GPs less popular: You cannot expect an under manned and underfunded service to maintain it’s all star rating, especially in our media led society.

Ian Westbrook reported 28th Feb 1018 for BBC news: Satisfaction with GP services at record low.. Correspondence in the Times 1st and 3rd March follows. You cannot expect an under manned and underfunded service to maintain it’s all star rating, especially in our Media led society. But since there is less continuity, less involvement in terminal care, and no emergencies, the shops of the job has changed, and distilling has been exchanged for quality of life.


…Only 57% of people were happy with the service – the lowest level since 2011 – while dissatisfaction has risen to 29% – the highest level in a decade.

Bar chart showing reasons for dissatisfaction with the NHS

The survey was conducted by the National Centre for Social Research (NatCen) and analysed by the Nuffield Trust and the King’s Fund think tanks.

A nationally representative sample of 3,004 people in England, Scotland and Wales were asked about their overall satisfaction with the NHS and 1,002 of them were also quizzed about their satisfaction with individual NHS services.

Sir, Further to your report “Patients give GPs lowest satisfaction rating for 35 years” (Feb 28), public perception of GPs changed irreversibly in 2003 when Tony Blair’s government allowed them to opt out of responsibility for 24-hour care. The tragic case of Ellie-May Clark (report, Feb 27) highlights (among other failings) how the GPs caring for her did not “know” her. That this five-year-old girl had a history of severe asthma should have been indelibly imprinted on her own GP’s memory rather than in a hospital letter in the depths of the computer record.

Attending one’s own patients in the middle of the night or at the weekend added an inestimable level of respect in the relationship between GP and patient. This has been further eroded with the trend towards part-time working and portfolio careers, and will sadly never be regained.
Dr Andrew Cairns

Retired GP, Liss, Hants


Sir, Dr Andrew Cairns (letter, Mar 1) falls into the (rose-tinted) common trap of a retired GP. Over the past 20 years GP workload has increased considerably. When I started as a GP in 1991, our practice did all the “on call” for our patients. There was time to rest between morning and afternoon surgery to gather strength for an evening and night on call. Now there is no spare time in the day, and in my view it would be very difficult to find a GP who thought that doing an evening and night on call after a non-stop 11-hour day would be a safe option, even if there were benefits to the doctor-patient relationship.
Dr Steve Brown

Beaconsfield, Bucks


The diabetic disaster… needs brave solutions linking agriculture and the environment.

With people living longer, the prevalence of Diabetes is bound to rise, as it is partly a disease of old age. It would be useful if the politicians tried to address agriculture to produce less, protect the environment, and reduce obesity, which  is far the greatest cause of the main disease causing the UK health services’ bankruptcy. Private care is expensive…

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Catastrophe looms if we fail to tackle diabetes

Readers, including Keith Vaz MP, respond to the report that diabetes cases in the UK are set to double

The crisis in diabetes (Health alert as diabetes cases double to 3.7m, 27 February) is only going to get worse. The system desperately needs a robust and uncompromising attack on the causes of type 2 diabetes and resolute support for those with type 1. We need to actively seek out the half a million Britons who have type 2 diabetes and are unaware of it. For them early diagnoses is vital. There should be regular testing, not just in GPs’ surgeries but in high street pharmacies as well.

Once diagnosed, patients should be supported every step of the way. Structured education programmes need to be improved and their reach expanded. As someone with type 2 diabetes, I have never received this education as I was only aware of their existence 12 months after diagnosis. It is never too late to enrol on a programme such as Desmond. We need to be offered lifestyle advice, not just pills. The creation of the 2016 diabetes transformation fund and similar initiatives will not achieve their objectives unless clinical commissioning groups (CCGs) are held accountable for how they spend the money. This is not happening……

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Nicola Davis reports in the Guardian 27th February: Diabetes Diagnoses double over 20 years.

BBC news reports that Diabetes is actually 5 separate diseases..

Are there any administrators in the declining UK health services? We need more professionals, and we get managers.

