Category Archives: General Practitioners

If Nurses fill the gaps left by the shortage of GPs, this will be the start of private practice in many towns..

Most GPS will be too busy to read or reply to Mr Darzi. As a retired GP I feel I have to reply. The letters from the Times’ replies are in the pdf below.

It seems a little ironic for a surgeon, who deals with operations and definitive outcomes, to comment on General Practice. The good GP uses time as a diagnostic tool, lives with uncertainty and handles patients with multiple symptoms and often multiple diagnoses.

Failure to train enough doctors is one problem. Training a disproportionate number of females to males is another. Making the job more and more desk bound and administrative is another. The shape of the job has changed a lot, but given time, appropriate training, and backup of a good team it would still attract. GPs need broader training especially so that all of them have the same opportunities in Paediatrics and Psychiatry, and Old age medicine and rehabilitation.

Doctors are trained to think laterally and make a diagnosis. The training takes a long time but why has only 2 out of 11 applicants been successful over the last two decades? Rationing places at medical school has now killed the goose that laid the golden eggs of efficiency. Nurses will probably refer more, request more tests, follow up more, and may well make more mistakes. The litigation will follow…

And will this mean that unpopular areas retain GPs, whilst unpopular ones have Nurse Practitioners? A health divide if ever there was one, and an encouragement for private practice.

Ara Darzi opines in the Times 9th October 2018: Nurses can fill the gaps left by the shortage of GPs

Primary care and public health are becoming even more important as the population ages, diseases change and the need for long-term community care grows. Yet at the same time, this work is becoming increasingly unpopular with doctors.

To add to the problems of retaining GPs, a survey of general practice trainees carried out this summer by the King’s Fund, a health think tank, found that only a fifth planned to be working full-time a year after qualifying. The proportion planning to be working full-time after ten years was the same.

This is an astonishing vote of no confidence. Like many of their generation, young GPs want a portfolio career. They want to be involved in research and education; the prospect of owning and running the same practice for the next 30 years is a million miles from what most hope to do with their lives. They are not alone. Surveys show a similar trend across the world, with fewer than 10 per cent of physicians choosing family medicine in some countries.

Here, then, is an opportunity for nurses. Advanced practice nurses, also called nurse practitioners, are as effective as doctors at many tasks and, according to one study, could take on 70 per cent of GPs’ workload. Their main areas of expertise are in the management of long-term chronic conditions such as diabetes; they can diagnose, treat, prescribe and refer patients to hospital, and admit them if necessary. There are limits to their responsibilities (they don’t treat children under five or expectant mothers and they can’t sign sick notes) but they are acceptable to the public, take less time to train and cost less than GPs.

A report by a group of international experts, to be presented at the World Innovation Summit for Health in Doha next month, which I chair, will argue that nurses are poised to become the dominant force in primary care. They tend to live in the communities they serve, understand the local customs and culture and are well placed to detect early signs of disease and help tackle the wider social determinants of health.

There is a growing recognition that nurses are well suited to provide the sort of patient-centred care that is needed to look after the rising numbers of people with chronic diseases such as cancer, heart failure, diabetes and dementia.

There are barriers. Improved education, recruitment and commitment from employers will be required. But if we are to solve the crisis in primary care, we must urgently look to positioning nurses as the new gatekeepers of the NHS.

Professor Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London

Doctors to see groups of patients – is probably madness. The fox is waiting..

Letters in reply to Mr Darzi

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Doctors to see groups of patients – is probably madness. The fox is waiting..

The one thing a Doctor does, which others don’t do, and for which he is indemnified for mistakes, is to make a diagnosis. The first consultation is the important one, and afterwards, follow up can be done by many others. Physiotherapists, psychologists (or cheaper and less trained nurse counsellors) , Parkinson’s or Macmillan nurses etc.  The achievement of a diagnosis involves examination, usually physical, but often psychological as well. Many patients present with “vague” or multiple symptoms, and some poor practices have demanded only one symptom per consultation!

