Category Archives: Paramedics

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

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You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

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

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

Nurses and pharmacists to replace GPs for 1 in 4 visits

The highest risk situations in General Practice are when seeing patients without records, when complex elderly people who may have communication difficulties are seen alone, and when there is no chaperone and /or a language/communication problem. Telephone triage may weed out the most risky cases, and reserve these for the GP, notes may be available on a portable computer, but there will be a temptation for “drift” and for those untrained in diagnosis to be over extended. The risk may be more than the insurers will accept. Expect mistakes, and premiums to rise, or for even more pressure on A&E as more patients are referred …. (defensive medicine).

Chris Smyth reports 16ht Feb 2017: Nurses and pharmacists to replace GPs for 1 in 4 visits

One in four GP appointments will be conducted by pharmacists or nurses under plans to relieve pressure on family doctors.

Health chiefs in the South West have said that by 2020 they want doctors to cut their appointments by 27 per cent by drafting in other health professionals and by getting patients to manage their own conditions.

Simon Stevens, head of NHS England, has said that he wants patients across the country to be treated by pharmacists, counsellors and physiotherapist to ease the pressure on GPs. For the first time, health chiefs have now estimated how many doctors’ appointments this could avoid.

The sustainability and transformation plan for Bristol, North Somerset and South Gloucestershire has set a goal to “reduce the number of consultations conducted by GPs by up to 27 per cent through diversion of work to more appropriate multidisciplinary team members and non-clinical services”.

Health chiefs in the area said that the figure was a rough estimate that aimed to show how big a change was needed to keep pace with an older, sicker population when cash and doctors were both in short supply.

They also want to use online consultation and monitoring services to reduce surgery visits by 15 per cent by helping people to look after themselves at home.

Medical leaders have backed the plan as a way to deal with routine problems when waits for appointments are lengthening, but warned that it must not become a way to stop patients seeing a GP.

Richard Vautrey, of the British Medical Association’s GP committee, said: “Nurses, pharmacists and other healthcare professionals could play a vital role in supporting GPs to deliver care in the community.

“This is needed particularly at present as the government has so far failed completely to deliver the much-needed 5,000 new GPs they promised.”

However, he added: “While expanded teams can be beneficial, they should not be seen as a replacement for GPs, as it remains essential that patients can access a GP when they need to.”

Mr Stevens announced plans last year to hire 1,500 in-surgery pharmacists to carry out blood pressure checks, to treat for minor ailments, and conduct routine follow-ups and medicine reviews for older people.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “These highly trained healthcare professionals can provide much-needed support to GPs and our existing teams at a time when the profession is under intense resource and workforce pressures, and they will be instrumental in freeing up GPs’ time to deal with complex patients who really need the expert skills of a family doctor who considers the physical, psychological and social context during the consultation.”

A spokesman for the plan said that the figures “reflect a blended assessment of the scale of the challenge we are trying to address with changes to the way we plan, organise and deliver services both in community and in hospital. What we do want to do is to reduce demand for GP appointments.”

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Crisis – what crisis?

Only the informed, the lucky, or those living near a tertiary centre are likely to get the best of care in the near and foreseeable future. There are not enough staff, doctors or nurses, to diagnose and care properly. The result has to be an increase in private medicine, and private medical insurance (PMI). This trend is all part of what is making voters more fascist. The media has not grasped the implications – civil unrest. Examples of the types of “stress” on our society litter the media, and some are included below. Since NHSreality wrote about the pressures on GP practices in Jan there have been many more closures. Ignoring petitions and triage at a distance is going to lead to problems.. (Health Service rules mean that GPs cannot provide the triage – only private companies. I suspect the company triaging Goodwick is owned and run by a group of GPs) Why is it not being run by Pembrokeshire GPs? What is the litigation cover?

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The sick parade – of GP closures. This list heralds the end of the health service as we knew it.

Jack Furness in The Sentinel reports 10th November 2016: Jeremy Hunt asked to intervene on plans to axe beds at Bradwell Hospital

Keane Duncan on the 6th November in the Gazette tries to explain: Q&A on A&E plans: What changes are proposed for Tees health services and why? – Health bosses have drawn up plans as services face increasing funding pressure

The Western Telegraph reports 5th November 2016: GP resigns from troubled north Pembrokeshire surgery and a triage system from Cardiff is being attempted. And for Goodwick Surgery the council has imposed car parking charges to boot. Car park fees slammed as ‘tax on illness’ to stay (Chris Betterley 14th October in the County Echo).