The recent headlines on health service management numbers reveals the impotence of the politicians. The fact is that these are administrators who sore paid as managers. They need contraception and/or sterilization, rather than reproduction. Perhaps they are “cloning” in preparation for the thousands of new doctors they are recruiting from thin air…… are there any administrators? The emperors (politicians) have no clothes.

Chris Smyth reported in the Times 1st march 2018: NHS manager numbers up, but GP and nurses down. And he had warned us before, on 17th February with Hiring of NHS managers soars by over a quarter In  only 5 years.

NHS manager numbers have risen by a quarter in five years and are higher than before the implementation of reforms designed to cut bureaucracy.

The increase in administrative staff far outstrips that for doctors and nurses over the same period, provoking anger from health unions.

More than 6,000 managers have been hired since April 2013 when controversial reforms by Andrew Lansley, then health secretary, came into effect, abolishing more than 150 NHS organisations and making thousands redundant.

The Times has previously revealed that pay-offs for managers have cost £2 billion, with at least £92 million given to staff who were quickly rehired. They included a married pair of NHS managers who were given new jobs at the same hospital months after a redundancy settlement of £1 million between them.

Jeremy Hunt, the health secretary, has defended the reforms on the ground that they had saved money by cutting bureaucracy. Yet analysis of NHS Digital figures by the Health Service Journal finds that manager numbers have grown almost without interruption since the reforms took effect.

The 26,051 full-time equivalent managers and senior managers in April 2013 grew to 32,133 in October last year. This exceeds the 31,041 recorded on the eve of the reforms in March 2013.

The latest figures include a 26 per cent increase in senior managers, who earn £77,653 on average, to 10,279. Ordinary managers earn an average of £47,459.

Nursing numbers have increased by 4.6 per cent since April 2013, to 287,147, but there is concern about the rising numbers of nurses that left the NHS last year. Doctors are up 11 per cent to 109,679.

Janet Davies, chief executive of the Royal College of Nurses, said: “The public don’t want to see the NHS haemorrhaging nurses but hiring more managers. The health service must be well run but the majority of patient care is given by nursing staff. Standards are being hit as their number dwindles.”

Yesterday it emerged that managers in a hospital in Grimsby were drafted on to wards to help to deal with a shortage of clinical staff. They wore scrubs and gloves to help with making beds, collecting medicine and serving meals after nurses called in sick. The Diana, Princess of Wales Hospital insisted that they were not involved in direct patient care.

Nigel Edwards, chief executive of the Nuffield Trust think tank, said that the Lansley reforms, and subsequent attempts to unpick the least popular elements, had left the NHS with an “alphabet soup of new structures”.

“It’s not surprising manager numbers have gone back up again but the question we want to ask is not are there more or less managers, but is what they are doing adding more value?”, he added.

John O’Connell, chief executive of the Taxpayers’ Alliance, said: “Not only are the NHS recruiting more senior managers, but they’ve also increased salaries at a faster rate than that of nurses. Taxpayers expect their money to be spent fairly.”

A Department of Health and Social Care spokeswoman said: “We have record numbers of dedicated frontline staff working on our wards while there are actually 3,600 fewer managers compared to 2010. We will continue to work with NHS Trusts to cut bureaucracy and red tape even further.”

And the recent article:

The NHS is losing nurses and GPs while senior managers are the fastest-growing group of staff, official figures show.

Demoralised frontline workers are quitting and there are not enough trained doctors and nurses to replace them, unions have warned.

Data from NHS Digital shows the equivalent of 283,853 full-time nurses in hospitals at the end of September last year, down 435 from 12 months earlier. There is mounting concern about higher numbers of nurses quitting the NHS because of rising workloads and stagnant pay.

GP numbers were down 742 to 33,062 despite a government pledge of a 5,000 boost to the workforce by 2020. Figures showed that public satisfaction with GP services hit a record low last year.

Managers were up 3 per cent to 21,673 while senior managers, paid an average of £77,653, were up 7 per cent to 10,282.

Janet Davies, head of the Royal College of Nursing, said: “It feels to front-line nursing staff that, in a cash-strapped NHS, they have become an easy target for cuts. It will be galling when they see senior management burgeoning too — now officially the fastest growing part of the NHS.”

