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Is the NHS sleepwalking into crisis?

The number of patients waiting too long for routine operations has risen to its highest level in nearly a decade.

New NHS data shows over 400,000 people waited longer than the official 18-week target for non-urgent treatment in August, with hundreds remaining on waiting lists for more than a year.

The latest waits are the highest for a single month since 2008, while the number of patients treated within the NHS target has fallen to its lowest point since 2011.

This has caused a strain on the NHS services in the summer months which is normally seen in winter.

The raft of new NHS statistics also laid bare strains in other areas as patients faced longer waits in A&E and cancer treatment times had slipped, although bed blocking rates had improved.

To ensure the NHS is able to cope with the inevitable spike in demand during the winter period, the Government needs to urgently put in place measures to address the funding, capacity and recruitment issues facing the system as a whole.

Shadow Health Secretary Jonathan Ashworth said the “shocking” figures showed how the winter crisis had extended to the rest of the year, prompting concerns over patient wellbeing.

Earlier, Mr Hunt told GPs there was no “silver bullet” to the problems facing them, but the Government was “absolutely committed” to increasing funding and capacity.

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Flu warning may put the NHS at risk?

Hospitals have been urged to brace themselves this winter season, as other countries have struggled to cope with an outbreak of flu. Some hospitals in Australia have had to close their doors to patients as they have struggled to cope.

The NHS will have to do a great deal of work over the next 2 months to ensure everything is in place to deal with the winter ahead.

GP services will be put under pressure trying to cope with the high demand of flu vaccinations, while hospitals will have to find extra beds.

The reality is that extra funding is needed to help with the existing pressures. It would help to free up extra bed capacity in hospitals, help to recruit more doctors, nurses and care home staff during winter pressures.

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The Importance of Locums

A GP online poll in 2016 suggested that three in five GP surgeries had to rely a great deal on locums to ensure they could provide services to patients.

23% of surgeries needed locums to provide nearly a fifth of GP appointments during the last year. (The poll had 370 partners and salaried GPs)

This was an increase compared to a similar poll conducted by GPonline last year. Last year just 14% said over a fifth of appointments were conducted by locums.

Around 6% of GPs confirmed more than 40% of appointments in their practice were being covered by locums.

The GPC said the data showed the ‘serious’ impact of workforce shortages and showed the essential role of locums.

GPC sessional committee chair Dr Zoe Norris warned earlier this month that many vulnerable practices would collapse overnight if doctors were forced out of locum roles.

Around 59% of GPs said the amount of appointments filled by locums in their surgeries increased over the last year.

It is becoming apparent that the NHS needs locums with their floating coverage in order to sustain services and relieve Partners for holidays or other commitments as surgeries are too stretched to be able to provide that cover from in-house. Shouldn’t NHS England and the local CCGs do more to support this fundamental part of the workforce instead of trying to force them out?

Doctors to declare private earnings

NHS England have announced plans to publish NHS Consultants earnings from private work undertaken in their own free time outside their NHS contracts by April next year.
It’s estimated that half of the 46,000 consultants in England top up their average £112,000 per year earnings by doing private work.

The concerns raised are in relation to conflicts of interest and suggestions that some may delegate much of their NHS work to junior colleagues which can in turn increase waiting times. There is even suggestion that some may take advantage of extended waiting lists to syphon off additional private work to line their own pockets.

Sir Malcolm Grant, Chairman of NHS England, stated on the matter: ‘We have a responsibility to use the £110bn healthcare budget provided by the taxpayer to the best effect possible for patients, with integrity, and free from undue influence. Spending decisions in healthcare should never be influenced by thoughts of private gain.’

However Neil Tolley, Chairman of the London Consultants’ Association disagreed with the plans saying: ‘What you earn in your own time is your own business and nothing to do with the NHS. We are very suspicious that this information will be used for political purposes.’ He continued: ‘I don’t feel there’s any conflict of interest. If you’re a doctor doing private work, that will already be with the knowledge of your hospital. You are already showing transparency.’

Will GPs be next on the hit list for transparency of earnings?

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My Son is my Twin!

