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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.

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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Farmer’s Tan

As a nation we love to talk about the weather and in my experience we do so often. It can be a way of starting a conversation with a stranger or a way of breaking an uncomfortable silence with a friend, family member or loved one.
We can’t even escape it if we pick up a newspaper or switch on the television and radio to listen to the news. It can unite us and it can divide us. In fact, so significant is the impact that the weather is having on people that it is no wonder it features regularly as a topical item for discussion.
In relation to healthcare, most professionals dread the winter months, as during this period our elderly and most vulnerable are at the greatest risk from the extremes of the weather.
Primary and secondary care nearly buckles under the weight of unprecedented demand year after year and each winter takes longer and longer to recover from.
Indeed, many who work in healthcare are already bracing themselves for this year’s winter onslaught.
There is already panic spreading into every boardroom of every Hospital and CCG across England, as the sudden realisation dawns upon us that all of the winter pressure wards are still open from last year, so where will we put our patients?
But it isn’t just the cold that we need to concern ourselves with. This year has seen severe snow, lots of rain, flooding and not enough sunshine.
The lack of sunshine becomes even more problematic, especially if we consider sunshine in relation to Vitamin D. Small amounts of Vitamin D can be obtained from food such as oily fish, eggs and fortified cereals, but mostly it is synthesized by the body through exposure to sunshine.
Vitamin D deficiency can lead to bone and muscle problems – yet another impact of the unpredictable weather patterns here in England.
The question therefore is, “should everybody in England be on Vitamin D supplements at certain times of the year?” Previous advice suggested this should be the case, particularly for pregnant women, people who are not exposed to the sun regularly and ethnic minority groups with dark skin.
New guidelines from Public Health England extend this advice to cover everybody in the UK during autumn and winter months.
The advice from Public Health England is supported by research carried out by the University of Manchester and Salford Royal Hospitals.
In a study of white children aged 12-15 it was found that 16% of those involved had lower than required levels of Vitamin D in their blood by the end of the summer period. This study focused on one season of the year and when it was extended to cover all four seasons, the study concluded that 75% of those involved failed to reach the level it should be by the end of winter.
As such, future studies are now underway focusing on people aged 65-84. The impact of poor muscle and bone health will be another significant health concern and financial headache for the NHS in the future, especially with an ageing population.
If 1 in 5 of the population will not get the necessary Vitamin D from the sun that is required to prevent bone disease, then action must be taken.
Regardless of how impractical or undesirable it is, the only course of action is to consider supplementation for all. At first glance, this may seem like yet another thing for GPs to do in their already busy day. But, if Vitamin D was prescribed to all during autumn and winter then these recommendations have the potential to alleviate some pressure on services, at the very least by avoiding the need to refer patients for screening for Vitamin D deficiency.

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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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CVD risk calculations error

Following a statement issued by the MHRA, an investigation has been launched into how a digital calculator (QRISK2) used by GPs to assess the potential risk of cardiovascular disease, has resulted in incorrect risk estimation scores being calculated. The SystemOne’s version of the QRISK2 calculator is used in more than 2,500 practices across the country and it is now thought that incorrect scores could have been determined for potentially hundreds of thousands of patients, dating as far back as 2009.

The MHRA confirmed that it was only the interaction between QRisk2 and SystemOne that have caused the alert and this must be reiterated to patients when concerns are being raised. Having said that, this is a major system error, one that could potentially result in a loss of confidence in the tool and one that could create a lot of additional work to already excessive GP workloads.

The risk to patients can vary and includes:

– Thousands of patients may have been prescribed statins when they are not indicated.

– Patients who should not be on statins may suffer unnecessary side effects from being on them.

– Patients may choose to stop their statins because of a loss of confidence in the decision making process. This may cause cholesterol to return to dangerously high levels in just a few weeks.

– The risk of a cardiovascular event from not being on a statin, when in actual fact one should have been commenced.

The numbers of patients affected by use of the tool are thought to be low because this is a tool to aid to clinical decision making. Therefore, the hope is that only a small number of patients will require changes to their CVD management plan. If only one patient is affected by a software system error this, however is one patient too many. GPs and the company that manufactures the SystemOne software system, TTP, are therefore working frantically to enable practices to identify patients to ensure that they receive accurate risk estimation scores and treatment where necessary is altered accordingly.

TTP have temporarily, but only recently suspended the use of their tool until the glitches within the system have been identified. The MHRA are working closely with the company to get to the root cause of the problem. One thing is certain, it is going to take a lot of time and reassurance from TTP before many GPs find confidence in this particular brand of the tool, especially in the face of so many other competitors whose end product is much more reliable. In the meantime GPs are advised that if it is necessary to use an algorithm to assess a patients risk then QRISK2 is available at www.qrisk.org

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GP Forward View – improvement on the horizon or more broken promises?

In recent months, GP Leaders along with the Government have been working tirelessly to ensure that a new strategic direction for the future of Primary Care is realised. This has come in the wake of what appears to be an endless release of new or changed policies, reform, documents and promises of investment to improve the current state.

