Category Archives: Junior Doctors

Many junior doctors have told me they are aware that their seniors are disengaged from the managerial process, and they often comment that if they focusssed on “significant Events” they could spend all day filling out forms and never seeing a patient.
What hapens to change the altruism which almost all doctors have when they qualify?
How does a MRCP qualified doctor feel about being made to do 6 months medicine in a GP training scheme?
What do they feel about management and the changes ongoing in the NHS?
Why would they go abroad? What is it about the foreign systems and opportunities that appeals?

Official gagging? “…a climate that threatens individuals with criminal sanctions and lets the system off. The hospital hasn’t been held to account.”

This case has been festering, and playing in the minds of many reflective doctors. The principal that we should be completely open in our reflection will not hold water for those doctors who have made mistakes – Is this a form of official gagging? Dr Vaughan’s comment at the end of this report reads: “You can’t learn from errors in  a climate that threatens individuals with criminal sanctions and lets the system off. The hospital hasn’t been held to account.” The Official BMA response (30th Jan 2018) is here.

Chris Smyth reports for the Times, 26th Jan 2018: GMC wins appeal to bar Hadiza Bawa-Garba after boy’s death

A doctor whose career was spared despite being convicted of the manslaughter of a six-year-old boy has been struck off after the General Medical Council won a High Court appeal.

Jeremy Hunt, the health secretary, joined doctors in arguing that the ruling could harm patient safety by making staff scared to admit mistakes.

Doctors accused the regulator of a vindictive campaign to use Hadiza Bawa-Garba as a scapegoat for systemic failings in the NHS. The GMC, however, insisted that patients would lose confidence in doctors if they could be convicted of criminally negligent treatment yet continue to work.

Bawa-Garba, who was 35 and a paediatric registrar, was on duty at the Leicester Royal Infirmary in 2011 when Jack Adcock arrived with diarrhoea and vomiting. She did not follow up on abnormal tests quickly, did not call in a consultant and missed what an expert described as a “barn-door obvious” case of sepsis.

She then told a crash team to stop resuscitation without looking at Jack’s notes because she had mistaken him for another patient after confusing their mothers. Although this did not contribute to Jack’s death, the trial judge said that the “extraordinary” error illustrated how bad her care was. She received a two-year suspended sentence in 2015.

Last year, an independent Medical Practitioners Tribunal Service panel decided not to end her career, citing “the context of wider failures”, such as short-staffing and IT glitches that delayed test results. It suspended her for at least a year, but told her the mistakes were not irredeemable and would not preclude a return to work. The GMC, which won the power to challenge such rulings last year, made an appeal.

Yesterday Mr Justice Ouseley overturned the panel’s verdict, citing a ruling by Lord Bingham that “the reputation of the profession is more important than the fortunes of any individual member”. He ruled that the tribunal had not respected the “true force of the jury’s verdict” that Bawa-Garba’s failings were “truly, exceptionally bad”. He said that a panel had no right to judge her culpability less severely after considering the same issues. “The holes in the patient’s safety net cannot reduce her personal culpability,” the judge wrote, arguing that systemic problems did not cause Bawa-Garba’s errors.

The health secretary said he was “deeply concerned about possibly unintended implications” of the ruling for the process of learning from mistakes. He said he was “totally perplexed” by the GMC decision to pursue the case.

Charlie Massey, chief executive of the GMC, said “doctors should have nothing to fear” from the case as he would not hold an admission of error against them. “People are confusing normal, everyday error with things that are ‘truly, exceptionally bad’.”

Jenny Vaughan, a consultant who has supported Bawa-Garba, said: “You can’t learn from errors in a climate that threatens individuals with criminal sanctions and lets the system off. The hospital hasn’t been held to account.”

Rob Hendry of the Medical Protection Society, which defended Bawa-Garba, said: “This decision may jeopardise an open, learning culture at a time when the profession is already marred by low morale and fear.”

Bawa-Garba may appeal to the Supreme Court.

