Category Archives: Retired

Improving safety needs a “buy in” by professionals. Scapegoating and denial, and causing antagonism are not the way to treat professionals.. but they might start a war.

In the Times 17th July 2015 Laura Pitel, and Jenny Booth  report: ‘Get real’ and work at weekends, doctors told and “Doctors ordered to work at weekends”.… as if they don’t already. This is not the way to win hearts and minds. Improving safety needs a “buy in” by professionals. Scapegoating and denial, and causing antagonism are not the way to treat professionals.. but they might start a war. The problems of August changeover (August comes around again – don’t be ill this month) for trainees/juniors are well known to the profession, and an easy gain would be to change the changeover dates by 3 months. Mr Hunt is betraying how he does not understand the profession, the altruism that drives all new consultants, and the long term mismanagement of manpower planning. The Health services really do need to be de-politicised to win back the hearts and minds of the professionals…

Hospital consultants will be forced to work at weekends, the health secretary announced today as he opened a new front in his war with doctors.

Jeremy Hunt laid down an ultimatum to the doctors’ union, ordering it to discuss a radical overhaul of hours and pay or face having new terms imposed from on high.

He said that 6,000 patients die needlessly each year because of the lack of an adequate seven-day hospital service. Patients are 15 per cent more likely to die in hospital if admitted on a Sunday than if they go in on a Wednesday, he said.

In a stark message likely to provoke doctors, Mr Hunt told the British Medical Association that it has six weeks to negotiate. “I will not allow the BMA to be a roadblock to reforms that will save lives,” he said. “Be in no doubt: if we can’t negotiate, we are ready to impose a new contract.”

The BMA has previously told Mr Hunt to “get real” about seven-day working, but in his speech to The King’s Fund this morning, Mr Hunt accused BMA leaders of being out of touch with what their own members believed.

“I have yet to meet a consultant who would be happy for their own family to be admitted on a weekend, or would not prefer to get test results back more quickly for their own patients ,” said Mr Hunt.

“Hospitals like Northumbria that have instituted seven-day working have seen staff morale transformed as a result.”

He added that he expected the majority of hospital doctors to be on seven-day contracts by the end of this parliament in 2020.

“No doctors currently in service will be forced to move onto the new contracts, although we will end extortionate off-contract payments for those who continue to exercise their weekend opt-out,” he said.

He denied that the reforms were an attempt to claw money back from consultants’ pay, telling the BBC this morning that he thought that they would end up being “cost-neutral”.

Dr Mark Porter, the chairman of the BMA council, said today that many consultants already worked at weekends, and that the whole of the NHS needed to gear up for seven-day working, not just the most senior staff.

“Putting a doctor in is not going to solve the problem – you need the support services to go with it,” he told BBC Radio 4’s Today programme, adding that the NHS was too underfunded and understaffed to move to seven-day working.

A “truly seven-day NHS” was part of the Tory manifesto but it has triggered bitter exchanges with doctors.

Terms agreed in 2003 under the Labour government gave hospital consultants, who earn an average full-time equivalent of £118,000, the right to opt out of non-emergency work outside the hours of 7am to 7pm on weekdays.

Those who agree to work at night or over weekends can negotiate higher rates of pay. A 2012 report by the National Audit Office found that 71 per cent of doctors struck local deals for these shifts, earning up to £200 an hour.

Mr Hunt has tried before to redraw consultants’ contracts but talks collapsed in 2014 after the BMA warned that the plans threatened patient safety by failing to guard against excessive working hours. The BMA also raised questions about how the new system would be funded.

Mr Hunt returned to battle today with a warning that thousands die every year due to a lack of senior doctors who can oversee emergency care and interpret tests and scans. “No one could possibly say that this was a system built around the needs of patients,” he said. “And yet when I pointed this out to the BMA they told me to ‘get real’. I simply say to the doctors’ union that I can give them 6,000 reasons why they, not I, need to ‘get real’.”

While ministers are powerless to change the terms of existing contracts, the government can force an arrangement on new consultants and Mr Hunt made clear that he is willing to do so if the BMA does not co-operate.

The proposed deal would remove the opt-out of weekend working by April 2017 and shake up pay incentives, with rewards for performance rather than years of service. The existing model for compensating doctors who work antisocial hours would be replaced with a system of variable allowances based on the demands of a doctor’s job plan.