The follow up rate of GPs differs according to their ability and willingness to live with uncertainty. Achieving a full diagnosis in physical, psychological and spiritual dimensions may take more than one 10 minute consultation, but this is unusual in todays accelerated world. All GPs need to know their follow up rate compared to their peers, but remember it needs to be adjusted for age and complexity of patients, and older GPs see older patients. Not many practices know their follow up rates, and very few GPs know theirs.

One technique to reduce uncertainty is to refer everyone. Nobody complains, but they do wait! Consultants used to know the GP, and after reading their letter, would often prioritise the referrals from those who sent patients infrequently. This unofficial form of rationing was reasonable. What happens today? Are letters sometimes handled by administrators and then treated equally?

Wriggleing on the hook of rationing health care in different ways, means that we will see many experiments until the numbers of diagnosticians increases. if a GP is needed for a 2 hour group surgery he could have seen 12 new 10 minute appointments in that time, along with the opportunity to examine and personalise the consultation. The old definition of a GP giving “personalised continuous care to patients and their families” has been abandoned in the modern world, but this does not mean we should not aspire to it. But if a GP practice follows up so many patients that they personally need to see groups, then that is not good use of resources. Others can do the follow ups. Leave doctors to diagnosis…

I found several current definitions (I have excluded those that focus on the negative (a doctor who did not specialise) and none of them mention the ability to live with uncertainty or to use time as a diagnostic tool. The GP was the goose that laid the golden eggs of efficiency in the original health service. No longer, and the fox is at the door..

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The RCGP 1977 definition is here and

WONCA updated it’s definition in 2011

Others are:

a medical doctor who attends to the everyday medical needs of individuals within a community.

a doctor based in the community who treats patients with minor or chronic illnesses and refers those with serious conditions to a hospital.

A physician whose practice is not oriented to a specific medical specialty but instead covers a variety of medical problems in patients of all ages. Also called family doctor.

A fully registered medical practitioner in the UK who provides general medical services to a particular group of patients or “list”, either in partnership with other GPs, as a salaried GP in a group or, less commonly, as a single practitioner. GPs may also provide inpatient care in community hospitals. A GP will refer patients “forward” to a consultant (hospital specialist) when the patients’ needs cannot be addressed locally. GPs in the UK are not NHS employees, but rather contract independently with the NHS.

Both the Telegraph and the Mail last weekend reported on the shortage of GPs, and that they were looking at solutions whereby GPs see patients together. Obvious confidentiality issues – but also a group support ethos…. GPs to see groups

Hannah Mays in the Times 8th October reports: GP surgeries to see 15 patients at a time.

Group consultations of up to 15 patients are likely to be made “the default” for the NHS in its ten-year plan to tackle waiting times, it was claimed last night.

The scheme has been promoted as a strategy to ease the strain on family doctors and cope with growing shortages of GPs, and been piloted in areas including London, Birmingham, Manchester and Sheffield.

Doctors involved in the pilots said that they had reduced the time spent repeating advice and that patients were given as much as 90 minutes to discuss their condition with fellow sufferers. The longer sessions could also help doctors to develop closer relationships with patients and their families. They said that the consultations had proved more efficient at tackling health complaints including obesity, diabetes, arthritis and erectile dysfunction.

NHS England describes group consultations as medical appointments provided by a clinician in a peer-group setting that “potentially doubles productivity and access to routine care”. The clinician may be a receptionist, clerk or healthcare assistant with one day’s training who would be able to direct the group towards advice on their condition. Patients are asked to sign confidentiality forms to ensure that what is discussed remains within the room. In some sessions test results are posted on a board and a consultant, GP or nurse leads brief discussions with each patient.

However, Joyce Robins, from Patient Concern, said: “This is a ghastly idea. GP appointments are supposed to be a private matter where you can openly talk about your most personal health issues. If you’re discussing things in front of a group of strangers, you might as well tell the local town crier.” Rachel Power, of the Patients Association, said that the sessions would be helpful in some cases but added: “We are concerned that these group consultations are said to replace traditional appointments, apparently without exception.”