Back to blame: the Bawa-Garba case and the patient safety agenda. Is there any Dr who will not stop putting any form of patient identifiers in their portfolio now? Medical errors may now be hidden for fear of litigation.

Update 1st Feb 2018: “Junior doctors fear reporting errors” by Kat Lay

Doctors have been warned that they risk disciplinary action if they carry out threats to stop recording mistakes in writing.

They fear that any admissions could be used against them, after a junior doctor was struck off last week for errors that led to the death of a six-year-old boy. Hadiza Bawa-Garba was convicted of manslaughter by gross negligence in 2015 over the death of Jack Adcock from sepsis in 2011.

Her case has provoked anger among thousands of doctors, who believe that she was a scapegoat for systemic failings and may have been the victim of racism. Jack was admitted to Leicester Royal Infirmary in 2011 with diarrhoea and vomiting. Bawa-Garba failed to follow up tests quickly, did not call in a consultant and told a crash team to stop resuscitation after mistaking him for a patient with a “do not resuscitate” order. She was covering the work of two doctors after return from maternity leave, with no induction into the role.

Last year the Medical Practitioners Tribunal Service decided not to strike her off but the General Medical Council appealed and won last week.

Kaanthan Jawahar, a junior doctor specialising in geriatric psychiatry in Nottingham, wrote on Twitter: “Your employer will scapegoat you for systemic failures . . . Your seniors will throw you under the bus.”

Doctors must keep an eportfolio as part of their annual appraisal process, in which they should reflect on how they could improve their practice.

Rob Hendry, medical director at the Medical Protection Society, which represents doctors in legal cases, said: “One particular area of concern has stemmed from reports that Dr Bawa-Garba’s eportfolio reflections were used against her at the criminal trial. In fact, her eportfolio did not form part of the evidence before the court and jury.

“We also advise doctors to bear in mind that not disclosing an incident or reflection during appraisal may lead to a greater risk of allegations of probity and referral to the GMC.”

Terence Stephenson, chairman of the GMC, said that although the court had ruled that the tribunal “had no powers to unpick the criminal conviction”, there was a “critical need” to examine how gross negligence manslaughter cases were initiated and carried out.

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A budget should make us all think. We are all lost, and in denial with health care, which depends on jobs, productivity and the economy, all of which are threatened.

Going back to the original roots of the Health Service: NHS ‘birthplace’ Tredegar’s GP services ‘unsustainable’ – why? how?

As your local Health Service safety net corrodes, you might be interested to see the headlines and links in the medical and general media following the budget. Mr Hunt would never want the health service to fall apart…. wouldn’t he? Desperate measures such as “on line” consultations are of no practical use.                 Nick Triggle for the BBC reports: NHS Budget plan not enough, say bosses

Many employees “need to leave” to keep their sanity. Threats to disallow medics and nurses from travelling seem to have been withdrawn. Doctors demanding clarity….Nick Bostock for GPonline)  and then in August in the Mail the government backed down. The Mail also reports on “physician assistants” being poached from North America! Dennis Campbell in the Guardian “Junior doctor Nadia Masood: ‘Hunt’s driven a lot of us out of the NHS’ – Medics felt justified in opposing a new contract and their defeat has left many feeling demoralised, Masood says. Health service is ‘haemorrhaging highly trained, experienced GPs at an alarming rate,’ says top GP. BBC reports on “Thousands of out-of-hours doctor shifts unfilled”, and then on the locum situation Andy Philip in the daily record 13th November reports: GP crisis forces Health Board to pay a whacking £2000 for one (8 hr?) shift.

The Motherwell Times spares no one: GP recruitment has failed and since 1/5th or 20% are from overseas, and many are returning or retiring….. These tend to be working in the less popular areas, and some cities are now appreciating the crisis: David Ottwell for the Manchester Chronicle 18th November – NHS at ‘breaking point’ as GP numbers fall and patients soar in North East

The British Medical Association warns a chronic shortage of doctors is putting patient care at risk

The Belfast Telegraph tells us overseas doctors are crucial….