Whitehall sources suggested that this new pay model would encourage many existing consultants, particularly those in A&E units or obstetrics wards, to move over to the new contract. They said that the government hoped that half of all hospital doctors would be on the new deal by 2020. They insisted that the aim of the reforms was not to increase the numbers of hours worked by individual doctors, adding that these should remain within safe limits.

Dr Porter has accused politicians of peddling “lazy caricatures” in pursuit of easy headlines. Last month he said that senior doctors were delivering 24-hour emergency care despite inadequate funding. He warned that the biggest danger to patients was an NHS budget shortfall, expected to reach £22 billion by 2021, and questioned whether weekend and evening services should be the priority against this backdrop.

Letters 18th July 2015:

Sir, A costly “one size fits all” solution may not be the best way to avoid 6,000 unnecessary weekend deaths in the NHS (report, July 16, letters and leading article, July 17). It is unlikely that such deaths are evenly distributed across all hospitals. If that is the case, problem hospitals should be identified for intensive correction.

Sadly, as every experienced hospital doctor knows, expertise, leadership and collegiate practice are not evenly distributed. As a workplace, some hospitals are much more desirable than others. That is one of the tragedies of the NHS.

J Meirion Thomas, FRCP, FRCS London SW3

Sir, Your leader implies that hospital doctors can opt out of weekend working. This is misleading. I was a consultant from 1989 to 2014, and can assure you that none of us can opt out. This paragraph in the 2003 contract relates only to non-emergency work. Almost all acute hospitals already have seven-day consultant ward rounds, but scans and operating space remain in short supply.

Tony Narula, FRCS Wargrave, Berks

Sir, Your headline “Get real and work weekends, doctors told” inspired me to go and do just that. Just as I have done for the past 18 years.

dr mark luscombe Consultant anaesthetist and intensivist, Doncaster Royal Infirmary

Consultants have always been reluctant to get involved in management. Doctors treat individuals first, management is divided, and the duty of government is to populations. In this regard the US is no example to follow.. The same Perverse Incentives apply to GPs who are equally reluctant to get involved in Commissioning..

The contract that lays out the terms for hospital consultants was drawn up in 2003, when John Reid was the Labour health secretary.

His predecessor, Alan Milburn, wanted to extend their standard hours to include evenings and weekends, triggering threats of the first BMA strike in 30 years. Mr Reid settled for 7am to 7pm, Monday to Friday. It included an opt-out for non-emergency weekend work.

Margaret Hodge, the former chairwoman of the public accounts committee, said in 2013 that the deal had been a “missed opportunity” to improve performance and provide value for money.

A first debate in West Wales BMA – on rationing – wins a majority in favour

Help families and employers to make it easier for patients to die at home..

Does the Dame feel that doctors are not trained in care of the dying? GP training used to include this as a key part of the curriculum, and most people should be able to be cared for by their GP practice. Unfortunately, the new contract and loss of 24 hour responsibility, has led to less continuity of care, and in effect made “palliative continuity” a voluntary service provided by a few…. Hospice doctors offer no more “continuous care” and their funding is only partial, but they are less distracted by other demands.. Perhaps the “Hospice at home” is the most cost effective and for many of us the most desirable, but the population at large needs to be educated to this effect, and perhaps there need to be incentives to help families keep patients at home, and employers need to be helped to facilitate this.. Traditional In-patient Hospices are not viable in small populations

Rosemary Bennett reports in The Times 1st June 2015: Doctors to be trained on care for the dying

All doctors and nurses would be trained in end-of-life pain relief and how to discuss death openly and sensitively with their patients under a bill to be presented in the House of Lords today.

The Palliative Care Bill would also make it a failure of duty of care if appropriate pain relief were not given in the final stages of life.

The bill has been tabled by Baroness Finlay of Llandaff, a professor of palliative care who came ninth in the peers’ ballot for private members bills.

She has been campaigning for better palliative care for many years and said the recent health service ombudsman’s report into end-of-life care showed that not enough had been done to address the problem.

Communication between health professionals and patients was an important starting point, she said. “Now that we can treat so much there is a kind of unrealistic expectation of us being in control . . . We need to get talking about the end of our days.”

The ombudsman found that hundreds of thousands of people were at risk of a painful, undignified or lonely death because of poor end-of-life care right across the health service. Among many problems, it singled out poor communication, citing examples of patients not even being told they were dying but finding out from their notes.

