We should be clear about the scale of the challenge.

One in four of the population has a long-term condition - many of them older people. Within the next few years, 3 million people will have not one, not two, but three long-term conditions. By 2020, the number of people with dementia alone will exceed one million.

We cannot treat chronic conditions on this scale with the systems, responsibilities and incentives we currently have in place. Too often care is reactive and disjointed, with mistakes caused as a result and in a way that endangers patient safety. Too rarely are our vulnerable older citizens looked after with a joined up care plan that pre-empts problems before they arise.

Now for the avoidance of doubt let me clear who I do not blame for this - and that is the professionals in the NHS, whether doctors, nurses, GPs or community practitioners.

Last year on a broadly flat budget, the NHS did 400,000 more operations than in 2010. There were a million more admissions to A&E. GPs now provide in excess of 300 million consultations every year.

All NHS staff are working extremely hard in the face of rising demand for their services, and they are working possibly harder than they have ever worked before. In fact, they are the ones who tell me how much better things could be organised - and it is conversations with them on the frontline that have informed my thoughts today.

GP surgeries

Everyone agrees that hospitals should only be a last resort for the frail elderly and that - for someone perhaps with dementia and other complex conditions - A&E departments can be extremely confusing places. But what alternatives do we offer?

Too often GP surgeries where it is impossible to get an appointment the next day;

Same day appointments but only if you call at 8 o’clock in the morning sharp and are lucky getting through;

Too often long waits on the phone to get through, sometimes at premium rate numbers which were supposed to be banned in 2009;

Difficulty in registering with another practice if you move home, or aren’t happy with the service you are receiving;

Out of hours services where you speak to a doctor who doesn’t know you from Adam and has no access to your medical record;

District nursing services are excellent, but can be very hard to access; and

Urgent care centres whose role is little understood by the public.

Hardly surprising then, that people turn to hospitals and that across England our 150 A&E departments are the busiest in their history. Something we all know is simply not sustainable.

Betrayal of GP ideals

And if it doesn’t work for the public, it doesn’t work for GPs either.

They feel rushed off their feet with a daily list of duties that can make it extremely challenging to develop trust with patients and exercise responsibility for their care - the very reasons that motivated them to join General Practice in the first place.

Things were by no means perfect before 2004. But it is clear now that in that year some changes were made to the GP contract which fatally undermined the personal link between GPs and their patients.

The new contract said that GPs were no longer responsible for their patients all the time, but only during working hours Monday to Friday. So at a stroke the need to think holistically about a patient’s entire needs was removed - although to their enormous credit many practices still make superhuman efforts to do this even under the new structures.

The result of that historic mistake is that GP practices are now remunerated not for looking after people as individuals, but for complying with a myriad of targets and requirements: the Quality and Outcomes Framework; Quality and Productivity; Direct Enhanced Services; Local Enhanced Services; Local Incentive Schemes and others too.

All of these targets are designed for important reasons: boosting immunisation, managing blood pressure, early diagnosis, HIV testing, extending hours and so on.

But taken together, the result is we reward GPs not for putting patients first, but for the number of biomedical boxes they tick when someone walks through their surgery door. “It’s like the patients have their agenda and we’ve got ours,” as one GP told me.

And with every target or process comes bureaucracy and paperwork. Updating different computer databases, chasing up test results or diagnoses or scanning in letters from hospitals. One GP practice I visited recently actually had a post called “head scanner” because of the volume of letters they receive, that have to be scanned in and linked to a patient’s medical record, a function that takes around 6 hours every day.

The consequence? We have turned GP practices into largely reactive places - sometimes with the feel of a mini A&E department - where the daily challenge is not keeping a watchful eye on the health of people on their list but simply keeping a head above water in the face of queues outside the surgery door, large call volumes, long appointment lists and mountains of paperwork.

And the proactive work of a family doctor - checking up on a frail older patient recently discharged from hospital, phoning someone who is depressed and living on their own to see how they are, looking up when someone suffering from recurrent back pain last came to see them - is too often forgotten or left undone.

Out-of-hours

Out-of-hours services are perhaps the prime example of where things have gone wrong.

We have had teething problems with the new 111 service. They were not acceptable and we are sorting this out. But those problems have rightly focused public attention on the variable quality of out-of-hours GP services.

No one is suggesting that GPs should go back to being personally on call during the evenings or weekends - they work hard, they have families and they need a life too. But should the quality of out of hours care for people on their list really have nothing to do with a GP? And is it right that most out-of-hours providers can’t even access your medical record even with permission?

Accountable clinicians

Which is all part of the same problem.