It’s been almost 20 years since Dolly the Sheep shocked the world and sparked moral debate regards cloning, but this week has been ablaze with new research findings sparking all kinds of new fanciful concepts like “parenting your non-identical twin” etc.
Earlier this year scientists in China reported they have created human embryos without the use of sperm. They took stem cells and tricked them into becoming a precursor of sperm called primordial germ cells and following this they then tricked them into becoming the next phase in sperm development called spermatids by exposing them to ordinary testicular cells and testosterone. They managed to successfully fertilise mice eggs with this artificial sperm – thus removing the need for male sperm – opening all kinds of doors for male infertility or for the fantasists – a world a without the need for men.
Earlier this week scientists from the University of Bath reported they have evidence that one day we could create babies without the need for eggs. They created mice pseudo-embryos by manipulation of unfertilised eggs and then successfully created real embryos by injecting them with sperm. They argue that pseudo-embryos are much like ordinary cells in many of their properties and their research suggests that it may be possible to achieve fertilisation of cells other than eggs one day. Now our fantasists are dreaming up a world without women.
It just got more exciting for those of you who love this stuff, as a group in China just yesterday reported they have successfully created 30 Human Embryo Clones.
All of this means there is hope on the horizon for couples with fertility problems, with the possibility of all kinds of magical combinations available, especially for same sex couples wanting to have a biological child of their own.
The question now is who will take that first step into the ethical mind storm and bring a cloned human into the world. Dolly the sheep was named after Dolly Parton, as the cloned cell was from a sheep’s udder in reference to the singer’s famous bust. What will the first human be called?

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GP Rebellion Quashed!

In what has been seen by many as a shock change of stance, the GPC have announced that it will not ballot their membership in relation to mass resignation. The idea was always a controversial one, but a decision that many were considering nether the less, which reflects the profession’s level of frustration with the Government and the slow pace of reform. After all, this type of threat has been used successfully in the past to lure the Government to the negotiating table, when all other attempts have failed.

In this instance, the ballot was avoided as early indications do appear to demonstrate that some headway is being achieved in relation to workloads, and the Government now appears ready to negotiate. NHS England has reportedly decided to take on board a number of suggestions from the BMA’s, Urgent Prescription for General Practice, and these will form the basis of future negotiations.
These relate to:
– Ensuring that GPs work within safe workload limits each day.
– Enabling GPs to have longer appointments, in particular for those patients with multiple and complex problems.
– Ending inappropriate workload that could be done by other services within the NHS.
– Empowering patients to better manage their own health when appropriate.
– Ending inefficient bureaucracy, such as chasing up hospital actions or re-referring patients.
– Providing GP practices with more frontline staff and facilities to meet increasing demand.

Whatever your stance concerning mass resignation, if the Government and GP leaders are successful in these negotiations then there is real potential for significant change across the Primary Care system. The system at least has a chance of becoming more efficient, especially now that more clinicians are involved in reform than ever before. Interestingly, General Practice Forward View is not being cited as having been successful in avoiding the ballot or future industrial action by the profession.

Other signs that workload inequity is beginning to reform can be seen at the hospital/general practice interface. The NHS Standard Contract now stipulates 6 requirements to be upheld, and these include:

1. Hospitals are prevented from discharging patients automatically back to their GP, if they fail to attend an outpatient appointment.
2. Hospitals are required to send discharge summaries for inpatient, day case or A&E care within 24 hours and must be standardised so that GPs can find key information in the summary more easily. This should be electronic whenever reasonably possible, and Commissioners are required to facilitate this approach to handling the summaries.
3. Hospitals are to communicate clearly and promptly with GPs following outpatient clinic attendance. If there are actions for the GP, then this needs to be communicated in a timely and achievable fashion.
4. Patients should be referred directly on to other services where reasonably possible and the Hospital should avoid re-referral back to the GP, especially for non-urgent conditions directly related to the complaint or condition which caused the original referral. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
5. Hospitals to supply patients with medication following discharge from inpatient or day case care. Medication must be supplied for the period established in local practice or protocols, but must be for a minimum of seven days (unless a shorter period is clinically necessary).
6. Hospitals to organise the different steps in a care pathway promptly and to communicate clearly with patients and GPs. This specifically includes a requirement for hospitals to notify patients of the results of clinical investigations and treatments in an appropriate and cost-effective manner, for example, telephoning the patient.

