cognitive test.

Antibiotics in dying patients, the academy said, could be avoided because they “may not prolong life and can cause discomfort through side-effects”.

The advice is supported by Healthwatch, a watchdog. Imelda Redmond, its national director, said: “The campaign is all about encouraging meaningful conversation between doctors and patients, enabling people to have a greater say over their treatment and care while also ensuring precious NHS resources are used to their best effect.”

• A senior health service official said last night that four in ten GPs quit the NHS within five years of finishing their training. Ian Cumming, head of the NHS’s staffing body, said: “Forty per cent of all the people who completed training five years ago as GPs are not working in substantive GP employment or as long-term locums. They are doing short-term locums, they are doing other things.”

Its going to get much worse. The difference in health, life expectancy and quality of life, in a two tier system. The finances are dire. Hospitals are bust.

It is now inevitable tat more and more people will vote wit their feet. Out of their health service, (private) or go abroad.  Its going to get much worse. The difference in health, life expectancy and quality of life, in a two tier system. The finances are dire. Hospitals are bust. And do you really think the minister will propose a sensible solution…..?

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The Guardian today: Two in five GPs in England intend to quit within five years – survey

Warning over standards of care as NHS falls short on targets

NHS deficit last year twice as high as expected, say sources The Guardian today

Catriona Webster May 3rd in the Times reports: Shona Robison has agreed to publish the finances of NHS boards monthly after pressure from the Scottish Conservatives.

Sky News today: NHS report reveals sharp rise in waiting times for care

BBC News today: Deficit for NHS trusts in England double the amount planned

NHS trusts in England have reported a combined financial deficit that was nearly twice the amount planned.

There was a deficit of £960m in the last financial year compared with the £496m they had planned for, the regulator NHS Improvement said.

Acute hospitals were largely responsible, mainly because of increased patient demand, it said.

All other providers, including ambulance and mental health trusts, had collectively underspent, it added.

The latest reported deficit is reached after taking account of extra financial support provided by the government.

Therefore, the Nuffield Trust think tank argued that the true underlying figure was much worse, as the finances had to be patched up with one-off savings and emergency extra cash.

Senior policy analyst Sally Gainsbury said: “Given the huge pressures on NHS providers, it is not at all surprising that the reported deficit for 2017-18 is £960m……

…Ministers have promised a new long-term financial plan for the NHS, which is expected within weeks.

In March, Prime Minister Theresa May said she wanted to get away from annual “cash top-ups” and would come up with a blueprint later this year to allow the NHS “to plan for the future”.

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The shortage of diagnostic and filtering skills is costing us dear. GPs retiring especially.

 It is the duty of a government first to protect the realm, then to avoid insurrection and protect the rule of law, then to protect the health of it’s people. Successive UK governments have shown they have no long term view or ability to manpower plan. We need to change the rules of the game that the politicians play, so that they have incentives to plan properly, or we need to take health away from them. The shortage of diagnostic and filtering skills is costing us dear. GPs retiring (or emigrating) especially. Add to this the parlous state of health services finance, and there is going to be trouble ahead… Image result for doctors  emigrate cartoon

Chris Smyth reports May 30th in the Times: Million patients hit by closure of GP surgeries

More than a million patients have been forced to change GP surgery in the past five years, with closures up tenfold as family doctors abandon the NHS.

Last year 458,000 patients had to find a new practice because their existing surgery shut, up from 38,000 in 2013, according to official data.

Patients are losing personal relationships with a GP and care is suffering, senior doctors warned.

The network of family doctors which props up the NHS is in danger of crumbling as GPs tire of staff shortages in a “serious failure of the system”, professional leaders warn.

Jeremy Hunt, the health secretary, has promised to recruit an extra 5,000 GPs by 2020, saying that hospitals will be overwhelmed if the NHS does not get better at looking after elderly people locally. However, more than 1,000 family doctors have been lost since he made his pledge.

Data gathered under freedom of information law by the GP magazine Pulse shows that at least 202 practices have shut down completely and 243 have closed branch surgeries since 2013. Last year 57 practices closed and a further 77 satellite surgeries were lost. Since 2013 this has displaced almost 1.4 million patients, the data suggests.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “A GP practice closing can have serious ramifications for the patient population it served [and] neighbouring surgeries . . . For those living in isolated areas, this can mean having to travel long distances to get to their nearest surgery, and is a particular worry for those who might not drive and have to rely on public transport.”

She said some centralisations into larger hubs could improve care, but warned that when a closure “is because the practice team simply can’t cope with the resource and workforce pressures they are facing, it’s a serious failure of the system.”

GPs are typically independent contractors paid by the NHS for each patient they look after. As older, sicker patients need a doctor more often, this model has become less viable and Mr Hunt has conceded GPs are on a “hamster wheel of ten-minute appointments, 30 to 40 of them every day, unable to give the care they would like to.”

With Britain short of GPs and younger doctors working fewer hours, there are fears of a spiral of decline as the overworked ones who remain become exhausted. Recent taxes on high pension pots also make it less lucrative for GPs to continue to work into their 60s.