Candace Imison, of the Nuffield Trust think tank, said: “The NHS actually spends relatively little on management compared to other countries, so I’m not too worried by the relatively small increase in the number of managers. What does worry me is the GP and nursing numbers. This isn’t a question of the NHS intentionally reducing numbers. We haven’t trained enough in recent years and there is no strategy in place which will guarantee that changes.”

Many NHS bosses are more concerned about the difficulty of recruiting trained staff than about money. Official estimates say the NHS could need another 190,000 frontline staff over the next decade.

A Department of Health spokeswoman said: “NHS staff are our greatest asset and whilst there are now record numbers working in the NHS, investing in our workforce will continue to be a top priority. That’s why we recently announced the biggest ever increase in training places for both doctors and nurses, as well as helping existing staff to improve work/life balance and work more flexibly.”


Choice and self determination in palliative care. Those in charge of us think they know our “will” better than we do…

There are many misconceptions about death, There is no need to die in pain, and there is no need to be taken from home to hospital or hospice if the preparation is well done. Most of us will have to change our perceptions as without the money, nursing homes  will be unaffordable in the UK. Alternative solutions have to involve families (where possible)  and every tone and city is going to need volunteers if we are to remain a civilised society. Finlay does not represent the people or the doubt views are polarised on this but can ]we not agree to self determination and choice for the individual?

On the 29th February 2018 the Thundered leader was Baroness Finlays opinion that The right to die is not the same as the right to be killed in response to letters of support published 17th Feb.

Assisted dying and the role of palliative care.

ir, Mark Taubert and his colleagues (letter, Feb 14) question whether “legalised assisted suicide” works well elsewhere in the world. The US experience of aid-in-dying, which began in Oregon more than 20 years ago, has been overwhelmingly positive. My experience over the past year and a half of law change in California has been of a law that both empowers and protects physicians and patients alike.

If it were any other way, why would palliative and hospice care organisations in Oregon, Washington and California support aid-in-dying as one of the choices that should be open to patients in their care? Why would the state of Colorado vote two to one to legalise it in 2016, and why would Canada and Australia join in legalising aid-in-dying among other end-of-life options?

Doctors in the UK ought to listen to their own patients, who want this choice for themselves.

Dr Catherine Sonquist Forest
Family medicine physician, San Francisco, and clinical associate professor, Stanford School of Medicine

Sir, Further to the letter from Mark Taubert and other palliative care consultants, those of us who have carefully examined the laws in Oregon and other places see that giving patients access to an assisted death improves honesty and clarity in conversations at the end of life. It also leads to greater uptake of palliative care and offers reassurance for those who want to have choice and control over their suffering in their final days.

It would be beneficial for the debate if those of us who have experience in palliative care would be open and honest about the limits of our abilities to relieve suffering at the end of life. We cannot pretend to be miracle workers and must be humble enough to learn from other countries that have taken the lead.

Richard Scheffer
Retired hospice medical director and consultant in palliative medicine, North Whilborough, Devon

Sir, Just before I retired as a rural GP the invariably helpful Macmillan nurse came to tell me that one of the nurses looking after a terminally ill patient in her home was unhappy to give the dose of diamorphine (heroin) that I had prescribed “because it was a lot”. The said nurse had seemingly not read the clear written statement in the house with respect to the patient’s wishes on her pain. I went to see the patient, who was shouting in pain, and the consultation was broken by a phone call from a doctor from the local hospice whose organisation had no responsibility for either the patient or the nurses. He asked me whether I realised that diamorphine was a strong drug and could depress the patient’s respiration. I had to point out that the screaming in the background was related to an inadequate dose of painkiller.

The problem for many doctors is that their duty of care to patients is trumped by fear of the opinions of others, including palliative care doctors and the General Medical Council.

Michael G Bamber
North Witham, Lincs

Sir, I suspect that those opposing assisted dying may have their views shaken when they are facing death themselves. I am facing a death sentence as a result of a diagnosis of cancer. I find that I don’t mind the thought of death at all, but I do dread what I may be made to suffer unnecessarily at the end.

