Category Archives: Doctors

Only a tiny fraction of the ocean of human physical and mental suffering reaches the shores of general practice, from where barely ten per cent of patients are referred for specialist attention. GPs have been trusted to refer judiciously, according to their clinical judgement, saving time and costs of specialist interventions. This gatekeeper role is widely acknowledged to be a key feature of the NHS, which keeps it at the forefront of cost effectiveness internationally.

In recent years, however, the rate of referrals began to rise – the opposite of NHS England’s strategic aim of shifting care away from hospitals. Some commissioners have been offering financial rewards for reducing the rate, a measure which many GP feel is unsafe. The reason for this situation lies in a basic policy conflict.

Since the Conservatives took power in 2010, NHS funding has been practically at a standstill, while costs have risen at a steady 6-7% per year, leading to the present catastrophic deficits with correspondingly desperate cost-cutting interventions. At the same time there has been an unprecedented focus on patient safety, resulting ironically, and tragically, in a culture of fear – reaching its zenith in the recent case of Dr Bawa Garba, a paediatrician who was struck off after a child died while she was working under in an understaffed department without senior cover. A culture of fear is overwhelming attempts to cut costs by doing less. Fearful of missing a rare diagnosis, GPs are investigating more than ever; fearful of a delayed diagnosis of cancer, GPs are referring more than ever; fearful of patient complaints, GPs are prescribing more than ever – with very few exceptions.

At a political level there is a refusal to acknowledge that the problems of high rates of investigations, referrals and prescribing are a consequence of fear, stress and overwork. It is impossible to do less if you do not have time to think more. The quadruple aim of improving patient and professional experience and the health of the population while decreasing costs has been in practice a single aim of reducing costs. By almost every measure, the other three aims (shown by the British Social Attitudes Survey and recent reports into the health of children) have worsened significantly. The only thing the government has succeeded in doing is screwing up (or down, depending on your perspective) the costs.

A few years ago I audited referrals of patients with headaches to our local neurology clinic. I read the referral letters to see if the reasons for referral were clearly stated and if there was sufficient detail about the clinical features, the treatment history, the social context and the patient’s concerns. Many letters had inadequate information and others were comprehensive but were about problems that a competent GP ought to be able to manage. Unsurprisingly all these ‘unnecessary’ referrals came from a handful of practices. We invited representatives to an ’education session’. The session was run by a neurologist to present the expert view while I was there to help think about some of the psychological reasons behind referrals. I told the group how, as a junior doctor working in A&E several years before, I had sent home a young man with a headache who was readmitted after my shift, unconscious and fitting. He had suffered a subarachnoid haemorrhage – a bleed from a vessel in his brain. I nearly gave up medicine then, right at the start of my career, and was very anxious about managing patients with headaches for years afterwards.

About a year before the education session I had met another patient who had suffered subarachnoid haemorrhages and together we spent several sessions teaching medical students about headaches. This way I got over my fear and became our practice lead for headaches. By sharing this at the session I helped the other doctors in the room to think about their own lack of confidence. A year later, referrals from the doctors that came from the practices represented at the session had reduced by between 50 and 100%.

The use of financial incentives to reduce GP referrals reveals a failure to recognise the complex reasons behind a referral. If I am anxious, stressed, rushed and lack time to think carefully and critically, it is much easier to refer patients so that they become somebody else’s problem. Working in the NHS in a time of austerity and digital technology I find myself with less time than ever to reflect or discuss cases with colleagues, while it is easier than ever before to order a wider range of tests. We need to shift our focus of attention onto the experiences of patients and health professionals and the quality of referrals and the outcomes, and then see what that does to cost effectiveness, not the other way around.

First published by the Centre for Health and the Public Interest

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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The BMA have begun to ballot GPs in response to the Tower Hamlets motion passed at LMC conference in May which said:

“That conference believes that the GP Forward View is failing to deliver the resources necessary to sustain general practice and demands that GPC ballot GPs as to whether they would be prepared to collectively close their lists in response to this crisis.”

It is beyond doubt that General Practice is in meltdown. Despite the best efforts of GPC Executive all we have been offered is a totally inadequate GP Forward View and a couple of other sweeteners such as reimbursement of CQC fees.

STPs will finally push us over the edge as patient care is moved out of hospitals into an already oversaturated community to “save” £22 billion in England.

Collectively closing our lists to manage our workload would benefit the safety of our registered patients and send a message to the Government that we cannot continue to work under the current level of pressure.

Many forms of action to reduce our workload, such as refusing to cooperate with CQC inspections, would risk practices being served with breach notices. List closure however is allowed under GMS and PMS contracts to give practices: “a degree of workload control…. in situations of workforce or recruitment difficulties that affect a practice’s ability to provide to an acceptable and safe standard.” Given that 84% of us said last year that our workload undermines our ability to provide safe patient care, most of us can surely argue that we can temporarily close legitimately on this basis.