A spokesman for the Department of Health called the findings appalling and suggested that ministers might back the bill.

Quality of death – is not talked about – General Practice is “Closing Down” …

Charities say letting people die at home could save millions for NHS

Happy with the NHS? Only if you have not used it!

Chris Smyth in an article in The Times, 29th Jan 2015 reports: Voters are happier than ever with NHS

It beggars belief. Who commissioned the report? What were the questions and how much bias was there in both the questions and the questioned? Yes, some targeted areas do very well, but access to A&E and GP services is dreadful, and there is chronic undercapacity. Politicians have ignored the long term investment needed – a natural weakness in our political system. The Regional Health Services, especially in rural areas are imploding. You may feel happy with the NHS if you have never used it. You certainly cannot complain if you are dead.. Without a New Zealand style approach to honest and overt rationing, and especially if Health and Social Services are combined, there will be an increase in covert rationing – mainly directed at the elderly, mentally ill, and inarticulate.

Pugh cartoon

John Appleby points out “… support for the NHS might be rising as health climbed up the political agenda rather than because care was improving markedly…. As well as an actual increase in satisfaction, this may in part reflect a desire among the public to show support for the NHS as an institution.” Read the whole article – Voters are happier than ever with NHS

Dead people don’t vote… End-of-life care ‘deeply concerning’

Alex Neil rules out ‘gagging’ former NHS staff

Anne Clwyd MP, “Husband Treated Like Battery Hen”

Will Hutton “How Good We Can Be” : The Guardian reports 25th Jan 2015 ‘Inequality has become a challenge to us as moral beings’

Pugh cartoon


GP partnership model dead within 10 years, says NHS England GP

Colin Cooper reports on an interview with Mike Bewick in GPonline 10th September 2014: GP partnership model dead within 10 years, says NHS England GP

The GP partnership model will disappear in a decade and primary care will be provided by organisations the size of CCGs, according to the deputy medical director of NHS England.

I would agree with Mike, and furthermore, I would say that in future the “real doctor” in the community will be one who maintains his emergency skills, is able to manage Out of Hours, and at the same time is involved in teaching and end-of-life care. Such individuals will be really valuable, especially now that successive government administrations have rationed the number of doctors in training so that we need to import for the next decade..

Dr Mike Bewick, a former GP in West Cumbria, said the combination of a growing shortage of GPs and the changing needs of patients and local populations, would require a major restructuring of primary care.

The advent of co-commissioning by CCGs, and the need to provide services ‘at scale’, meant it was now ‘squeaky bum time’, he told a Westminster Health Forum conference in London.

‘This is the time when we actually have to say what we are going to do. And I am going to say just two things that I think are going to be true.

‘One is that in 10 years’ time the term independent contractor will be anachronistic and probably it will be gone.

‘And the second is that we will not talk about primary care, we will talk about out-of-hospital provision and out-of-hospital providers.’

GP shortage damaging partnerships

He said the lack of new GPs being trained meant that ‘we are going to lose doctors from the frontline very, very quickly’, and this would impact on the partnership model of general practice.

‘If you look at primary care, more than 50% of the doctors are salaried. There will be a force majeure to move away from a partnership type organisation because it will not serve them. And equally if you cannot recruit to partnerships you will need to think of something different.’

Dr Bewick said that ‘organisational nihilism’ in the NHS was preventing the system developing to meet changing priorities.

Primary care unsustainable

‘I do not believe that the current organisational structure of primary care is sustainable or, increasingly, desirable.

‘I do believe that in the end, the whole of the out-of-hospital service needs to come together to form a more integrated service.’

He expected new provider organisations to develop, each covering populations of about 300,000 – the average size of a CCG. ‘The provider at scale is in the six figures. It is not in four or five figures.’

Pharmacists and other healthcare professionals would be better utilised to fill the gaps left by GP recruitment problems.

But the move to large-scale primary care provider organisations would not mean the loss of local, personal healthcare services, said Dr Bewick.

‘I do not think we should be confusing that with not delivering healthcare by people you know in your locality. Localism is in my blood.

‘We should be forming organisational mergers with either community trusts or secondary care, or with other providers from other sectors. Providing they have the values of the NHS at their heart, I am not too worried about who delivers but more how it’s delivered and the outcomes for patients.’