It is estimated that this reform will release up to 13.5 million appointments a year and will therefore create additional capacity to care. Additional capacity is a commodity for all Practices, and therefore one can only hope that any time that may come as a result is used wisely by GP Leaders and Practice Managers. There is no doubt that workloads do need to be addressed and there is no doubt that the Government and NHS England has its part to play. One has to consider though, that if we are to avoid freed capacity just filling up with more of the same, then frontline teams have their part to play too. “If you always do what you’ve always done, you’ll always get what you’ve always got.”
England is facing a GP shortage and so now is the time to ensure current workloads are analysed to identify what work lies only within the scope of practice of GPs and what work can be done by other professionals. There is a real opportunity to ensure that the right care is provided in the right place at the right time by the right staff. Otherwise, the only other outcome for the future will be the profession will once again resort to yet another threat of mass resignation and the cycle just continues.

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GP Mass Resignation.

In January 2016, at a special LMC conference delegates voted overwhelmingly to carry a motion proposing that the GPC should canvass GP’s on their willingness to submit undated letters of resignation. At that time www.dealdirectlocums.com reported on the likelihood of a mass resignation from GPs across England. The only caveat to avoid such action was for successful negotiations with Government to take place. GPs have been demanding an equitable and sustainable rescue package for General Practice for years. A deadline of six months was issued before industrial action would be considered.

Six months have now elapsed and during this week the GPC will be informing LMCs on their decision about whether or not the profession will be balloted in relation to mass resignation. It seems likely that a ballot is imminent despite lots of engagement with NHS England, as not all of the demands of the GPC which are outlined in the ‘Urgent Prescription for General Practice’ have been met. ‘General Practice Forward View’ has generated mixed opinions across the profession, and despite some seeing the reforms as a step in the right direction; the changes they are set to bring about may not be radical enough to prevent the ballot from going ahead.
The measures that GP’s are insisting must be enforced include:

– The introduction of 15 minute consultations.
– A maximum limit on the numbers of patients that a GP can see in a day.
– A detailed list of services, not currently covered in core GMS, which are optional for Practices and are subject to national benchmarks in relation to pricing.
– Cessation of duplication concerning CQC and NHS performer list registrations.
– Agreement of nationally defined contract for GPs employed by other providers.
– The creation of a new care home DES.

Compounding these issues are increasing demand, low recruitment and retention rates, professional isolation, increasing rates of stress and mental health amongst the profession, and creeping indemnity fees. These issues are making General Practice an unattractive place to practice medicine. The solution for many within the profession is simple; the Government need to provide better contracts and working conditions for their workforce. With a more motivated and engaged workforce comes better patient satisfaction and outcomes. One therefore has to ask, why is the Government not doing everything within their power to stop this from becoming a reality? This isn’t just about pay, as reports from across the media suggest, but instead it is about time and investment, and the inevitability of real system change that can result if both are made available.

With most Practices being private businesses, the issues within General Practice are financially, morally, politically and ethically a minefield to traverse. GP’s want the best for their patients, but the ballot is a long time coming for many, and the Government doesn’t appear to be taking the necessary steps to avoid industrial action. There is widespread opinion from many within the ranks of the LMCs that the ballot is being welcomed by Government, who would be happy to lose the independent provider status of GPs, especially as the media once again aggravates stories of privatization of the NHS. Half-hearted attempts to ease lay members of the public don’t cut to the heart of the problems in General Practice and that is why the GPC may call to arms. Only real reform and a real commitment from the Government will prevent GPC members from voting with their feet.

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Compensation Nation

Medical indemnity and the fees that some GPs have to pay, is once again hitting the general practice arena, but this time the news is of a more positive note. Hope is on the horizon, and the first signs are now visible that ‘General Practice Forward View’ will soon begin to make a difference for those being hit hardest by the dramatic fee hikes. ‘Forward View’ promises large scale reform of some of the more inefficient, outdated and unfair working conditions facing today’s modern profession. It has recently been announced that with immediate effect NHS England will release £60million of funding, over a 2 year period, to Practices across the country in an effort to combat spiralling costs associated to indemnity fees.