Practices in areas of high turnover may be concerned that list closure will result in sharp drops in income as patient numbers fall. This could be mitigated by choosing a maximum list size which enables safe patient care, closing when the list exceeds this number and opening again when it drops below. The requirement that practices opt out of additional and enhanced services if they close their patient list, is no longer in the regulations. There will thus be no impact on the services practices are currently commissioned to provide. Collective list closure would mean lack of access for some but General Practice will collapse and there will not be access for anyone if we do nothing. Patients will support us if we explain that we want to provide safe, comprehensive General Practice to everyone, but that in the current climate this is not possible. We do not contemplate this action lightly, but the Government have not listened to years of warnings and General Practice is now on the point of collapse. We struggle to provide a safe service due to our workload and this is not good for patients. Many already understand the pressures that the health service is under, 250,000 marched in defence of the NHS earlier this year.

Patients can be engaged by asking them to sign petitions in our waiting rooms or to write to their MP.

The Government could easily avert this crisis. They could:

  1. Accept the GPCs Urgent Prescription for General Practice in full
  1. Take responsibility for indemnity as they do with hospital doctors.
  1. Allow patients to refer themselves directly for services such as antenatal care, weight management programmes and physiotherapy to remove this needless administrative burden from General Practice.
  1. Get rid of the hoops that we are forced to jump through for tiny pots of money, such as those in the GP Forward View, and put these sums into our baselines to allow us to plan our services.
  1. Assure rights of residency for non UK born doctors and nurses so that these valuable NHS staff stay.
  1. Stop outsourcing to profit driven companies like Capita whose appalling service causes daily chaos.
  1. Resource the NHS adequately. We are the fifth richest country in the world and can easily afford the NHS which remains the most cost effective health care system in the developed world. In 2015 the UK spent 7.3% of GDP on the NHS. This is lower than comparable European countries and is set to decease to 6.6% by 2020. The UK has fewer hospital beds per head at 2.8/1000 than the OECD overage of 3.3 and has fewer doctors and nurses per head than comparable developed nations.
  1. Abolish the NHS market, which fragments the health service and costs billions to administer.
  1. Repeal The Health and Social Care Act, with its myriad of committees and procurement panels which take us away from patient facing care.
  1. Abandon the STP project.

The key to success is in the word “collective”. We must all take part. Together we are strong. Of course there are risks and none of us will undertake this lightly but we cannot continue to work under these pressures. It is not safe for patients. If Government won’t listen we must make them listen.

Q: Why are we balloting for willingness to take action?

A: It is beyond doubt that General Practice is in meltdown. STPs threaten to finally push us over the edge as they demand £22 billion in “efficiency savings” Young doctors are not choosing General Practice as a career and many older GPs are retiring early. To add insult to injury the public sector pay cap has meant that doctors have effectively taken a 22% pay cut in the last decade. Despite the best efforts of GPC Executive all we have been offered is a totally inadequate GP Forward View and a couple of other sweeteners such as reimbursement of CQC fees.

Q: Why are GPC proposing list closure?

A: General Practice is governed by contract. Refusing to comply with many clauses in the contract, such as refusal to cooperate with CQC, would risk a breach notice. List closure however, if carried out on the grounds of patient safety, is allowed under the contract.

“A practice can decide not to register new patients, provided it has ‘reasonable and non-discriminatory grounds for doing so’, (such as protecting the quality of patient services.) In such cases, the regulations allow practice to refuse to register new patients (Schedule 6, Part 2, paragraph 17).”

Q: What should I say to patients?

A: Be honest. Tell them we regret taking this action and do not do it lightly, but that the Government have not listened to years of warnings about the strain on General Practice and that now it is on the point of collapse. We have to do something to stop it breaking down altogether. We struggle to provide a safe service due to our workload and that this is not good for patients. Ask patients to support you, put a petition in the waiting room and ask them to write to their MP. Our patients are the strongest weapon we have in fighting for general practice. Tell them what you are doing and why.

Q: My practice has a high turnover, if we close our list we will rapidly lose income.

A: For practices like yours, consider deciding a minimum list size to sustain the service, then temporarily close your list until patient numbers had dropped below this. You could then re-open until your safe limit was reached, closing again and so on. Remember the aim is to highlight the dangerous working conditions we all face and the impact this has on patient care. You can still achieve this.

Q: What about the patients who are not registered with a GP?