Whilst management attempt to apply artificial waiting times as “routine”. Henry Bodkin for The Telegraph 13th November offers : “Phantom waiting time branded unethical”. The Sun calls it “Op woe”.

In April atie Foster for the Independent warned us: Almost half of GPs plan to quit NHS due to ‘perilously’ low morale, survey suggests and then in November: Jeremy Hunt’s GP recruitment pledge in tatters as 1000 full-time …

If you cannot register or see a GP then you may not have a local A&E to go and see a medical student or a junior inexperienced Dr for your primary care needs either:  Dennis Campbell in the Guardian: A&E units, GP surgeries and walk-in centres to close as cash crisis bites

NHS bodies have decided in the last four months alone to shut or downgrade 70 services, says campaign group 38 Degrees

The Mirror: Budget pledges extra £1.6 billion for NHS next year but it’s less than half what health service chief asked for – The announcement also included a commitment to fund a pay rise for NHS nurses, midwives and paramedics – but only if negotiations on wider pay reform are successfully concluded.

Promises have been broken and the profession have no faith in discredited politicians. We always knew 5000 instant Drs and GPs was impossible. There are many doctors being trained, of whom 80% undergraduates are women, but the graduate courses are usually 50:50. men to women. Many will take career breaks, or work part time, or go abroad for relevant experience. They may decide to stay!  Chris Smyth in the Times 22nd November: Fewer GPs despite pledge to hire 5,000

GP numbers have fallen again, throwing a key NHS pledge of thousands more doctors into question.

The NHS has 541 fewer family doctors than a year ago. Doctors said they were “gravely concerned” by the figures at a time when patients were waiting ever longer to see a GP.

NHS Digital figures show that there were 41,324 GPs working for the health service in England at the end of September, 240 fewer than in June and 541 fewer than September 2016.

Full-time numbers are down even more as doctors cut back their hours, citing intolerable workloads. The NHS has the equivalent of 33,302 full-time GPs, 1,193 down on a year before.

Jeremy Hunt, the health secretary, has promised to recruit 5,000 more GPs by 2020. However, Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “We need to start seeing some progress, and fast. We understand that change takes time, but we desperately need more family doctors.”

A Department of Health spokeswoman said: “There are more than 3,000 GPs in training and 500 new medical school places will be available in 2018, with a further 1,000 in 2019. We’ve also outlined more flexible working options so we can retain the expertise of more experienced GPs.”

We have rationed medical school places for too long. The country does not deserve to be treated like this. We need honesty and admit that we cannot have “Everything for everyone for ever“.

The facts, What doctors earn – except that GPs are self employed and you wont know their overhead/expenses/debts which will vary by GP and by practice.

BMJ has helpfully published the latest data on GPs (BMJ Aug 30th article by Tom Moberly

Data chart: what doctors earn

Authors: Tom Moberly

Publication date:  30 Aug 2017


In 2016, the mean annual pay for all doctors working full time in the UK was £78 386, according to figures published by the Office for National Statistics (ONS).

The ONS data show that 78% of doctors work full time. For the remaining 22% who work part time, the mean annual pay was £46 277. Across all doctors, working full time or part time, the mean pay was £71 455.

Separate figures on doctors’ earnings are published by NHS Digital, and these figures provide data on the earnings of different sections of the workforce.

These figures show that, in 2014-15 (the latest period for which these data are available), the mean earnings for GPs was £101 500. This figure is for income before tax, but after expenses, for salaried GPs and partners working under either general medical services or personal medical services contracts.

For consultants and other hospital doctors, NHS Digital has published data on earnings in the year up to March 2017. These show that the mean earnings for consultants were £111 563. For specialty and associate specialist doctors they were £69 336, and for all doctors in training, mean earnings were £49 318 (£55 629 for those in higher specialty training, £47 420 for those in core training, and £36 122 for those on the foundation programme).