On Wednesday 12th October the Yorkshire Post reported: Fury as hospital beds and minor injuries units face closure and the community have organised their petition to be given to Mr Hunt (The Stoke Sentinel 10th November 2016 – Jeremy Hunt asked to intervene on plans to axe beds at Bradwell …)

London is not immune and in June the Guardian reported: North Middlesex hospital A&E faces closure on safety grounds. Dennis Campbell comments: “Move would be first in NHS history, as internal documents seen by the Guardian show junior staff often left in charge of casualty unit”..

Laura Donelly in the Telegraph foretold 26th August: NHS takes axe to hospital units amid financial crisis – The NHS has begun drawing up a formal list of hospital departments which will be closed amid the worst financial crisis in the history of the health service, officials have revealed.

Hospitals will embark on a “glut” of closures, with Accident & Emergency units and key services for the elderly among those stripped out and centralised, NHS leaders have said.

It came as two NHS hospitals suspended A&E services for children, after admitting they could not run them safely……..

One fortunate patient (a child in Fishguard) managed to get access to some of the best available treatment (available since 1990 in USA). Nobody seems to be asking whether referral before the original surgery would have given a better outcome, and why the UK still has too few Proton Beam therapy units. Ceri Coleman-Phillips , reported in the Western Telegraph 8th March 2016: Fishguard girl Abbie Dunn, 22, to get pioneering proton beam therapy treatment for rare brain tumour

Proton Beam Therapy – it’s covert rationing in all UK regional health services since 1990!

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“Will all those that are not dying please go home!” Rationing hits the headlines..

Its all going the get worse….“Will all those that are not dying please go home!” Rationing hits the headlines again and again whilst denied by government.. More and more Health Service employees realise the truth and are voting with their feet. Katie Gibbons reported 2nd August – “Exodus of paramedics causes 999 crisis” and nobody cares…The Perverse Incentive to deny is evident in the fact that none of the paramedics or the midwives (see below) will get even get an exit interview, so their masters will not hear the truth.

Rob Merrick reports in the Independent firstly on 18th October: Jeremy Hunt tells NHS Bosses who are “rationing” not to make ‘easy’ choices

The Health Secretary also dropped his claim that the NHS had been given all the money it requested – admitting it was only enough to “get going” on a restructuring plan

19th October 2016: Theresa May fails to rule out possible casualty department closures in hunt for ‘efficiencies’

Challenged by Jeremy Corbyn, the Prime Minister said key decisions must be made ‘at local level’

and the Guernsey Press on the same day reports: Charity calls on Jeremy Hunt over pledge to ‘step in’ where care is rationed

A fertility charity has called on the Health Secretary to take action after he promised to “step in” where care was being rationed.

Laura Donnelly in The Telegraph on 19th October reports: NHS spending will drop per head despite ageing population and growing demand, says chief executive 

…Officials said it is unclear whether a per capita cut to the health budget has ever happened before in the NHS’ entire 68-year history….The NHS last year recorded the biggest deficit in its history, at £2.45bn, and hospitals across the country are drawing up plans to try and make services “sustainable”….

“We are looking after one million more over 75s than were were five years ago and in five years time we will be looking after another million over 75s in England and that produces massive pressure on the NHS front line.

“People working in hospitals have never been busier, people in GP practices and in the social care sector the same.”

The Health Secretary refused to be drawn on recent reports that Theresa May has said the health service will see no increase in funding, or on whether the Autumn statement will see a boost for social care.

Mr Hunt said all areas of the NHS needed to make “painful and difficult efficiency savings”. But he said this should not mean denying patients the care they needed.

“I don’t at all accept that in order to make these efficiency savings we need to reduce the quality of care for patients,” he said….

Mr Hunt pledged to intervene, if the local NHS took decisions to ration care for patients.

“When we do hear of occasions that we think are the wrong choice has been made – where an  efficiency saving has been proposed that we think would impact negatively on care – then we step in,” he said.

He said improvements in safety and quality of care would save the NHS money, in the long run.

“If you get an infection when you are having a hip replaced that will cost theNHS £100,000 to sort out as well as being incredibly painful and horrible and for the patient concerned,” he said.

Improvements in cancer care would save NHS funds, as well as lives, he suggested.  “We know its two to three times cheaper to catch cancer at stage one rather than stage three or four,” he told the select committee.