A: GPs will remain able to see patients as temporary residents in emergency circumstances. We regret that this action will mean a delay in registering fully with a GP, but failure to act will lead to the collapse of General Practice which would mean a lack of access for all. As a profession we do not do this lightly, but the risk to our patients is greater if we do nothing. NHS England will still be able to allocate patients to closed lists, as is the case currently in many areas where all practices have closed lists. If this list closure happens nationwide however it causes a significant increase in workload for NHSE, as well as public embarrassment to the government.

Q: I understand the need to take action but I am nervous.

A: Of course. We are a caring profession who are reluctant to do anything to hurt or upset our patients. Having considered many options, we genuinely believe this is the best choice to cause maximum disruption for Government, but minimal harm to patients. The risk of continuing to provide care at this unsafe workload outweighs the risk of carrying out this action.

Q: Why are we balloting for “collective” list closure?

A: Because together we are much stronger and can have a much bigger impact. If we stand united across the profession, supporting each other we can make rapid gains. Uniting GPs across the country means we can deliver a stronger message and hopefully achieve our aims quickly.

Q: What do you want the Government to do?

A: There are many things that Government could do. These are some suggestions:

  1. Enact BMA policy and fund the NHS to the level of comparable countries and at the same time increase the proportion of NHS funding which is allocated to General Practice to at least 15%.  In 2015 the UK spent 7.3% of GDP on the NHS. This is lower than most other European countries and is set to decease to 6.6% by 2020. The UK has fewer hospital beds per head at 2.8/1000 than the OECD overage of 3.3 and has fewer doctors and nurses per head than comparable developed nations. Despite this the NHS is regularly found to be the most cost effective health care system in the developed world.
  2. Take responsibility for GP indemnity in the same way that they do for hospital doctors.
  3. Allow patients to directly refer themselves for services such as antenatal, terminations of pregnancy, podiatry, physiotherapy, weight management programmes etc, to remove needless administrative burden from general practice.
  4. Remove all of the hoops that we have to jump through to for example obtain the tiny pots of money in the GP Forward View. Funding must be made directly available for all practices.
  5. Deal with the incompetence of companies such as Capita and NHS Property Services whose failures cause such time wasting in surgeries.
  6. Sort out NHS Property Services so that they stop wasting practices time with repeated premises surveys and sending unjustifiable service charge bills.
  7.  

    Attract doctors and nurses into General Practice, both young doctors and those who have left. Increasing doctors and nurses will help decrease the workload which 84% of us have said undermines our ability to provide safe patient care and enable us to provide a safe service for patients.

  8. Confirm the residency status of all non British born doctors and nurses immediately so that they remain here making their vital contribution to our health service.
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Despite all the negative vibe around the medical industry, this is still an overall good time to become a doctor in the UK.

With the shortage of skilled labour in key areas now affecting the NHS, it is a fact that there are more positions available for highly motivated and well-trained doctors, who can rapidly move up the ranks within the ranks of the public service or start a career in the private sector instead.

As admitted by senior figures in the UK medical world, the country is not training enough individuals to become doctors, so deciding to become one is a decision that will have a positive impact on the wider society as well as on your professional life.

But what are the main skills needed – and the approach required to become a doctor in today’s highly competitive industry?

First of all, resilience is key to success in medicine. The lengthy and testing academic side of the degree along with the practical tests that surgeons and nurses have to deal with from an early stage mean that this a profession for those who are really passionate. And possibly ready to make a sacrifice in terms of social life. Resilience will also be essential from a professional perspective, as a doctor’s life is always full of tests – from appraisals to sudden changes in the industry.

Fear not, however, as the very low dropout rates in medicine go to show that once you are ready to set out on this rocky academic and professional path, it already probably means that you are ready to face the tests that lie ahead.

If you are willing to become a doctor, also bear in mind that empathy and people skills are essential to a career that revolves around the way you deal with patients and how you relate to them. So if you are after a humanly, rewarding job, which allows you to see a positive impact on the people within the community, it is likely that starting a medicine degree will be a great choice for your future.

On top of all this, the capability to deal with numbers and a solid background in scientific subjects will help greatly, especially as you attend the first two years and deal with the most theoretical parts of your degree.

Finally, you shouldn’t forget about the importance of collaboration and the ability to work within a team. At the beginning of your career, you will hardly ever work autonomously, so make sure you have a good attitude to teamwork and have a curious approach. Your colleagues will ultimately be a priceless source of knowledge and inspiration.

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Medical translation services can be crucially important in this day and age bearing in mind that translating from one language to another can be a challenging task, especially when it comes to interpreting between patient and a doctor.

People with no or less English-speaking abilities often do not receive the health care they deserve due to language barriers. Many medical organisations do not provide translation services due to which patients suffer, unfortunately. In fact, some incidences indicate that it can cost lives as well.