The challenge of overhauling the system to efficiently meet the increasingly co-morbid health needs of the UK population is extremely complex. Even more so when one considers that quality care and patient and staff experience are the core values driving the work-streams. Its success is dependent upon lots of diverse microsystems (GP surgeries), working collectively and cohesively in the best interests of patients, colleagues and national health. Many GPs out there do think reform is possible, despite seeming like an unsurmountable task at this stage, and of the recent literature reviewed a lot of the successes are aimed at ensuring that;

  • Primary Care is sustainable for the local populations for which they serve and that the health needs of the local population reflect what the GP surgery can offer without one size to fit all.
  • The role of the GP is one that appeals to the future medics of tomorrow, but at the same time proves attractive enough to entice back those who have left the profession.
  • GPs are given time to spend some of their professional working lives freed up from only patient facing activities so that they can provide leadership on improvement, strategy and service development.
  • Workloads don’t cripple the system that they are so desperately needed to support, by ensuring that work that can be completed by another suitably trained professional is completed by that professional. It doesn’t have to remain the role of the GP, just because ‘that is the way that it has always been done in the past’.
  • GPs are nurtured and develop the necessary skills required to be able to manage and adapt to the future landscape of an ever changing NHS.

Many GPs have their own ideas on what the root cause of the problems within primary care are, what actions are necessary so that improvement occurs and what change is required in order to ensure sustainability. ‘General Practice: Forward View’ (NHS England, 2016) is the latest document released outlining change, investment and reform. It seeks to address rising workload pressures and growing patient concerns about access.

To summarise ‘General Practice: Forward View’ focuses on improvement in the following areas:

On investment: by 2020/21 recurrent funding to increase by an estimated £2.4 billion a year, decisively growing the share of spend on general practice services, and coupled with a ‘turnaround’ package of a further £500 million. There will be investment in staff, technology, GP premises, and action will be taken concerning indemnity and growing red tape.

On workforce: attempts will be made to try to double the growth rate in GPs, through new incentives for training, recruitment, retention and return to practice. During the last 10 years there has only been a net increase of around 5,000 full time GPs, however the aim will be to achieve a further 5,000 net in just the next five years. In addition, the aim will be to recruit and train 3,000 new fully funded practice based mental health therapists, an extra 1,500 co-funded practice clinical pharmacists, and nationally funded support for practice nurses, physician assistants, practice managers and receptionists.

On workload: there will be a new practice resilience programme to support struggling practices, changes to streamline the CQC inspection regime, support for GPs suffering from burnout and stress, leadership and management development for GPs, legal limits on administrative burdens at the hospital/GP interface, and action to cut demand on general practice.

On infrastructure: there will be new rules to allow up to 100% reimbursement of premises developments, direct practice investment tech to support better online tools and appointments. Consultations and workload management systems along with better record sharing to support team work across practices.

On care redesign: there will be support for individual practices and for federations and super-partnerships. There will be direct funding for improved in hours and out of hours access, including clinical hubs and reformed urgent care; and a new voluntary contract supporting integrated primary and community health services.

This is a substantial investment and strategy for reform. It represents a significant amount of support and should add a large amount of resilience in to a system that has been under resourced for the last decade. It is aimed as a five year piece of work and within that time period it will be important that the system continues to learn and respond to changes in circumstance, national health and government.

Will this represent the solution to the complex challenge of solving the primary care system crisis?

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NHS 111 Chokes A+E

NHS 111 which was meant to offer help to patients and direct them away from emergency services has come under fire in recent months by both Government and Senior Clinicians, about its effectiveness at performing this function.

As the latest data released by NHS England shows, of all calls triaged by NHS 111, a staggering 12% had ambulances dispatched, while a further 8% were referred to A&E. Of note, 62% were recommended to primary care, 4% were recommended to another service and only 14% were managed directly by the service. The figures for further referral represent the highest ever recorded since the service first began in 2010.

The service is currently facing criticism on many fronts with many of its referrals being regarded as inappropriate and therefore placing unnecessary pressure on frontline services.
Is this the service, or is this a product of the system as a whole, which is widely regarded as inefficient and cost ineffective?
This criticism is also being fuelled by the fact that the majority of the workforce do not have a Nursing or Medical background, and therefore lack the necessary knowledge and skills to triage appropriately, without recourse to an automated rigid computer algorithm.

There is a growing body of evidence suggesting that many patients are being inappropriately referred on to A&E because of issues arising in primary care. For example, at the peak call times for NHS 111, there are a significant number of calls for urgent repeat prescriptions. These patients are then booked into out of hour appointment slots as the call handler cannot triage the urgency of the missing medications. This blocks OOH slots which would be better utilised by GPs assessing patients with higher medical acuity.  Instead, appointments are full and because of the risk adverse nature of the 111 service, patients are referred on to A&E.

With a public perception of lack of appointments and inadequate services in primary care, there is growing pressure on GPs to provide leadership on improvement and change within the NHS.