Guernsey Press: Government to step in if local NHS chiefs make ‘wrong choices’ over care

The Government will step in when it thinks local NHS leaders have made the “wrong choices” about care being rationed in the health service, the Health Secretary has warned.

The Times reports 19th October: Midwives quit over dangerous work conditions and Kate Gibbons reports that “A third of ambulances miss emergency response targets”

Civil Unrest starts in Enfield? This site began life on 15th October 2016: Defend Enfield NHS – Their strap line is “Will all those that are not dying please go home!” 

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Getting to see a Health Service physio – like getting to see a health service dentist

What an opportunity for dentists and physios who wish to enter private practice. Of course they need training and experience, usually in one of the UK health services, but prolonged undercapacity and poor manpower planning mean they can virtually work anywhere once they have confidence and experience. The irony of the BBC report provokes only laughter… Who would choose to work long term on the factory floor production line management – and probably not long before Performance Related Pay? Physio is another area where gender bias in recruitment has always damaged service delivery.

BBC reports 18th March 2016: Physios in surgeries ‘can save GPs time and money’

GPs could spend longer with their patients if physiotherapists worked with them at their surgeries, says the Chartered Society of Physiotherapy.

If patients with back pain, for example, were directed to a physio instead of a GP, an extra five minutes could be spent with other patients.

Physios are already working in a small number of GP surgeries in England.

GPs’ leaders welcomed the initiative but said staff would have to be trained to the highest standards.

Musculo-skeletal conditions are thought to make up as much as 30% of all GP appointments.

Physiotherapists say that if they could be the first point of contact for patients with these conditions, GPs could dedicate more time to people with other conditions.

During a three-month pilot in West Cheshire, more than 700 patients who would otherwise have seen a GP, were seen by a physiotherapist.

The arrangement is now in place in 36 GP practices in the area.

Teamwork

According to Karen Middleton, chief executive of the Chartered Society of Physiotherapy, GPs and patients regularly say they are concerned about the inadequate length of appointments – which are usually around 10 minutes – and this could be a solution.

“More GPs are choosing to invite physiotherapists to work alongside them in surgeries up and down the country to save time and money,” she said.

“Our ambition is for this to be the norm rather than the exception.”

The Society also said putting physios in GPs surgeries could save the NHS money.

It calculated that a typical GP practice could save around £2,500 a week by sending patients with musculo-skeletal conditions to see a physio rather than a GP.

Dr Richard Vautrey, deputy chair of the British Medical Association’s GP committee, said: “Implementing services like this in GP surgeries would be good for patients, good for practices and good for the wider NHS.”

However, he said that to make this a reality, funding from CCGs [Clinical Commissioning Groups] and NHS England was essential.

‘Need assurances’

Dr Maureen Baker, chair of the Royal College of General Practitioners, said she welcomed any initiative which helped to ease the pressure on GPs, as long as it was well-regulated.

“Whilst the services GPs and physiotherapists provide complement each other, they are very different, so whilst we would welcome better integration between the two we would recommend that any self-referral schemes reflect local needs and are continuously evaluated.

“We would also need assurances that patients do not fall prey to providers who are not accredited by the Chartered Society of Physiotherapy, whose members are trained to the highest standards and have the skills to identify health problems that go beyond musculo-skeletal conditions.”

She added that more investment in general practice and more emphasis on recruiting and retaining GPs were equally important in delivering longer appointments for patients.

A reminder in poetry: “I am a child of the NHS”

On the 60th Year of the NHS I read a poem “I am a child of the NHS”… Unfortunately I don’t have the author… Reader –  let me know..

I am a child of the NHS
And despite my complaints you cannot guess
How grateful I am for the service I get.
Sometimes I reflect on the media and press
Which are patently unable to cope with the stress
Of  projecting the truth to the Nation.
The whole concept
Of cradle to grave
Caring for the dying, the elderly, the depraved,
(of nothing to pay, and no duty to save)
For that rainy day or medical surprise
Is “in place of fear”; A fantastic idea.
Aneurin Bevan was the constructor/designer
But time and reality are mean destroyers
Budgets and acronyms abound
To confuse the public in getting around
The shape of a wonderful dream
Which is becoming a nightmare
Said our friend Anne today:
“you can go to hospital well (if you dare)
And come out smelling of MRSA”.
So what is bringing back the fear?
And to compound the rationing, beware
For now both Dental and Physio care
Are unavailable to most – were you aware
That those  words “commissioning” and “fund-holding”
Were parodies of the truth?
And hidden deep in the morass
Of a beurocracy this crass
Is absenteeism so perverse,
It is shamed by every organisation
In the whole Universe
A reflection of a system designed
For the assertive, with morale much worse.
Forget Equity, Forgive Access,  Remove Choice, Allow unfairness
Remain National, not regional,
Counter litigation paranoia with no-fault compensation (none can afford lawyers)
And save my NHS.
So who is the “gatekeeper” in this mess? Your GP,  would you guess.
(that person who does sustained, unpredictable, often imperative, multitasking, for individuals families or groups)

