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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.

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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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.

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GP workloads are now at saturation point.

During recent years, there has been a widespread and shared belief, amongst many GPs and others working in Primary Care that workloads have increased exponentially. The Government has failed to resource adequately for this and, as such, not only is this having an impact on the health and wellbeing of GPs, it is also at times affecting their ability to provide safe and consistent levels of care.

It is now commonplace for the media to sensationalise issues occurring within Primary Care concerning the supply and demand of services and the impact that this has on other frontline services. Most GPs want the best for their patients and, as such, the increase in workloads has been raised repeatedly and consistently with the Government, only for these concerns to be rebuffed, by both NHS England and the Department of Health, with promises of thousands of extra staff in Primary Care by 2020.

Despite the attractiveness of thousands of more staff in 2020, a new study in the Lancet led by researchers from the BMA and the Royal College of GP’s, provides clear objective evidence of what GPs have been saying for years and demonstrates that action must be taken now.

The key messages from the study, which covered over 100 million GP and Nurse Consultations at 398 practices in England during 2007 and 2014, include:

– ‘There is a substantial increase in practice consultation rates, the average duration of the consultations being given and the total patient-facing clinical workload.

– GPs are facilitating more consultations than ever before for patients who are living longer, who often have multiple long-term conditions resulting in a complex presentations of symptoms that cannot be dealt with in the previously allocated time.

– Due to the change in nature and volume of workloads, GP practices and their teams are working harder than ever before, but struggle to provide basic levels of care as services are overwhelmed.’

The impact of inaction in the face of such significant objective data could be disastrous not only for staff but for patients also. With many GPs now facing the prospect of burnout or feeling the impact of being overworked, over tired and exhausted the results could be damaging for patients especially if this results in substandard care, harm or misdiagnosis.

Compounding these issues are figures released from Health Education England, who have revealed that one third of GP training places still remain vacant. Despite this representing a 1% increase on last year’s figures these results are second lowest recruitment results of all the specialities. This is not unsurprising as in 2015; GPs in England reported having the lowest job satisfaction rates since records began in 2001.

The solution for many of the problems reported across the NHS, according to the Government, is a greater shift towards ‘place based care’, a new model being explored to reduce the burden on the acute care system. However, without a serious focus on patients’ and communities abilities to self-care and make the most of non-traditional services, such as the extended pharmacy offer, the ‘place-based model’ will only once again serve to shift the burden from acute to primary care and resulting in further pressure to under-resourced and overworked GPs, and once again endanger the whole system of collapse.

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Fallout from EU Referendum.

On the 24th June 2016 the people of the UK made the decision to leave the EU, a decision that has since sent shockwaves across the entire global community. Politically, this has sent the country into chaos with changes and challenges of leadership across the three main political parties. Economically, the impact is widely expected to result in recession in the UK, which could then have a knock on effect and force other EU countries down the same path.
With the decision to leave predicated on strong views concerning NHS Funding and Immigration policies, it now seems ironic that these two issues, along with economic gloom, once again plunge the future sustainability of the health service further towards uncertainty. Furthermore, with the ‘Leave’ campaign distancing themselves from claims that were made indicating that funds previously sent to the EU could be reinvested into the NHS, this is an uncertain time for many of the 110,000 EU healthcare workers who already work tirelessly to deliver more with less resources.
Previous estimates relating to shortages in both the future Medical and Nursing workforces may potentially pale in comparison to the reality, especially when one considers that the UK has traditionally tried to fill existing gaps in healthcare workers from abroad. A huge majority of these workers – 10% of Doctors and 20,000 Nurses, have come from other EU countries. With already rising social unrest and concerns over existing immigration policies the current challenge of motivating, recruiting and retaining an already disenfranchised GP profession will continue to escalate, especially if no help is perceived to be coming from anywhere other than inside the UK. The GMC is currently exploring how doctors from the EU will be granted access to the UK medical register once the UK is no longer a member state. As it stands, the EU vote will have no impact on the current registration of any doctor on the register, but there may be implications relating to regulation in coming years.
In the aftermath of a heavily sensationalised and manipulative leave campaign, many of us now ask if it was right to trust such an important decision to the people, especially when the outcome now stands to jeopardise so much. Should this have been left in the hands of people with the power, knowledge, experience and understanding to assess the impact on our services, our economy and our health care system? It’s too early to be able to ascertain with any great certainty, but one thing is for certain there is an ageing population. By limiting free movement of skilled workers, we are widening the gap concerning demand and supply for our health care services and we are pushing our already heavily burdened finances a step closer to the brink of destruction.