Patients in hospitals are under the care of accountable clinicians. The consultant responsible doesn’t do everything him or herself. But if something goes wrong, you know where the buck stops.

But when a vulnerable older patient needing follow-up and ongoing support leaves hospital, who is the accountable clinician?

As a member of the public, I would like that to be my GP.

I’m not talking about one person personally providing every element of care for a vulnerable parent or grandparent. Clearly, there will often be important roles for geriatricians, district nurses, social workers and others.

And we can debate whether in certain cases the accountable clinician might not be a GP - just as in hospital sometimes the individual responsible consultant can change based on the needs of a patient.

But at any stage, a patient, or his or her family, should know where the buck stops.

That there is someone whose job it is to know how someone is, ensure good care is in place, and make sure there is access to good advice both in and out of hours. Someone who helps our most vulnerable older people navigate their way through the complex and sometimes scary world of health and social care.

But it does not mean mandating a single model for primary care from the centre and seeking to “roll it out” irrespective of local circumstances. The NHS has tried that many times before with very mixed results.

In fact we need quite the opposite: bold experimentation with integrated care models where our focus is on outcomes rather than inputs and processes, something that Norman Lamb was talking about here just last week when he announced his integration pioneers programme.

Indeed if we do that I am convinced we have the keys to unlock global best practice right here in Britain, where from last month commissioning now lies in the hands of GPs. But we need to go much further, actively combining the best traditions of NHS primary care with the transformative power of modern technology - not just for the benefit of clinicians but also to help patients to manage their own conditions.

Assessment

Finally, getting this right will need a complete overhaul of how GPs are assessed by the CQC. Too many GPs feel that the current registration system feels like yet another tick box exercise.

As with hospitals, we need to reform inspection so that it makes a holistic assessment of what General Practice is for. Inspections need to look at clinical outcomes, patient care, access and safety. But most of all - just like in hospitals - inspections need to look at whether the practices are putting the needs of patients at the heart of their work.

So I am pleased to announce that we will this year appoint a Chief Inspector of General Practice to help drive up standards of excellence in GP practices across the country through clear, open and robust assessments of how well each practice is serving its patients. Working inside the CQC, the new Chief Inspector will work alongside the Chief Inspector of Hospitals and the Chief Inspector of Social Care.

This will involve working together to make sure that primary care, hospitals and care homes are all playing their part to provide a seamless, joined up and integrated service for people with complex needs. The Chief Inspector of General Practice could have an additional responsibility to assess the degree to which this joining up is actually happening.

These ideas are not going against the grain of what GPs want. Nor are they trying to turn the clock back to an ideal that probably never really existed as much as we imagine. But even as technology changes so much, some fundamentals must remain constant: the importance of people, of relationships, and of accountability.

If we are to succeed, we must rediscover the concept of personal responsibility for the care of our most vulnerable - something that most GPs have always felt should be at the heart of their profession.

A few GPs have already pulled out of involvement with their local clinical commissioning groups (CCGs) because they could not spend enough time with patients while also helping run the groups. The growing demand for GP services is also making others consider withdrawing, even though CCGs are meant to be GP-led.

Dr Clare Gerada, chair of the Royal College of GPs, said the difficulty of reconciling patient care with new managerial duties in their local CCGs meant it was “inevitable” some GPs would pull out of the CCGs.

Read more in The Guardian.

This is key finding of a report by the Institute for Fiscal Studies and the Nuffield Trust, which illustrates the changing relationship between the public and private sector in both the financing and delivery of health care.

In the 2000s, rapid growth in public health spending was matched by a slowdown in the growth of private health spending. At the same time, an increasing volume of publicly funded care was delivered by the private sector – meaning that the NHS became a major client for many private healthcare providers.

Read more in PrivatePracticeDr.

We now have a procession of GP leaders on TV and radio banging on about how it is not fair to blame them and that the problem is far more complex and multifactoral. Indeed my fellow blogger and colleague, Bob Bury, has posted recently on this theme.

I listened to Dr Laurence Buckman, the BMA GP chairman speaking on the Radio4 Today programme stating that the health secretary Jeremy Hunt is spouting “rubbish” (no great surprise there). The work load of GPs, he claims, has risen hugely since 2004 much of it related to the huge amount of box-ticking they are required to do. The real problem, he states, is the massive disinvestment in social care with frail old folk trapped in hospital beds. He obviously has a point!

However, and I am about to make a lot of doctors very cross, I am getting pretty fed up with listening to GP leaders, including Dr Buckman, bleating on about how hard they have to work during the day and that is quite impossible to expect them to work all night as well.