Death discussions ‘taboo’ for many in UK, survey finds

BBC News reports 12th May 2014: Death discussions ‘taboo’ for many in UK, survey finds

Where health is concerned we often get what we deserve both as families and as individuals. If people are not prepared to plan they will have a prolonged death, and more death duties…. Should there be a reward for making and registering an advanced directive?

Discussing dying and making end of life plans remain taboo for many people across the UK, a survey suggests.

The poll of 2,000 adults for the Dying Matters Coalition of care organisations indicates that only 21% of people have discussed their end of life wishes.

Only a third said they had written a will and just 29% had let loved ones know of their funeral wishes.

The findings are being released at the start of the Dying Matters Coalition’s annual awareness initiative.

The coalition was set up by the National Council for Palliative Care in 2009.

The chief executive of both organisations, Claire Henry, said: “Dying is one of life’s few certainties, but many of us appear to be avoiding discussing it or in denial altogether.

“Talking more openly about dying and planning ahead is in everyone’s interests.”

‘Fear of the unknown’

The survey also suggests about four fifths of the public believe people are uncomfortable discussing dying and death.

And 51% of respondents said they had not made their partner aware of their end of life wishes….

Palliative and Terminal Care should be fully funded.

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.

The threat of Malignant Melanoma: it may expose the Post Code Lottery at it’s worst

There are new drugs for Malignant Melanoma (MM), and if you get the diagnosis early, the result can be favourable. However, MM is still the diagnosis I would least like to have. The new interactive map (The environment and health atlas of England and Wales) shows the increase in incidence around the country. It does not show prevalence, which would include those who are alive with the disease…. The good news is that “Gene Therapy” is making great but expensive advances in this area. The bad news is that, in the crisis to come, your region may not be able to afford the treatments for everyone, and especially if you are elderly. You may need to be assertive, or to game the system to get choice, (Move between regions) in order to get the best care.

The Packet (Falmouth & Penryn) reports 26th April 2014: How Healthy is your post code?

The South Wales Argus reports: Wales sees big increase in skin cancer

Island Tribe reports: Southwest England burns red on malignant melanoma map

Malignant melanoma: Big rise among over-50s in Wales

Deserts Based Rationing – government support?

Age based deserts rationing: the opinion of Professor Karol Sikora. : “Doctor wants to deny elderly cancer drugs”

Elderly care demand to ‘outstrip’ family supply – The system is imploding

Covert rationing of Cancer Care for the Elderly. Dead people don’t vote, and staff are fearful. Rationing by age…

The Post Code lottery at it’s worst? 


Care home fraud soars among middle classes

Jill Sherman reports 4th May 2014 in The Times: Care home fraud soars among middle classes

Almost by sleight of hand, and over some years, elderly care in Nursing & Residential Homes has been taken out of the state and become private. The state controls the payments to nursing home owners (because most residents do not have the means), which means owners are having great difficulties covering their overheads, let alone making a profit. They are mostly privately run enterprises, but are sometimes owned by listed companies. Southern Cross (2011) was one of these… and has gone bust. It is not surprising that families try to plan their affairs so that estates are at or around the threshold for means testing at death. The incentives are to avoid or reduce payments, and if this is unplanned/unexpected then avoidance amounts to “fraud”, but if it is planned well in advance, and assets are given away well before death, then it becomes acceptable. Financial advisers call death duties the “voluntary tax”, which is paid more by those who fail to plan ahead… and nursing home contributions appear to be becoming a similar thing..

Fraud in the care system has almost doubled in a year as middle-class families try to hide their assets from the taxman, a watchdog has claimed.

The Audit Commission recorded an 82 per cent rise in the amount lost to councils last year as families avoided nursing-home fees, pocketed money destined for home-care services for elderly relatives, or failed to report the death of a loved-one to keep receiving payments of up to £60,000 a year.

The commission, which monitors fraud across councils, said that government policies and the ageing population had led to scams costing taxpayers tens of millions of pounds a year.

Anyone with savings over £23,000 has to pay for residential care, which can cost £200,000 a year, until their assets fall below that threshold. Some families are trying to hide their savings by transferring money out of their accounts, while others are falling foul of arcane rules when the transfers are legitimate……

Nick Triggle for the BBC reports: Care homes: The known and the unknown