In recent years fees have risen dramatically, as a result of an ever increasing number of claims being made against the profession. When claims have been successful, in some instances, the awards paid have been relatively staggering in their amounts. Ironically this comes at a time when quality and safety has never rated so highly amongst patients in relation to their service. With an upward trend in claims being made and the ‘compensation’ culture affecting the whole of the NHS, the situation looks set only to worsen.

Conservative estimations place fee rises during the last twelve months at 26%, which has affected 90% of all GPs. Clearly this isn’t sustainable for the workforce and it is also affecting where GPs choose to work. The greatest risks and therefore the greatest costs are associated to locum, urgent care and out of hours work. It’s often much cheaper for GPs to work part-time, which at a time when GP workloads are at saturation point is a major cause for concern. We need our GP workforce to work more sessions, not less. We should be incentivising the profession to give more and reap the rewards of their hard work and dedication. We shouldn’t be forcing GPs to work in other areas of the UK where it is more affordable to work because litigation claims, and the amounts paid out for successful claims are significantly lower than in England.

In the latest news it has been revealed that the additional money will be shared out according to the list size of individual Practices, and this will not be influenced by the current indemnity fees of the GPs working there. In the process that will no doubt follow this news, one can only hope that this additional funding filters through to the Locum workforce, to ensure equity to all of the profession. Locums can be the life line for many Practices across England, but often face some of the dramatic charges reported within the media.

It is too early to assess how much of a difference this cash injection will make in the pockets of GPs. £60million may not even scratch the surface, with some in the profession speculating that by just throwing money at the problem this may only prove to worsen the current situation in the future. NHS England and the Government need to take steps towards standardising and legitimising the amounts paid out by the MDU and MPS, if the ‘blame and claim’ culture is truly to be overcome. The rising and unrealistic expectations of the general public need to be addressed, especially when resource and funding fall short in attempts to meet demand.

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Save the dragon receptionists from slaughter.

The public perception of access to GP services is already at an all-time low and as such this is having a devastating impact on our health service. In a recent analysis by the Royal College of GPs, this perception and now ‘fact’, is set only to worsen over the next five years. That is unless the actions promised within the GP Forward View begin to become a reality.

In 2015/2016 there were 9 million occasions when patients tried to access GP services and could not, but did not seek healthcare from an alternative provider. Whilst it can be safe to assume that not all of those patients would have required further intervention and follow-up, an ageing population means that a large proportion of them would have needed to have been seen. It is widely acknowledged that there is more risk of harm to patients within the system than ever before.

When patients do seek to access alternative health care providers, then this is often through 111 and more inappropriately via A&E. This just compounds the financial crisis and pressure on the system further, as bottlenecks develop in places that they shouldn’t and patients face referrals and investigations that they do not always need. This is unnecessary demand and waste on expensive services!

Why is it so difficult for the government to recognise, that by investing the finance and resource at the front door of the health service, this will ease the pressure at the back door? It doesn’t work if you do it the other way round ! Yes, patients need to be seen and cared for in the community, but they also need services they can access easily and they also need to feel supported enough so as to avoid going to hospital, unless it actually is an accident or an emergency.

The fact that Primary Care receives only 8% of the total budget assigned to the NHS in the face of so much reform is ludicrous. A new Prime Minister and a major cabinet reshuffle gave hope to many GPs that the inequality between primary and secondary care resource and funding would be addressed. These hopes were dashed when news was released that despite the cabinet reshuffle, Jeremy Hunt remains the Health Secretary. One can only hope that the new Prime Minister therefore honours the pledge and promises that David Cameron made, and funding increases significantly, giving primary care a chance of long term survival.

If not, then the RCGP’s analysis goes on to conclude that of the reported 69 million occasions whereby patients had to wait more than 7 days for an appointment in 2015/2016, is likely to rise to 98 million occasions by 2020/2021. GPs and patients around the country are being ‘called to arms’ to ensure that this situation is not allowed to escalate to the figures being forecast. The impact of doing nothing risks health care across the whole of England. And let’s face it, our poor GP receptionists take a hard enough hit as it is when patients can’t access our services, and they become branded the dragon on the other end of the phone.

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Integrated Care – Why the big fuss?