Well Dr Buckman may I point out that as a hospital consultant I have to work bloody hard too, as do my colleagues. Over the years we also have seen our work load rise inexorably and many of us feel that we are like rats on a treadmill, never managing to keep up but goaded on by endless “targets”. It is the hospital doctors who are bearing the brunt of the A&E crisis – my own trust seems to be on “black alert” almost continually.

But in addition to this there is the EWTD, strongly supported by the BMA, which has resulted in a marked reduction in the hours which juniors are allowed to work. Many consultants report that the post-take ward round frequently takes place with no juniors and no one who knows the patient. Consultants are now regularly being required to “act down” to cover absent juniors. Wearing my HCSA hat I have occasionally been involved with consultants who have been through a disciplinary process by their Trust because they refused to be compliant with such requests.

Also there are the reports showing that patient outcomes are much poorer at weekends when there is reduced senior cover; consequently there is now pressure for the 24 hour “consultant present” model of working (which is already happening in some specialities) with additional pressure for full seven day working.

Many consultants now work heavy on-call rotas with increasingly frequent call-outs and in most cases still have to work normally the next day. This is especially true in smaller hospitals with fewer junior staff to help cover rotas.

My point is that if it is inappropriate for GPs to work a full busy day and then work at night it is equally inappropriate for consultants. But since 60% of the profession (GPs) have opted out of unsocial hours working this simply dumps the load on the rest of us. Add to this the prospect of working to the age of 68 and we have what is, in my view, a very damaging toxic mix.

So I am sorry Dr Buckman, but although the A&E crisis is clearly multifactoral your wretched 2004 contract is a significant factor and to whine that you are all too busy to contribute to OoH working is simply to close your eyes and hope that the problem will go away (or that the hospital consultants will sort it for you). But then we all know that the BMA is largely regarded as the GPs’ union!

My rant is nearly over. But to try to be positive I think the solution must be that the profession as a whole should take responsibility for OoH cover. There should be models of care which allow for combined working and shared responsibility. No one wants to go back to the days when the GP alone had to be available day and night to treat a case of acute dandruff because the patient had no time during the day to make an appointment. Clearly there must be contractual arrangements for GPs and consultants which allow proper scheduling of OoH shifts with appropriate rest periods. This will inevitably require investment and new ways of working.

Sadly the Health & Social Care Act has simply increased the divide between primary and secondary care. The GPs are now in the driving seat as health “commissioners” while the consultants are increasingly demoted to merely one group of “providers” among many. The BMA are clearly becoming entrenched in their view that the 2004 contract is irrelevant to the issue and I doubt will show any leeway to support hospital staff.

Interesting times…

The competition regulator has sought to allay fears around the controversial Section 75 regulations by issuing draft guidance suggesting that CCGs will not be forced to put services out to tender, even when there is more than one potential provider.

The guidance from Monitor follows fears expressed by commissioners that they would be hamstrung by the competition regulations - which state that CCGs would have to put services out to tender unless they could prove the service could only be provided by one provider – despite a rewrite by the Government.

But Monitor’s clarification suggests that CCGs can carry out a review of provision of a particular service and identify the most capable providers as part of that review, negating the need to put the services out to tender.

Read more in Pulse.

]]> http://www.hospitaldr.co.uk/blogs/web-news/monitor-attempts-to-allay-competition-fears/feed http://www.hospitaldr.co.uk/blogs/web-news/monitor-attempts-to-allay-competition-fears http://feedproxy.google.com/~r/HospitalDr/~3/CuvexZ4dxJU/the-nhs-is-under-real-threat-says-bma-leader http://www.hospitaldr.co.uk/blogs/dr-blogs/the-nhs-is-under-real-threat-says-bma-leader#comments Thu, 23 May 2013 10:14:42 +0000 admin http://www.hospitaldr.co.uk/blogs/?p=13639 Dr Laurence Buckman, chair of the BMA’s GP committee, gave a speech which was highly critical of the health secretary to the Conference of Local Medical Committees, in London, today. Here are the highlights of what he said:

We meet today at a critical point for the NHS and for general practice. It is no exaggeration when I say: a signal has been passed at danger – the NHS is under real threat. All of us but the politicians can see the buffers fast approaching. When is the driver going to pay any attention to any advice? Mr Hunt, start listening now.

As we have over the last 65 years, doctors, nurses and other NHS staff can work together to find a way through the current challenges and continue to provide more and better health care, free at the point of delivery, accessible to all. But not if the government insists on denigrating us and using the NHS as a political weapon as it has increasingly been doing over recent months. Speeches, spin and sound-bites really aren’t going to achieve anything beyond a bit of political point scoring.