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

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

Letter in the Times 9th October:

SHARED GP VISITS
Sir, I thought my eyes were deceiving me when I read your article “GP surgeries to see 15 patients at a time” (Oct 8). I was also surprised by the Patients Association being reported as saying that this move “would be helpful in some cases”.

Are we now all to believe that Samuel Butler’s work of fiction, Erewhon, is likely to become a reality? He wrote about an imaginary visit to a topsy-turvy country where it was a punishable offence to be physically ill but where criminality and immorality were looked kindly upon as treatable diseases.
Ken Mack

Wrexham, north Wales

Sir, In deeply rural villages, we all have the same doctor. Now I love my neighbours, but do not yearn to know the condition of their nether regions, or to recount my symptoms to the butcher, the baker or the gossip maker.
Sylvia Crookes

Bainbridge, Wensleydale

Why won’t GPs return? We are burned out and uninsurable, need retraining, and have no belief that the system is well founded.

The letter from Dr Sweeney is a good one. But the answer to his own and the general metaphorical question “Why won’t GPs return?” is in the headline.  We are burned out and uninsurable, need retraining, and have no belief that the system is well founded. Dr Sweeney will not have had an exit interview. Neither will his colleagues in practice, or his consultant peers. ….. This tells you that the administration is unwilling to hear what they would like to say.

An aside: As a GP and now a patient on the Welsh border. Dr Sweeney will potentially benefit form being able to choose whether he is treated in the WHS or the EHS (Welsh Health Service or English Health Service) Choices are restricted to those living on the border. In West Wales we have no such choices…

CASH LURE FOR GPs
Sir, Regarding your report “NHS offers £18K to lure Australian GPs”(News, Oct 5), I retired six years ago after working for 25 years as a GP. I worked full-time and spent many years running my own “out of hours” service; I had a wealth of knowledge and experience born of hard work, dedication and service. Although the NHS is trying numerous (and expensive) ways of recruiting new doctors, I have never been approached, invited or even cajoled to return to the NHS.

I am enjoying my retirement and would not return, but am baffled that no effort whatsoever was made to retain my services before or after retirement.
Dr David Sweeney

Penperlleni, Monmouthshire

“Shortage of workers “threatens new winter crisis in hospitals”. The NHS is under threat. Only a new model of care will save it. “can we keep the lid on health and social care until after the next election?”

Si desperatis petere auxilium. Volunteering?

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A new West Wales Hospital – an inevitable utilitarian decision. Today’s children are going to live shorter lives than their parents. Todays West Wales adults could also live shorter lives than their parents.

The decision to commit to a new hospital in West Wales has been inevitable – since the WG has no intention of combining Hywel Dda and Abertawe Bro Morgannwg (ABMU) and providing a sensible solution, a mistake is being made. Recruitment to West Wales has been poor at the best of times, and now that the rationing of medical school places over the last 30 years is coming home to roost, the Hywel Dda board have no other option. There are not enough professionals ready and willing to work in West Wales, and not enough money to fund them if there were. There is an ethical argument, from a population perspective, that rationing covertly )whereby nobody knows what is not available until they need it) is better than rationing covertly (whereby citizens know in advance what is not available in their post code). But from a liberal and individual perspective, this is unethical, as it discourages autonomy and choice. It seems some choices have to be planned for by saving money, and of course this option divides us into the haves and the have nots. Exactly what Aneurin Bevan tried to avoid. Medical professionals accept that the pace of advance of medical technology is faster than any states’ ability to pay, and that rationing is inevitable and endemic already. Politicians deny the need to ration, and until this becomes honest and overt, the hearts and minds of the caring professions will be disengaged from the politics.