The ONS data show that, between 1997 and 2016, mean pay across all doctors increased from £36 849 to £71 455.This equates to an average annual increase of 3.5% over that period.

What doctors earn

Consultants £111 563
GPs £101 500
Specialty and associate specialist doctors £69 336
Trainees (higher specialty training) £55 629
Trainees (core training) £47 420
Trainees (foundation programme) £36 122

Source: NHS Digital. Note: GP data are for 2014/15; other data are for 2016/7.

Tom Moberly UK editor BMJ

The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

A Times leading article alludes (correctly) that undergraduates are less value to the state than graduates who enter medical school. But Zawad Iqbal in “Doctors’ training needs streamlining before it’s too late” does highlight the problem of declining standards, and lowest common denominator medicine. The problem with the new GMC suggestion is that too low a standard may be deemed acceptable in order for us to have enough doctors in the short term. The fact that NHSreality would never have chosen to start from here is omitted. Long term rationing of medical school places, as well as too many undergraduates and too few graduates is to blame. A ten year program of capacity management may be undermined if we admit too many overseas doctors suddenly.. On the other hand, if the bar is set high enough… OK, I forget, nurses can do the job of a GP can’t they? NHSreality feels it is already too late, and it’s going to get worse… (Katie Gibbons reports from Kent: NHS operations postponed to save cash). Decommissioning is going to get worse still.

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In a letter to The Times 3rd Feb 2017 Prof Derrick Wilmot of Sheffield writes: on DOCTORS’ TRAINING..

Sir, A medical licensing assessment for doctors is long overdue (“Doctors face tough new test on basic skills”, Feb 1). There is a similar situation for dentists. A third of the dentists entered each year on the General Dental Council’s register qualified at an overseas university. UK graduates are not tested by a common examination but by the individual university dental schools, which do try, mostly with success, to maintain sufficient quality and commonality. Many of the overseas new dentists entering the UK come from EU countries and cannot be tested. Brexit is the ideal opportunity to introduce a new robust common assessment for all doctors and dentists registering in the UK.

Recent years have seen a frightening increase in medical and dental litigation. Evidence for an association is weak but if a basic clinical education is lacking problems surely lie ahead both for the practitioner and, more worryingly, for the patient.

Emeritus Professor Derrick Willmot of Sheffield University, and past dean, Faculty of Dental Surgery, Royal College of Surgeons: Doctors’ training needs streamlining before it’s too late

The news that thousands of newly qualified doctors aren’t confident enough to perform basic tasks such as taking blood is a real canary in the coal mine moment — a warning sign that the way we teach doctors urgently needs to change.

Part of the problem is that the basic structure of medical training hasn’t changed in more than a hundred years. The General Medical Council sets the standards for undergraduate medical education and supervises the training and education of students. But the content and length of a medical degree varies widely, depending on which institution you attend, and the different medical schools are allowed to set their own criteria for licensing doctors.

There is no common standard to practise in the UK. Doctors from the European Union can work here if they’ve passed relevant exams in their own country. Doctors from other parts of the world are given a separate test, resulting in a confusing system with no overall benchmark.

So it’s a relief that medical regulators now want to introduce a standard test. But that’s still some years away and frankly it’s not enough. We should seize the opportunity to conduct a bigger and more wholesale review of how we train our doctors and whether these decades-old methods are up to scratch.

What doctors needed to know ten years ago is often a world away from what they need to know today. Basic science and clinical science remain the core modules on medical courses but healthcare delivery is becoming ever more important. As well as introducing a common approach to basics such as taking blood samples and performing lumbar punctures, areas such as data analysis, IT skills and interpersonal ability must play a bigger role in medical training.

One of the biggest opportunities being missed is in postgraduate medical education. This is because postgraduate training falls under the NHS rather than a university or medical school. Our doctors need to keep learning new skills if they’re going to give their increasingly well-informed patients the best treatments. The doctor of the future will not necessarily carry a stethoscope around his or her neck but will more likely be one of a specialist team working alongside health technicians, pharmacists and nurses.