The debacle over the huge pressures on A&E departments is a good case in point. The government’s own analysis shows that the causes are complex and are due how emergency activity is calculated, reductions in bed numbers, staff shortages in key hospital departments and the botched introduction if NHS 111, not a failure in out-of-hours primary care. Yet, the headline response is to say it will all be ok if patients have named GPs.

Now, believe it or not, there is actually some sensible thinking going on in the Department of Health about how we can tackle the crisis in emergency departments – much of it influenced by doctors through bodies like the BMA. But it’s not headline grabbing – it’s focused on collaboration and better integration of the different emergency and out-of-hours services like doctors in Hertfordshire are doing with the NHS 111 service there. Herts Urgent Care provides both the GP out-of-hours service and NHS 111. In contrast to the situation in many other parts of England, the Herts NHS 111 service is operating well: one patient who used the service over the last bank holiday weekend described their experience as ‘gold standard’.

The fact is, GPs are undertaking more consultations per patient and we are diagnosing and treating more conditions that ever before.

We believe real and lasting improvements to out-of-hours care are possible, but only if we put a greater level of investment into primary, community and social care.

If we don’t work together constructively to find a way forward, we’re quickly going to have doctors all over the country so desperately worried about their patients and their colleagues that they will follow the example of a group comprising almost all of the medical leads of emergency departments in the West Midlands who last week wrote an open letter to trust chief executives and clinical commissioning groups to say they could no longer guarantee safety in their units. GPs are not prepared to shore up a system that has been rendered unsafe by unwise political meddling. We are happy to work closely with others, including CCGs where there is full GP input, to improve out-of-hours services.

We need to be freed from the oppression of box ticking and micromanagement. It’s time to reduce the huge, unnecessary GP workload so we have time to treat patients holistically, to treat patients as people not diseases, and offer the continuity of care that we and they want and need. It’s time to give time to the patients who really need our care and attention, the vulnerable and the frail and the patients who the NHS currently fails.

In the poll of 102 FY doctors, published in the JRSM, 64% of respondents admitted their understanding of NHS reforms and health politics was poor, although 69% still said they were interested in the reforms.

This apparent contradiction chimes with my own experience of working with young doctors and trainees. While they are generally delightful to work with, enthusiastic and able to focus on the task at hand, they often find it more difficult to think beyond the next exam or assessment of their skills. In a recent interview skills session that I held with a group of trainee doctors, few were confident about discussing the big issues of the day and their likely impact.

I think this is an unintended consequence of the way that our society trains its doctors. If you need to jump a series of hurdles to reach your ultimate goal, it makes sense to dedicate your time and energy to that clinical audit or management course and not allow yourself to be distracted. But too many doctors emerge from this intensive training experience as if they have been wearing blinkers for the previous few years: they have the knowledge to regurgitate for exams, the clinical skills to practice but little understanding of the wider context in which they are working.

Many doctors might argue that having qualified, they simply want to focus on the patient in front of them but medicine cannot be practised in a vacuum and such an approach could actually be detrimental to the care you are able to provide to patients. It’s not possible to be impassive about diminishing healthcare budgets; the introduction of Clinical Commissioning Groups; the planned integration of health and social care by 2018; and the Francis Report. We all need to recognise the impact these developments will have on the services we can access; the budget at our disposal and our professional obligations.

Today, the amount of information we have to absorb to understand a subject means there are fewer polymaths with an interest across sciences, the humanities, arts and political life. But in focusing almost exclusively on our own specialisms perhaps we have lost something. As far as doctors are concerned, I think we need to remove our blinkers and engage with the wider world for the good of our patients and ourselves.

Healthcare Performance was established by two doctors with over 30 years’ experience of clinical governance and medico-legal work, and specialises in careers coaching, professional development and organisational trouble-shooting within the healthcare sector.

The idea has been proposed by a Department of Health commissioned review of clinical excellence awards (CEAs) by the Pay Review Body which recommended changes to the pay structure to recognise different stages in a consultant’s career.

The report suggested introducing a break point in the pay scale and a new “principal consultant” grade to reward up to 10% of the senior consultant workforce.

Delegates at the BMA junior doctors’ conference said they were concerned that no extra layers should be introduced before trainees could become fully qualified consultants or GPs. They were concerned that a new sub-consultant grade could fragment career progression and increase the tiers of an already elongated career path.

Doug Pendse, a London clinical lecturer in radiology, said a CCT (certificate of completion of training) should be an end point. “If you haven’t completed your training, you shouldn’t have a CCT,” he said.

BMA consultant and junior doctor representatives have held exploratory talks with NHS Employers this year about possible contract reform to see whether they can agree some broad principles that would form the basis of more formal negotiations. But no decision has yet been made on whether any negotiations should go ahead.