It has been a “least harm for the greatest number” decision that Hywel Dda has been asked to make. It will please nobody. It will satisfy nobody. It may lead to more emergency deaths. As the population ages and the demographic suggests this will be for several decades, the problems of type 2 diabetes and dementia will become worse. The Welsh Health Service costs more per capita than the English because of poverty, and yet the WG takes more from the overall budget by top slicing. When dealing with a population as low as 3 million, this really matters and adversely affects the options in devolution. That is just one of the reasons devolution has failed.

Aberystwyth finds it even harder to attract staff, and the longer term prospects for their people are worse. Llanelli and Carmarthen citizens have speedy access to Swansea, and NHSreality, and most GPs in Pembrokeshire, feel that joining the two boards would be best. The decisions to build relatively new A&E and Renal units at Withybush in the last decade now seem very strange.

Is the fact that every county wants the new hospital the opposite of NIMBYism?

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Today’s children are going to live shorter lives than their parents. Todays West Wales adults could also live shorter lives than their parents.

…Babies of both sexes in Scotland and Wales and baby boys in Northern Ireland are even projected to live shorter lives than their parents do after average longevity dropped slightly in parts of the UK.

Experts said that the government must investigate the reasons behind the stalling of life expectancy, which some have blamed on cuts to public services.

Between 2015 and 2017 the average life expectancy remained at 79.2 years for men and 82.9 for women, the Office for National Statistics said. There were falls in Scotland and Wales for both men and women, and among men in Northern Ireland, averaging 0.1 years.

Greg Hurst September 26th in the Times: Today’s children set to live shorter lives than parents

Nicola Davis in the Guardian 25th September: Children becoming physically weaker found team who measured handgrip, arm-hangs and sit-ups in Essex children

Western Mail (Walesonline) 26th September: Hywel Dda Board in shake up decisison

May 4th 2018: The agony of Damocles sword hangs over West Wales..

The fourth option for West Wales? Do we want “soft lies and gentle indifference”, until we realise the safety net is failing for us personally?

February 2018: A bigger and bigger deficit in West Wales…… Now at £600 per head……

January 2018: The West Wales options.

West Wales Health has to have a future – somewhere in the “middle” ground… Back to 2006 and reversing the wrong decision taken then not to build a new Hospital.

Leimyoscarcoma treatment options unfair…. in west Wales where choice is anathema.

Banal and sanitised Drakeford interview shames the local press in West Wales

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Axe the Fax. Why more communication with your GP could be through the post..

We had a local GP who, when frustrated with the local health service, or when he had a beef to complain about, would, in the days when faxes were de rigour, tape his fax message in a circle to the recipient, who would of course run out of paper as their machine kept repeat printing. This technique he used with his MP if he did not listen, as well as health departments.

My own surgery does not receive nearly as many faxes as it did, but there are some trusts who have never moved on. Far from sharing a database with their GPs, they keep losing paper, notes and the result is miscommunication and increased risk of mistakes, and litigation, inefficiency and cost.

Thank goodness patients never caught on that they could ask for appointments by fax!

The reason that written communication may become more common is the blocked phone lines, long waits for appointments, and general constipation of the system of seeing patients. I sometimes write with a Stamped Addressed Envelope (SAE) asking for an appointment. I can explain when I am absent, and when I would prefer to be seen. For a non urgent appointment this is very reasonable, but so few people do it. All written communications have to be scanned into the notes, unlike telephone calls, which are rarely recorded, especially with receptionists. This means any new symptoms which might be important are in the record, and an appointment will be forthcoming.

The Times reported 17th September: NHS trust axes faxes

An NHS trust has announced a “challenging” programme to bring its technology into the 1990s. Leeds Teaching Hospitals NHS trust, which runs six hospitals in and around the city, has pledged to remove 95 per cent of its 340 fax machines by the end of the year. “We simply cannot afford to continue living in the dark ages,” it said.

Healthcare IT news reported: CDIO Richard Corbridge leads ‘Axe the FaxNHS modernisation …

The Mail reported: Major technology upgrades promised for NHS in a ‘bonfire of fax

And Practice Business: Why healthcare should axe the fax

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Health Services Data collection: Tribalism has ruled so far….