I am a child of the NHS
And, still, despite my complaints you cannot guess
How grateful I am for the service I get.

and it’s worse in wales..

NHS cuts back on IVF treatment due to cost pressures – The Mail 3rd November 2015

It’s Inevitable: more CEOs to follow: Addenbrooke’s Hospital chief executive Keith McNeil resigns. Another Aneurin Bevan is needed..

When NHSreality began I predictedMy prediction is that the financial imperative, the dominance of “emergency” medicine to trump all other needs, will mean slowly but surely the softer areas of the health services, such as dementia, psychiatry and disability will be downgraded. Covert rationing by knee-jerk decisions will increase and only when there are sufficient numbers of the public with stories of failure that the politicians have to act, will something happen… Combining Health and Social Services had potential, but only when there was enough money to make the changes. Now the risks of failure are very high..” It’s an edifice built on sand, and although standing, it’s inevitable degradation has become evident, even to Keith McNeil . Disengaged professionals, denying politicians and a media unable to get to grips with the philosophical issues is not helping.. Another Aneurin Bevan is needed.. come on Kieth – lets have an exit interview.

BBC News reports 15th September: Addenbrooke’s Hospital chief executive Keith McNeil resigns

The chief executive of a major NHS hospital has resigned a week before a care watchdog report is published.

Dr Keith McNeil, who was appointed to the job at Addenbrooke’s Hospital in Cambridge in November 2012, said the hospital faced “serious challenges”.

Chief finance officer Paul James has also resigned from the hospital, which is running a deficit of £1.2m a week.

Both have stepped down ahead of a Care Quality Commission report, which is due to be published on Tuesday.

Dr McNeil said it had been “a very difficult decision” to step down.

“It is a matter of public record that we face a number of very serious challenges, including a growing financial deficit, and I feel the time is right to have new leadership in place,” he said.

“I am pleased our hospitals continue to provide our patients with outcomes that are not only some of the best in the UK, but in Europe.”

Financial investigation

In an official statement, neither Cambridge University Hospitals NHS Trust nor Dr McNeil gave a reason for his resignation.

The trust’s finances were being investigated by Monitor after the hospital introduced a £200m computerised patient record system last year and one of its doctors, Myles Bradbury, was convicted for sexually abusing child patients.

Jane Ramsey, chairwoman of the trust, thanked Dr McNeil “for his efforts”,

She continues: “He has shown great leadership qualities and has helped the trust to maintain its reputation for high quality care and excellent outcomes for our patients.”

Daniel Zeichner, Labour MP for Cambridge, said: “The introduction of the new computer system was troubled and difficult and I suspect that’s contributed to their problems, but I think the basic responsibility for this is the [financial] pressure that’s been put on the National Health Service by the government.

“The Conservatives promised extra for the health service – we haven’t seen it.

“This is not the only chief executive we’re going to see taking this action.”

The Department of Health has yet to respond to Mr Zeichner’s criticism.

Cambridge University Hospitals NHS Foundation Trust, which runs Addenbrooke’s, said its director of workforce David Wherrett would become acting chief executive while a permanent replacement was found.

The Cambridge News: Addenbrooke’s chief executive Dr Keith McNeil resigns as hospital faces “very serious challanges”

Jersey Evening Post: Addenbrooke’s Hospital chief quits before watchdog report is published

ITV News: Chief Exec leaves Addenbrooke’s

Some of the factors influencing the overspend:

Cambridge News 7th September 2015: How involving pharmacists in A&E shorten waiting times and help doctors?

The Guardian 2nd September 2015:: How the care crisis is making old age a nightmare

Only on July 8th this year: Cambridge University Hospitals boss Dr Keith McNeil named as one of country’s top clinicians