However juniors discussed at their conference how they would like to see their contracts reformed.

Junior Doctors Committee chair Dr Ben Molyneux said that in the current difficult financial situation juniors would have to be realistic about pay should formal contract negotiations go ahead. He said: “We are unlikely to achieve increases in pay but we have made it clear [to NHS Employers] that the current pay envelope must not be cut.”

Former JDC chair Dr Tom Dolphin said there needed to be a mechanism to protect doctor and patient safety by ensuring there were ways of verifying controls on hours.

The conference agreed measures to safeguard high-quality education and training were essential for patient safety and should be included in contract negotiations because it is currently often provided in a “haphazard and opportunistic way”.

Juniors also agreed that priority issues for any new contract should include: a distinction between social and unsocial hours; the introduction of “humane” working patterns, maintaining the differentiation between weekend and weekday working for both juniors and consultants; protection for clinical teaching and training and a ban on routine annual leave embargoes.

Reform of the junior doctors’ contract has been talked about for several years. The current contract is more than 12-years-old, and many things have changed since it was introduced.

An NHS Employers scoping report into the contract, published in December described the current arrangements as “not fit for purpose”.

The JDC 2013 annual report says if they could agree a “Heads of Terms” to use as a framework  for talks, negotiations on a new contract could follow in Spring 2014.  Any new contract would be subject to a ballot before possible implementation, likely to be in Summer 2014.

Reforms to the consultant contract that the four UK governments would like to discuss, in addition to changes to the pay structure, include: linking pay progression more closely with performance, extending the consultant presence in hospitals at evenings and weekends and a new approach to the way national and local CEAs work.

Sir David has announced he will retire in March 2014 from his position as chief executive of NHS England. He has already spent seven years in charge of the NHS, but in recent months has found himself under attack for his role in the Stafford Hospital scandal.

He spent 10 months in charge of the regional health authority in 2005 and 2006 - at the height of the problems.

Campaigners and MPs had called for him to resign after publication of the public inquiry into the failings.

Read more at BBC Health.

Duck it as much as you want, avoid the issue as much as you want, try and twist the media as much as you like, there will come a point when someone has to put their hand up and dash the great expectations of the public.

The great expectation that as things stand the NHS will continue to provide everything and more; the great expectation that errors will cease; the expectation that communities will be equipped to keep people at home away from the cold corridors of emergency departments; the expectation that GPs and specialists can do more, and junior doctors can work harder.

But, at some point, someone will have to let the cat out of the bag. That there is no more money to give everything to everybody at the highest quality possible.

And it doesn’t matter how many conferences you attend about integrating health and social care, unless there is more investment, it simply is not do-able any more.

The latest drive within hospitals? A seven-day service.

Skeleton staff over weekends compared to weekdays have been known to harm patient care. So, have no doubt that seven day cover is a must - no dispute allowed.

But, we have forgotten the simple facts, how does one move to seven day service when even the five day service isn’t sometimes good enough?

We want consultant reviews over seven days a week, but often this doesn’t happen over five.

Either consultants are busy with their other scheduled work or are doing something not quite within their job plans. Their respective managers know that to move to a five day service review, something will have to give, something will have to stop.

We decide not to - ergo we can’t do five day cover consistently and yet we’re attending conferences on seven day cover.

We are looking at workforce implications; we are talking loudly as to how we are about to universally embrace seven day working; but,  no one has any answer to whether it will get blocked at the financial stage, or does it mean something else has to stop.

A good example? I can do seven day cover but that would mean me also taking time off to compensate for my weekend work - which means cancelling my type 1 diabetes clinic. Something suffers, something gives.

All this while the expectations keep getting fuelled. Politicians of any colour need to be honest, and engage with the public to say we have no more money left to pour in. Funding has flat-lined.

The thing with visionaries is that they rarely do the implementation and the NHS is now in a bind. Nurses have kept on saying they are short on the wards, but it is evidently all about working differently, ‘making efficiencies’, or some other lingo that which sounds clever but increasingly means very little to frontline staff.

As a Consultant, I get paid to spend 46 hours per week at my work, my average runs at about 70. And I am not unique either. The majority of staff whether they be GP or nurse or specialist are doing exactly that - working far and beyond what their contracted hours trying to bridge that gap, and meet the great expectations.

I am still passionate about making a difference to people’s lives but let us, please, be realistic. In an era where cost cutting is such a huge priority, let’s be realistic and start to have honest conversation about what’s achievable and what’s not.

As JFK said: “The great enemy of the truth is very often not the lie, deliberate, contrived and dishonest but the myth, persistent, persuasive and unrealistic.”