At first glance it seems incredible that there is no joined up combined data set for the 4 UK health services. The media and the press don’t help with headlines that indicate that all 4 health services are impacted by a decision, when it is actually only NHS England. The proposal was rejected in Pembrokeshire in 1996. Even today, some 22 years later, there is no comprehensive information available to the Out-Of-Hours (OOH) doctors or paramedics or nurses. Resistance to change at the time was due to fears about workloads in transferring from one system to another, and no compensation or mitigation was offered. |Today all GP computer systems are excellent. Any one of them would be better overall in A&E and Casualty departments. It would then be “demanded” by the wards, radiology and laboratory, physiotherapy etc. Managers could ask the system for waiting lists “real time”, and for operations and other outputs. Complications, infections, and complaints could also be recorded, along with waiting times and waiting lists. NHS Digital may cover all 4 jurisdictions….but much of it’s news headings relates to England only. Missing notes (commonplace) would only happen if all system was down.. Are you ambitious to be famous? Do you trust the confidentiality of health records?

So why has it not happened? Will all 4 health systems agree? Tribalism has ruled so far…. both in GP and in Hospital systems, which are all different!

There is a new incentive to make it happen: the potential profit in data mining, and the Health Services, if put together, cover a large population. Apart from England the numbers are small, but the power of the combined 4 systems is high. Regional Innovation hubs (Walesincluded?) may help….                (NHS England chief executive Simon Stevens has said the NHS needs to recommit to exploiting the potential of anonymised clinical data for driving research and innovation.

Stevens announced that the NHS will set-up two to five regional Digital Innovation Hubs, each covering regions of 3-5 million people.  “We need to advance on exploiting anonymised clinical data.”) When the system does work we will all wonder why it took so long and so much money to get there.

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Philip Aldrick in the Times 5th September reports: NHS set to be offered a ‘fair share’ of data profits

Companies using NHS patient records to build the next generation of healthcare tools will have to demonstrate that any commercial gains they make are shared “fairly” with the NHS, ministers will say today.

The Department for Health has drawn up a code of conduct for technology firms that use the NHS’s “unique” data to train their algorithms.

The code will establish commercial principles to ensure that the NHS shares in the financial gain from any innovative treatment or device created with the help of its data. It also will ensure that patient records are used solely to improve health outcomes.

Britain is at the forefront of advances in artificial intelligence healthcare, with companies such as Google’s Deepmind and the UK-listed Sensyne Health mining electronic health records to build tools that can transform patient outcomes. Deepmind has built algorithms that are better than doctors at spotting eye disease and is developing diagnostic tools that catch critical illnesses early.

Under the code of conduct for data driven technologies, companies will be asked to “enter into commercial terms in which the benefits of the partnerships between technology companies and health and care providers are shared fairly”. All health records must comply first with data protection regulations that protect privacy.

Lord O’Shaughnessy, parliamentary under-secretary of state for health, said that NHS data was “like oil” and should be considered a form of capital. “AI needs data to work on and the NHS, because of the way it was set up, has this unique longitudinal data set of 60 million people alive today,” he said. “When NHS data goes into create an algorithm and the company owns the algorithm, does the NHS get a fair share for the contribution that the patient data has made to that algorithm? Patients want to know that NHS data is generating benefits for patients directly. This has to be valued and there has to be a sense of a fair distribution of benefit.”

The government will consult the private sector about potential partnership models, but Lord O’Shaughnessy said that the benefits could be through “discounted use or free use” of the tools for the NHS, or equity partnerships and royalty streams, as Sensyne has pioneered.

Ministers emphasised that the highest ethical standards would apply and that only companies that could show potential health benefits would be granted access to the data. The code would be voluntary but “at some point we will need to think about how accountability becomes tougher”, Lord O’Shaughnessy said. He said that the government “does not want to discourage innovation”.

One proposal is that devices and treatments developed in line with code of conduct receive an NHS kitemark. The code of conduct is set to be formalised at the end of the year.