A fundamental rethink of how healthcare should be organised and provided is now necessary if we are to ensure the long-term sustainability of Health and Social services, and meet the increased demand now being faced on our healthcare system, on all fronts. Demand has increased exponentially in recent years, due in some part to the success and advances made in modern medicine. People now live much longer than in previous years, there is a better understanding of disease aetiology and, as such ageing patients live with varying degrees of quality of life, with one or multiple long term health conditions. With increased specialisation and new options for diagnosis, treatment and care, these successes make healthcare much more complex and therefore more costly than ever before. Despite these successes more coordination of care is needed, not only between Primary and Secondary healthcare services, but between Health and Social services.
Pressure on the healthcare system arises in the form of sub-optimal care, avoidable ill health, inappropriate use of care and services, duplication and waste. These factors need scrutinizing and improving to ease unnecessary burdens. They are a result of how services have historically been set up, how the budgets have been divided and how care is organised across Health and Social care boundaries. If we were to consider only healthcare, then Primary and Secondary Care have both been treated as separate branches of one system and the many structures, governance and management arrangements that have developed across each branch have done so in silo. ‘The left arm doesn’t always talk to the right arm’. Now Introduce Social care into the equation, and once again the differences in their structures, governance and management arrangements become even more apparent. In the past little thought, if any, has been given in relation to the impact that these services have on one another. Often there has been no risk assessment of the impact changes to one service will have on the other, especially if it crosses professional boundaries. This is a fundamental design flaw and one which must be addressed if we aim to provide services that focus on quality, are less fragmented and have improved channels of communication that enhance care.

There have been many attempts in the past to integrate services, none of which have yielded any lasting and positive results. The fact that previous attempts have failed will act as a significant barrier to reform and this ‘elephant in the room’ will need to be addressed by Leaders and Clinical staff before any redesign work can proceed. Other barriers to Integration include:

– Separate budgets in key care areas, for example, between Primary and Secondary care, and between budgets for Health and Social care.

– Institutional separation between Primary Care – independent small businesses generally owned by GPs, Secondary Care – entities owned by the NHS, and Social Services – owned or commissioned by local authorities.

– Professional separation between the staff working in all three domains, resulting in different cultures, pensions and contracts.

– Lack of integrated data and information systems between major care providers.

– Repeated reforms of NHS commissioning bodies that have disrupted efforts to develop effective joint commissioning.

The approach considered by the vast majority of professionals as now being able to deliver on integrated care, is through the creation of Integrated Care Organisations. Various models of the Integrated Care Organisation are now being piloted across England, with their primary goal being to improve coordination of care, prevent avoidable ill health and provide more cost effective services.

So, why then is this approach more likely to deliver than previously explored approaches? The driver for change now centres on an unsustainable system and finally the realisation that if Organisations continue to work in silo, they will just bankrupt each other. Health and social care therefore need to come together and look at the system as a whole and work out how to spend the whole system budget collectively to create a sustainable system. This is driven out of the fact that the system was designed to cure ill health, not manage long term disease.

Now that leaders finally agree that they need to work this way, we are in a much better position than in previous years to design a new integrated model of care. The blockers to this work can also be identified and this is where ICOs are especially useful, as they facilitate the removal of blockers, especially when these are people working for and within different organisations. With this in mind, there is a real potential that the use of expensive hospital services will be reduced by redesign of current services. Collaboration provides the opportunity to overcome the fragmented responsibility for the commissioning and provision of care in the NHS – all with the patient at the centre of the chosen model.

The various models of these Organisations include:

– Networks of provider organisations operating under a single, integrated budget (‘virtual integration’).

– Organisational mergers (‘real’ integration) to bring together different care sectors (acute trust ownership of GP services, for example).

– Integrated commissioner–provider organisations that combine commissioning care for a designated population with the provision of some or all of these services.

This is an exciting time for many working in Primary Care and Social services, as Secondary Care has in the main, always been the priority for funding and development. Whilst it is still too early to assess the impact that these Organisations will have, never has there been more of an exciting opportunity to be involved in improvement work that will promote whole system change. One can only hope that GPs are freed up from some of their clinical commitments so as to collaborate on the best possible designs for patients. Otherwise, a potential pitfall is they will be under represented and whichever model is introduced will be rebuffed through fear that it is another model imposed by the hierarchy and professionals feel forced rather than engaged and empowered.