Anthea Watson
London WC1

THis was followed by correspondence: Scare tactics and the right to die on 19th Feb.

Sir, Baroness Finlay of Llandaff (Thunderer, Feb 19) is right to highlight the illusory “safeguards” of Oregon’s Death with Dignity Act. Such laws are merely a foot in the door. If a “right to die” gives competent “terminally ill” people a right to physician-assisted suicide, why deny those who cannot kill themselves even with assistance and who want a lethal injection; those who face many years of suffering; and those who are suffering but lack the competence to ask for death?

Booth Gardner, the former governor of Washington state who campaigned for its Oregon-style law, admitted it was “a first step”, that gradually “the nation’s resistance will subside, the culture will shift” and more permissive laws would follow.

Parliament, the courts and medical profession have been wise to resist the temptation to take the first step.
Professor John Keown
Kennedy Institute of Ethics, Washington DC

Sir, It is remarkable that Baroness Finlay should accuse those of us who want terminally ill patients to have a choice in the manner and timing of their death of “scaremongering” while suggesting that an assisted dying law would make doctors “agents of death” and would lead to doctors “disposing of the patient”. As for what doctors think about assisted dying, we have no idea as no one has asked us. The opposition of the British Medical Association is the result of the votes of only 198 doctors, hardly a fair basis for Baroness Finlay’s conclusions. The BMA did review its policies on death and dying in 2016 but its remit around assisted dying was very narrow. Indeed, the BMA reaffirmed its position on assisted dying before even debating the contents of the review and only after very narrowly deciding to discuss the issue at all.

We know that more than 80 per cent of the public support legislation for assisted dying; we as a profession should be listening to them.
Dr Jacky Davis
Member, BMA council; chairwoman, Healthcare Professionals for Assisted Dying; board member, Dignity in Dying

Sir, Baroness Finlay is right to be concerned about scare tactics in the campaign for assisted suicide. Some of the worries of my patients and their families flow from being told that life with a terminal illness has to be painful and undignified and that death is inevitably distressing unless its timing is artificially controlled. We cannot legislate to control illness but we can help people to manage it and live with dignity. We do not control the timing of death any more than we control that of birth, but that need not prevent it being peaceful. I have my hands full dealing with fears about death while doing all I can to help people live well. Campaigning is one thing but doing it by stoking those fears does not help.
Dr Idris Baker
Consultant in palliative medicine, Swansea

Sir, Professor Rob George (letter, Feb 19) writes that morphine doses need to be titrated carefully to control a dying person’s pain. He works in a hospice where no doubt the skill to do this is readily available, as it is in a hospital. However, many terminally ill patients die in nursing homes, where doctors are not on hand 24 hours a day and where nurses are understandably wary of increasing morphine levels in case they are held legally responsible for accelerating death. This can lead to unnecessary suffering.
John Sharpe



The reducing standards…. Improvement service “unsafe for children….”


It is not just young children services which are declining. Adolescents with eating disorders are also suffering, and adolescent mental health is in crisis. Referrals are being screened and rejected, sometimes by doctors in referral centres, and sometimes by untrained administrators. What happens depends on your post code..

Caroline Wheeler reports in the Sunday Times 35th Feb 2016:NHS Improvement: service ‘unsafe’ for children amid lack of nurses

NHS services for children are substandard in every region of England owing to nurse shortages and safeguarding failures, the NHS regulator has revealed.

NHS Improvement says that “few” children’s services are “safe or well-led”. The regulator reviewed 96 hospital and other NHS services for children that had failed inspections by the Care Quality Commission last year.

It found that 54 children’s wards fell short of expected standards and, when reinspected, only two had improved and four had deteriorated further.

The report, which will be sent to all parts of the NHS with guidelines to help trusts improve, lists unfilled nursing posts as the top concern from the review of failed inspections. Low staff levels and high medical vacancy rates were cited as the most common reason for poor ratings in all four regions covered by the report, the Midlands and east, the north, the south and London.

The disclosure comes days after NHS Improvement’s quarterly performance report for the three months to December revealed 100,000 NHS jobs in England are unfilled — including 36,000 nurse vacancies.