Rather than introduce a new standard test for doctors after they have qualified, they and their patients would be better served if medical schools standardised the courses they begin at 18.

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Nursing degree applications fall by a fifth – a two tier service is evolving by neglect.. State basic, and Private enhanced.

Most of the doctors feel that Nursing took the wrong course when they tried to push through the degree increments and “Agenda for change” demands in the first decade (2004) of the century. GPs as self employed businesses resisted most as our funding was not future proofed. Those who capitulated are regretting it now. Stephanie Jones-Berry reports in “Primary Health Care”.and Greg Hurst reports in The Times 17th December: Nursing degree applications fall by a fifth despite the Agenda for change”  This decline is a disaster for those of us in our sixties and seventies who hoped for the quality of nursing care our parents received. Continuous neglect, rationing of training places in medicine, and over borrowed nurses-in-training, and Agenda for change has led to government preferring to hire nurses and doctors from abroad, at cheap rates of pay, rather than train our own, with whom patients have cultural affinity and good communication.

A two tier service is evolving in Medical and Nursing care, by neglect: state basic, and private enhanced. It would be better this change was managed and overt..

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Applications for nursing degrees have fallen sharply since the government withdrew their funding via bursaries and forced students to pay for their courses with loans.

Universities said last night that applications for nursing, midwifery and allied health courses were down by about 20 per cent compared with this stage last year. In some institutions applications have halved.

Shortfalls in applications were worse in London and the southeast, among mature candidates and in specialist fields such as learning disability nursing, occupational therapy and podiatry. There are fears that some small courses may become too expensive to run if numbers dip too low.

It is too soon to judge if the fall will mean fewer student nurses starting in September next year but universities are considering contingency plans to avert a shortfall in nursing graduates, including accelerated two-year postgraduate nursing courses.

Vice-chancellors are planning a campaign with health bodies to encourage more people to train as nurses, which is likely to run well beyond the normal deadline for university course applications next month to encourage candidates to make late submissions or apply through clearing in the summer.

Some caution is needed with the figures as the Universities and Colleges Admissions Service says year-on-year comparisons are complicated this year because calendar dates mean we are two or three working days behind last year’s cycle, and university applications generally are running behind last year’s figures. But the drop in applications for nursing, midwifery and allied health subjects is twice that of other courses, according to a survey by the vice-chancellors’ body Universities UK (UUK).

Ministers claimed that ending the bursaries would create 10,000 more training places, as costs are met by students taking out loans rather than direct government funding. It would be an embarrassment if numbers fell.

Janet Davies, head of the Royal College of Nursing, said her organisation had consistently raised concerns to the government that its decision would result in a drop in applications. “Our advice fell on deaf ears. The government went ahead in gambling on the future of the nursing workforce,” she said.

Steve West, vice-chancellor of the University of the West of England and chairman of UUK’s health policy network, said that the numbers were down. “We want to ensure . . . we get the right message out that there are fantastic career opportunities in nursing.”

Vice-chancellors say that mature students are likely to find it harder to take on a student loan of £27,000 to fund their degree and worry that potential student nurses may not fully understand that they will only start repaying once they earn above £21,000.

A Department of Health spokesman said that it was too early in the application process to predict reliable trends, adding: “We are committed to increasing the number of training places for homegrown nurses, as well as making sure there are more routes into nursing including through apprenticeships.”

The RCN is concerned the effects on the future workforce will be exacerbated by Brexit and an ageing population.

To date many midwives and nurses have not been able to “demonstrate they can communicate effectively”. Communication and cultural barriers in health acknowledged. Litigation results..

In an undercapacity market who can blame the nurses or doctors? £190m is “comeuppance” for politicians. NHS nurse recruitment from EU ‘too aggressive’!