The minister emphasised that consented and anonymised patient data was already being used for research purposes and by companies such as Deepmind. “The question is not whether, it’s when and how,” he said. “People are very aware that if you are working with the NHS you have to play by the rules. We need trust so people don’t opt out because they believe the benefits are fairly shared between the hospital and the private operators.”

Then there are confidentiality issues. The minutes of the Independent Group Advising on the release of data (IGARD) minutes are dry but lead to an understanding of the issues.

GPs could be forced to switch IT systems under new NHS Digital contract

Untrustworthy staff – continuing saga of data collection failure blights the Health Services potential. GPs cannot have had enough say and power in planning…

Health Secretary pledges to overhaul NHS IT system

It is a small risk (of fraud), but mainly notes missing is incompetence. Best keep a running file of your own notes.

The potential risk for blackmail – think about your medical records when you are young. Are you ambitious to be famous?

Not hacking it… Sangfroid?

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If a placebo is recommended by NICE, and patients have to buy it, why not any thing less than 2 pints of beer and a packet of 20 fags?

I understand some trusts are still providing honey for wounds. If a comprehensive, free at the point of delivery, cradle to grave without reference to means health service is providing honey for one condition, why not for another? This is of course nonsense, and we simply need to be honest about rationing. Sugar paste is as good as honey for all medical conditions, and far cheaper. If a placebo is recommended by NICE, and patients have to buy it, why not any thing less than 2 pints of beer and a packet of 20 fags?

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The Lancashire Telegraph reported a nationally reported news item 23rd August: Treat coughs with honey not antibiotics, doctors and patients told.

Honey and over-the-counter remedies should be the go-to treatment for coughs rather than antibiotics, health officials have said.

Doctors will be told not to offer the drugs in most cases and to instead encourage patients to use self-care products, under new draft guidance from Public Health England (PHE) and the National Institute of Health and Care Excellence (Nice).

The advice is part of a growing effort by to tackle the problem of antibiotic resistance.

In most cases, acute coughs are caused by a cold or flu virus, or bronchitis, and will last for around three weeks, according to the guidance.

Antibiotics make little difference to symptoms and can have side-effects, it warns.

Patients are instead advised to try honey or cough medicines containing pelargonium, guaifenesin or dextromethorphan, which have been shown to have some benefit for cough symptoms, before contacting their doctor.

Antibiotics may be necessary treat coughs in patients with pre-existing conditions such as lung disease, immunosuppression or cystic fibrosis, or those at risk of further complications, the guidance states.

Dr Tessa Lewis, GP and chairwoman of the antimicrobial prescribing guidelines group, said: “If someone has a runny nose, sore throat and cough, we would expect the cough to settle over two to three weeks and antibiotics are not needed.

“People can check their symptoms on NHS Choices or NHS Direct Wales or ask their pharmacist for advice.

“If the cough is getting worse rather than better, or the person feels very unwell or breathless, then they would need to contact their GP.”

As many as one in five GP prescriptions for antibiotics may be inappropriate, according to research published by PHE earlier this year, and the body has warned that overuse of the drugs is threatening their long-term effectiveness.

Dr Susan Hopkins, from PHE, said: “Antibiotic resistance is a huge problem and we need to take action now to reduce antibiotic use.

“Taking antibiotics when you don’t need them puts you and your family at risk of developing infections which in turn cannot be easily treated.

“These new guidelines will support GPs to reduce antibiotic prescriptions and we encourage patients to take their GPs advice about self-care.”

A consultation on the draft guidance will close on September 20.

If a placebo is recommended by NICE, and patients have to buy it, why not any thing less than 2 pints of beer and a packet of 20 fags?

Interesting suggestion low cost for high volume treatments to be excluded… GPs will take no notice as their job is to put their patient “at the centre of their concern”.

Cough medicine is a waste of money: NHS recommends Honey … The Mirror

Honey for burnsNHS

Pouring granulated sugar on wounds ‘can heal them faster …

Why do some cavity wounds treated with honey or sugar

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