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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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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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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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The Paracetamol Debate

So what’s all the fuss about paracetamol? And should we be using it in the management of OA.

Controversy emerged regarding the use of paracetamol in the management of OA a while back when NICE were drafting their new guidelines.

At the time they warned of the potential side effects of paracetamol and said it has ‘limited benefit’.

NICE warned GPs against prescribing paracetamol for patients with osteoarthritis after its experts said they were ‘extremely concerned’ about the links of higher doses to cardiovascular, gastrointestinal and renal adverse events.

When used, it should be the ‘lowest effective dose’ for the ‘shortest possible time’ and clinicians should be particularly cautious of using it in combination with an oral NSAID, the guidance added.

The Guidance Development Group felt that the increase in renal adverse events with long-term cumulative doses of paracetamol particularly would be a surprising finding for most clinicians and wished to highlight this issue.

Shortly afterwards NICE was forced into a U-turn on its previous advice not to routinely prescribe paracetamol in patients with osteoarthritis, following criticism that the recommendation would have a drastic impact on GP analgesia management.

The dramatic change came after medicines regulators disagreed with NICE’s concerns about patient safety and experts said the move to other analgesic options such as opioids could put patients at greater risk.

See the full NICE guidance on OA here. The clear message is that we should be focusing our attention on physical treatment instead. These may be more difficult to sell to our patients but are far more likely to provide both better analgesia and better functional outcomes than medications.

Try directing some of your patients to Arthritis Research UK website where they can find information on Exercises to Manage Pain.

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GP Indemnity Rises by 25%

It has been reported that GP indemnity costs have gone up by 25% in just one year according to a Pulse Today report.

The survey carried out in August reported that the annual fee for a GP doing 10 sessions a week had gone up to £11,320 in 2015, as member annual cost per session rose from £869 to £1,132 in the last 12 months.

This has concerned many people in the profession because it has been reported in a survey by Urgent Health that a high percentage of GPs are limiting the amount of Out of Hours shifts they do because the cover is too expensive.

With this said, Private sector firms are stepping in and claiming that they can reduce the cost of the insurance by up to 75%, but this may come at a risk of not being fully covered according to Pulse.

The Medical Defence Organisations have ensured GPs that they remain Not-for-profit, and will support GPs with any claims that arise, even if the GP is retired or ceased practice years before.

This poses a question which every GP must ask – Do they keep paying the increased  fees from the MDO or do they shop around for cheaper indemnity that might not cover them for all possibilities?