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Unified DNA-CPR

End of life and palliative care symptom control can be some of the most fulfilling aspects of the GP role, but huge variations still exist across the whole of the UK. Getting it right every time for every patient is the ultimate goal in these situations, and supporting people to live well before dying with peace and dignity in a place of their choice can be incredibly satisfying for all involved, despite the bleakness of the situation.
A number of strategies have arisen in recent years to help GPs and other professionals to facilitate the wishes of patients approaching the end of their lives, and they have ensured that care is uniquely tailored to the patient. This has resulted in their needs increasingly being met and care is often managed in a much more collaborative and coordinated way. Ironically, the ultimate goal of healthcare, which is to save lives, can be a barrier in these circumstances and can prevent patients from achieving a peaceful and dignified death, especially when we consider the issue of CPR.
Discussions relating to resuscitation can be one of the most sensitive and difficult that GPs, patients and family members may ever have to be involved in. It is essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their lives and for whom CPR will fail or is inappropriate. It is also essential to identify those patients who would not want CPR to be attempted and who competently refuse this treatment option. Some patients may wish to make an advance directive about treatment. Such directives must be respected as long as the decisions are made by patients with the mental capacity to do so. These decisions should be informed, current, made without coercion and should apply to the current clinical picture. All of these variables have to be considered and should include the patient where appropriate. With emotions high in these situations, unsurprisingly there are still many reports detailing when patients have been excluded and decisions made in their best interests, with some of the worst cases reaching the media. This does nothing but create a culture of fear and results in further anxiety around such discussions. There needs to be convincing reasons not to involve patients in these discussions, or as seen with the Tracey Judgement, there is a risk to patients under Article 8 of the European Convention on Human Rights.
Once the decision concerning CPR is made, it is absolutely essential that inappropriate, futile or unwanted attempts do not occur. This is not to say that decisions cannot be reviewed and amended accordingly, if it is appropriate to do so. Variations in local policies can cause further misunderstandings and can lead to distressing incidents for patients, families and staff. The increased movement of patients and staff between different care settings makes a single integrated and consistent approach complex and difficult to achieve. The caution for Locums is that this can be very confusing, especially if they work in one area of the UK where there is a unified approach in place and then they choose to work in another area, where this approach is yet to be implemented and the policies once again differ significantly.
The introduction of the ‘Unified-Do-Not-Attempt-CPR-Form’  represents a significant step in the right direction for standardising the approach relating to decisions concerning CPR. The concept is quite simple but very effective and just involves the appropriate professional completing a resuscitation form. Ideally this form should be initiated in the Primary Care setting, and therefore should be a GP, but it can be commenced when the patient is still in the Secondary Care setting. Its significance comes from the fact that once the decision has been made it doesn’t mandate the process be revisited just because the patient may move between different settings prior to their death. Of equal importance, is it is recognised by the Ambulance Service and will therefore prevent inappropriate CPR if the service is contacted, when previously Paramedics would have been duty bound to act. The paperwork is transferable to all services.
It isn’t without its criticisms. The decision is only applicable if the lilac form stays with the patient at all times (or can be easily found) regardless of their setting. There are reports that this is much easier said than done, and forms often get lost and need re-writing. The fact that it is currently only available in a paper format when most services are working towards an Electronic Patient Record is also another area of weakness and a potential pitfall.
The introduction of the Unified DNA-CPR Form is in varying degrees of implementation across the UK. Due to the positive impact the process can have on patients and their families, there needs to be increasing amounts of pressure from all healthcare professionals to ensure that there is rapid roll out in those areas that are lagging behind, or have yet to embrace the idea.