Not enough nurses or doctors? Or are we just inefficient? The situation is a disgrace and a scandal, and needs a war like atmosphere of honesty to address it…

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

Not enough doctors – just keep lowering the bar & reducing the funding

A third of A&E doctors leaving NHS to work “in a non toxic environment” abroad

 

Will you be more likely to die with a male doctor? Patients less likely to die if doctor is female…

The report by Kate Gibbons in in The Times and other newspapers on 20th December 2016 is an interesting read, and it has statistical power. “Patients less likely to die if doctor is female” is reprinted below. The study needs to be reproduced in the UK’s 4 services, where junior doctors are mainly female, and see if it applies. Justification of the bias in selection would be retrospective, and some consolation to those on waiting lists. If they do get admitted they are at least more likely to return home.

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Yusuke Tsugawa was the original author in JAMA Internal Medicine October 13th 2016, and the article has free on line access. There were over 1.5 million patients analysed for nearly 60,000 physicians. The gender distribution of the physicians is not mentioned, but as they have graduate entry we can assume it is equal male to female, (unlike the UK where undergraduate entry results in 80% females).  The report is about internal medicine and there is a readmission rate of around 250K patients in 30 days. The potential total lives saved in the USA would be 32K if this is valid and reliable, and is accounted for by a difference of 4% in outcomes. It says nothing about quality of life, cost, or future care needs.

Elderly hospital patients treated by women doctors are less likely to die than those in the care of men, research has indicated.

A study found that people aged 65 and over who received hospital care from a male doctor had an increased risk of dying within 30 days.

Female doctors were less likely to flout national care guidelines and had better communication with patients.

The study, published in the journal JAMA Internal Medicine, was the first to examine how gender differences could affect mortality rates.

Analysis of more than a million patients aged 65 and over who had been in hospital for a variety of conditions, including diabetes, cancer and heart failure, found that those treated by a female doctor were on average 4 per cent less likely to die prematurely than those with a male doctor.

The researchers at Harvard University found that the differences were most significant for patients who had more severe conditions.

Yusuke Tsugawa, the study’s lead author, said: “The difference in mortality rates surprised us. The gender of the physician appears to be particularly significant for the sickest patients.”

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The long term results of rationing midwives and doctors in training…

Two items in the news today (Sunday Times – Sarah Kate-Templeton 15th October 2016) reveal the long term results of rationing midwives and doctors in training. When you control the supply side completely, and have many years notice to plan, this is irresponsible government. It represents a collusion of denial. Market forces are giving the government a problem, but they control the market..

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NHS breaches (forced to bust) pay cap for locum doctors

NHS hospitals have had to pay up to £155 an hour for doctors despite a cap introduced last year on the amount trusts could spend on agency locums.

One hospital in the north of England paid more than £10,000 a week for three locum agency doctors. Two locum agency doctors between them racked up more than 4,400 hours over a year, which equates to them each working more than eight hours every weekday.

This weekend NHS Improvement, the hospitals regulator, warned that while the government cap had succeeded in reducing the amount the NHS spent on agency nurses, trusts were still overriding the limits, sometimes paying double the permitted agency rates…..

Last year the NHS spent more than £72m on agency, overtime and bank midwives, according to a report by the Royal College of Midwives (RCM). The RCM says that, for the same cost, 3,318 full-time midwives could have been employed.

The report found that, in December 2015, NHS hospitals spent an average of £50.58 an hour on agency midwives….

Mothers face 30-mile trips to give birth

Hundreds of mothers booked into their local maternity units have had to give birth in towns more than 30 miles away because the hospital closest to them had temporarily closed.

The maternity units were either full or too short-staffed to admit the women. During one closure of maternity units at Cambridge University Hospitals NHS Trust, which lasted for 3½ days, 22 women due to give birth in the city had to have their babies in a range of towns including Norwich, Ipswich, Bedford and Harlow, Essex.

In Chester, women due to give birth had to travel to hospitals up to 32 miles away in north Wales.

The Royal College of Midwives will highlight the problem at its annual conference this week.

Jon Skewes, a director of the royal college, said: “Senior midwives are telling us that they are having to close units because of staffing shortages and the increasing demands on the services that often simply do not have the resource to cope.”….