Last night Jonathan Ashworth, the shadow health secretary, demanded action from ministers, adding: “Not only is it a massive worry for parents everywhere that so many children’s units are dangerously understaffed, it’s totally unacceptable too.”

Fiona Smith, of the Royal College of Nursing, said the shortage of nurses applied “across acute, mental health and community services”.

Saffron Cordery, the deputy chief executive of NHS Providers, the association for NHS trusts, said children’s services had not been made a priority. “They are under-funded and fragmented. In this report although most services scored well for treating people with kindness and compassion, there were serious failings, which were clearly unacceptable.”

A spokeswoman for the health department welcomed the new framework but said more than 90% of children surveyed by the Care Quality Commission reported being well looked-after in hospital.

Britain’s newborn death rate higher than in Belarus or Cuba





Compassion needs to be tempered with honesty.

We need more compassionate care of the dying and elderly for whom there is no curative treatment.  If we are to improve patients’ experience and quality of life in the last few months, as well as saving money, we will need more trained primary care people explaining what is going to happen when the time arrives. Compassion needs to be tempered with honesty, and this needs to come from a doctor you know. Unfortunately there are fewer rather than more, of these individuals, and less and less time to discuss choices with patients. A good professional handover to adequate numbers of staff with good language and cultural awareness would negate this “need”, but whilst standards fall it is for the greater good. More patients die in Hospital than at home, and their desire is the other way round. This good news initiative needs integration into Primary Care…

Kent and Canterbury begins “compassion” symbol.

The Pilgrims Hospice logo which is being used for compassion signs on hospital wards

Chris Smyth reports 19th Feb 2018: “compassion” symbols alert hospital staff to dying patients.

Dying hospital patients will be marked with “compassion” symbols to encourage staff and visitors to be more respectful.

Hospitals in Kent have begun placing the symbol on bedside curtains or on doors next to people expected to die within days.

The project, thought to be a first in the NHS, is in use in 50 wards after managers found that it went down well with grieving families by encouraging a more dignified atmosphere on wards.

Annie Hogben of Pilgrims Hospices, which runs the project with East Kent Hospitals University NHS Foundation Trust, said: “How a loved one dies can have a profound and long-lasting impact on those who are left behind. Therefore it’s essential that staff and visitors are sensitive to the needs of the person who is dying, and their loved ones at all times.”

The hospital insists that symbols are only displayed with the consent of patients and relatives, and are not designed to single them out or chastise rowdy visitor.

Dying hospital patients will be marked with “compassion” symbols to encourage staff and visitors to be more respectful.

Hospitals in Kent have begun placing the symbol on bedside curtains or on doors next to people expected to die within days.

The project, thought to be a first in the NHS, is in use in 50 wards after managers found that it went down well with grieving families by encouraging a more dignified atmosphere on wards.

Annie Hogben of Pilgrims Hospices, which runs the project with East Kent Hospitals University NHS Foundation Trust, said: “How a loved one dies can have a profound and long-lasting impact on those who are left behind. Therefore it’s essential that staff and visitors are sensitive to the needs of the person who is dying, and their loved ones at all times.”

The hospital insists that symbols are only displayed with the consent of patients and relatives, and are not designed to single them out or chastise rowdy visitors.

“It would never be done without consultation and is really about raising awareness among other visitors to the ward that someone is receiving end-of-life care and to encourage an atmosphere of quiet dignity and respect in that area,” Steve James, a spokesman, said.

Almost 300,000 people die in hospital every year and the NHS has been criticised for not taking end-of-life care seriously enough. A review by the Royal College of Physicians two years ago found that thousands were dying thirsty and in pain because doctors and nurses were terrified of talking about death.

Bill Noble, medical director of the charity Marie Curie, said that compassion was an “essential part of palliative care”, but urged the hospitals to learn the lessons of the well-intentioned Liverpool Care Pathway, which was scrapped after patients were left thirsty and suffering because of misuse of the end-of-life protocol.