Richard Vautrey, head of the British Medical Association’s GP committee, said that family doctors built up long-term relationships of trust with patients “but when practices close this important foundation can be put at risk and patients’ experiences may suffer as a result . . . Without proper investment in primary care, the knock-on effects on the rest of the health service and society as a whole will cost the government dearly in the long run.”

In Plymouth, one of the worst affected areas, a fifth of practices have closed in the past three years, leaving 34,000 patients without a GP. Local doctors say that they get only four hours’ sleep a night as they try to deal with remaining patients and one, Mark Sanford-Wood, said the city’s plight was “a warning of what the rest of the country faces”.

A spokeswoman for NHS England said: “More than 3,000 GP practices have received extra support thanks to a £27 million investment over the past two years and there are plans to help hundreds more this year. NHS England is beginning to reverse historic underinvestment with an extra £2.4 billion going into general practice each year by 2021, a 14 per cent rise in real terms.”

Katherine Sanz in N Ireland reports 10th May 2018: Shortage of GPs as third set to retire

Revealed: 450 GP surgeries have closed in the last five years – Pulse today

 

Selecting doctors, and portfolio careers crossing from primary care to Hospital.

In the past NHSreality has opined on the missed opportunity in palliative care. At one point we had 6 qualified diplomas of palliative care, and could have really focussed the oncology and palliative care departments to be more realistic, and to work as teams. There are many other areas of hospital care which GPs could help in. Geriatrics and Rheumatology, Dermatology and even minor surgery and endoscopy.

The rationing of places at medical school has been a disaster. Combined with the advantage women seem to have at 18, being more mature, the workforce is declining rather than rising. Medicine is keen on evidence based research, but one wonders if there is any evidence that 3As does better over 40 years than 3Cs.

A letter in the Telegraph opines on recruiting doctors:

Sir, the difficulties of GP recruitment are complex (Letters May 16th).

I have long held the view that it tarts with the selection process for medical school entry. The requirement of 3 Cs at A level in the sixties and early seventies resulted in a much more diverse student population (although it was predominantly male).

Selection based purely on high academic achievement will perhaps attract undergraduates with different aspirations. Working hours are highly regulated and limited within the “acute sector”. Combine this with the diversity of career options within hospital medicine and you have the perfect storm.

A. portfolio career integrating elements of GP and Hospital work may go some way to address this.

Belfast Telegraph 5th May: Doctors have job offers withdrawn after recruitment error

Western Telegraph 17th May: GP resignation sees Tenby surgery back under control of health board

The Telegraph 22nd May 2018: Most hospitals and GP practices have shortage of doctors, survey …

You have been warned…. No genetic secrets will remain ….

We already ration infertility treatment, in most commissioning groups, and we also restrict the use of pre-embryonic blastocyst selection to avoid inherited disease to one child in most commissioning groups. This is despite the cost (long term) of looking after an individual with HD or CF. The result is that affluent families pay for the embryo selection, but poorer families are faced with either having one child, or taking the risk and having more. If the state wishes to construct a data base of risk, and the potential is there, we will have to let rationing become as overt for everything as it is for infertility.

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The Economist has pointed out in 2003 (jan 23rd) No hiding place – The protection of privacy will be a huge problem for the internet society and now more recently. In Science and Technology May 5th “No hiding place” (Genomes and Privacy) reports: Police have used genealogy to make an arrest in a murder case – The did so by tracing the suspect via distant relatives’ DNA

….If a serial killer really has been caught using these methods, everyone will rightly applaud. But the power of forensic genomics that this case displays poses concerns for those going about their lawful business, too. It bears on the question of genetic privacy—namely, how much right people have to keep their genes to themselves—by showing that no man or woman is a genetic island. Information about one individual can reveal information about others—and not just who is related to whom.

With decreasing degrees of certainty, according to the degree of consanguinity, it can divulge a relative’s susceptibilities to certain diseases, for example, or information about paternity, that the relative in question might or might not want to know, and might or might not want to become public. Who should be allowed to see such information, and who might have a right to see it, are questions that need asking.

They are beginning to be asked. In 2017 the Court of Appeal in England ruled that doctors treating people with Huntington’s chorea, an inherited fatal disease of the central nervous system the definitive diagnosis of which is a particular abnormal DNA sequence, have a duty to disclose that diagnosis to the patient’s children. The children of a parent who has Huntington’s have a 50% chance of inheriting the illness. In this case, a father had declined to disclose his newly diagnosed disease to his pregnant daughter. She was, herself, subsequently diagnosed with Huntington’s. She then sued the hospital, on the basis that it was her right to know of her risk. Had she known, she told the court, she would have terminated her pregnancy.

That is an extreme case. But intermediate ones exist. For example, certain variants of a gene called BRCA are associated with breast cancer. None, though, is 100% predictive. If someone discovers that he or she is carrying such a variant, should that bring an obligation to inform relatives, so that they, too, may be tested? Or does that risk spreading panic to no good end?

It may turn out that such worries are transient. As the cost of genetic sequencing falls, the tendency of people to discover their own genetic information, rather than learning about it second-hand, will increase. That, though, may bring about a different problem, of genetic snooping, in which people obtain the sequences of others without their consent, from things like discarded coffee cups. At that point genetic privacy really will be a thing of the past…..

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