“This [compassion symbols] appears to be excellent idea but like all interventions of this nature it requires evaluation. We have learned there are unintended consequences of labelling people as requiring end-of-life care,” Dr Noble said.

The logo, featuring a stylised pair of hands cupping a person’s face, is also used on bags containing property of patients who have died that is awaiting collection by relatives.

Andrea Reid, from Folkestone, said that the sign made a big difference to her aunt’s final days. “The nursing staff all hesitated at the door, explained why they needed to come in and gave us time to either leave the room or move out of the way with a calm, unhurried air,” she said.

“Our hospital staff are often working in a pressured and high-speed environment but the small and unassuming compassion symbol is just enough to trigger a pause and a moment’s consideration for those dealing with the worst news possible.”

Sue Cook, a palliative care nurse and the trust’s end-of-life clinical lead, said: “Those of us who work in the NHS have a duty to ensure that our patients are cared for with dignity, respect and compassion until they die. That’s why the Compassion Project and its symbol is so important to us and all who help those approaching the end of their lives.”



Standards “Going into reverse”….There is no button to push… we need tens of thousands of staff

Chris Smyth reports in the Times on the reality of the staff shortages, which are worsening as those who failed to move on to pastures new fail to manage the brutal workload. “100,000 job vacancies as  NHS pushed to limit” in the Times 22nd of Feb 2018. Stories of leaderless dysfunctional consultant teams spread over wide regions, of GPs who take sabbaticals being shocked that even after a break they cannot cope, and resulting early retirements are legion. There are only politicians to blame, as the administrators are only doing their behest. There is a risk of anger, walkouts, burnouts, and serious mistakes through a collusion of denial and disengagement. Exit interviews conducted by an outside and independent HR department are now an essential and emergency need.

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About 100,000 NHS posts are vacant and hospital deficits are twice as high as planned even after a winter bailout, according to official figures.

A rapid financial deterioration means that hospitals have overspent by £1.3 billion so far this financial year while waiting times have not improved.

Patient numbers continue to rise, with 5.6 million A&E visits in the three months to December, a quarter of a million more than in the same period the previous year.

Despite efforts to improve links with social care, patients spent almost half a million nights stuck in hospital over the quarter.

One in 11 NHS posts cannot be filled amid a shortage of doctors and nurses. In London, one in seven nursing posts is empty, rising to almost a quarter in the ambulance service. Overall 35,000 posts for nurses are vacant and 9,500 for doctors.

Janet Davies, chief executive of the Royal College of Nursing, said: “All the evidence shows that standards of patient care rise and fall as nurse numbers do. That was the lesson from Mid Staffordshire and we cannot afford to forget it.”

Nigel Edwards, chief executive of the Nuffield Trust think tank, said that the “dangerous” shortage of nurses was more worrying than worsening NHS finances.

“Shortages of nurses damage patient care and make working life harder for those who remain, potentially driving them away too,” he said. “We can bring back more money onstream if the will is there, but there is no button to push which will suddenly bring us tens of thousands of qualified extra staff.”

Hospitals warned that they were being “pushed to the limit” by rising patient numbers. “Having one in eleven posts vacant makes it much more difficult to provide high-quality care,” Saffron Cordery, of the lobby group NHS Providers, said. “There is an increasing feeling among frontline trust leaders of ‘We cannot carry on like this’.

carry on like this’.“The NHS has shown extraordinary resilience in sustaining performance in the midst of an unprecedented financial squeeze. We have managed to keep the show on the road. But the warning signs are now clear and in plain sight. The time to act is now.”

Officials pinned the blame for worsening finances on a minority of hospitals that were overspending by far more than planned. However, Richard Murray, director of policy for the King’s Fund, the independent health charity, said this “raises serious questions about how reasonable the financial targets were in the first place . . . these are not pressures that have sprung up in the last few months and [they] show no sign of abating.”

Ian Dalton, chief executive of NHS Improvement, the financial regulator that published the figures, said: “More people than ever before are going to emergency departments up and down the country at a time when providers are already having to tighten their belts. It would be unrealistic to assume the demand, which has been building for a number of years, is going to reverse.”