It can be important in this age of modern travel as well. One might need translation for immigration purposes or apply for insurance in a foreign country. Medical translation is the means through which one can personally communicate in any language eliminating uncertainty.

Bilingual is not sufficient

Medical translation is not an easy task as mentioned above earlier. Medical terminology can make it sophisticated. Complete or partially incorrect interpretation can result in a faulty diagnosis and inappropriate treatment. Many patients rely on family members for interpretation but this is not sufficient in many cases. Using a professional service is of paramount importance in such critical situation when someone’s life is at stake.

Help for healthcare workers

Not only patients are reliant on translation services but professionals working in the healthcare field can receive immense benefits from competent translation services. From nurses to doctors to medical researchers, all can draw advantages from it. Specialists can help them comprehend test results more accurately and make sure that each and every word is properly interpreted. Translation of reports is immensely important in the medical field.

Technology

Personal communication between doctors and patients is critical but it is not facing to face anymore. Technology is progressing at a swift rate and these services can now be provided through web conferencing and video calls.

This approach provides further benefits as well. Conversations can be recorded and interactions can be reviewed all over again when in need. Items can be uploaded on the system where medical translator can access them and work on it. This even enables hospitals to cut off operation costs in multilingual areas.

Challenges

Medical translation field is high in demand and many translators are considering to move into it. But in order to provide competent services, the translator needs to have a considerable amount of knowledge and skills in their respective field. Knowledge of medicine, chemistry and pharmacology is the pre-requisite. In fact, knowledge in information technology is also important due to massive usage of technology in the medical field. Most importantly, medical translation is a field where there is no room for mistakes. Even the slightest error can put lives at risk.

This is why it is a promising field and one must consider several factors before pursuing a translation service. There are a number of services available, https://www.translateshark.com/ being one of them. Just make sure you get access to experts linguists worldwide in order to get the best services as it is crucially important to ensure a safe medical process.

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International Women’s Day seems a suitable time to publicize the campaign to decriminalize abortion in the United Kingdom. In February 2016 BPAS the leading charitable abortion organization in the UK launched their campaign “We Trust Women” to scrap cruel and archaic abortion laws. Many people do not realize that under the 1861 Offences Against the Person Act (OAPA), abortion remains a criminal offence unless the criteria set out in the 1967 Abortion Act are followed.

The Director of Public Prosecutions (DPP) decision in October 2013 not to prosecute two doctors caught up in the Daily Telegraph ‘sting’ operation in February 2012, where a woman accompanied by a reporter posed as a patient requesting an abortion on grounds of fetal sex was greeted with fury by the anti-abortion lobby and resulted in a Westminster Hall debate where normally pro-choice MPs deplored the possibility of abortion on these grounds. The DPP decided that although there were grounds to prosecute these doctors it would not be in the public interest to do so (2). Both doctors were referred to the General Medical Council and conditions put on their registration banning them from abortion work. In early 2015 after a private prosecution was brought but failed, one doctor had the conditions lifted and the second was sent to a Fitness to Practice Tribunal where he was suspended from practice for three months. He was not found guilty of recommending an abortion illegally but guilty of a probity issue. The uncertainty and stress of this three year ordeal was considerable but fortunately both doctors had supportive employers. The Chief Medical Officer wrote to all doctors in February 2013 setting out guidance as to how the 1967 Act should be operated although some of us had questions about her interpretation of the law.

These cases and an unrelated investigation about pre-signing the necessary forms under the 1967 Abortion Act have had a chilling effect upon doctors working in the field of abortion.

On 4th November 2014 Fiona Bruce MP introduced a 10 minute rule bill, Abortion (Sex selection Bill) to outlaw this alleged practice which passed by 180-1, the lone dissenter being Glenda Jackson. As a private members bill there was little chance of finding time for the next stage and it was withdrawn and replaced with a new clause in the Serious Crimes Act outlawing abortion on the grounds of fetal sex. This was debated in February 2015. This proposal was a departure from the way the Act had operated successfully for 46 years. Lobbying by pro-choice and women’s organisations helped educate MPs and to defeat this clause by 292 to 201 votes. A motion asking the Department of Health to assess the extent of the problem and if necessary prepare a strategy to tackle this passed almost unanimously by 491 to 2 votes.

The politicization of abortion and the effect of the strong and well organized, well funded anti-abortion lobby makes it difficult for rational decisions to be made about changing the law which is now almost 50 years old. Considerable changes have taken place in the way that abortion is carried out and medical abortions in 2014 made up 51% of the procedures in E&W and 80% in Scotland. Nurses can take the history, examine the woman and administer the pills and should be able to sign the forms required by the 1967 Act.

An investigation was ordered by the Secretary of State for Health into abortion clinics by the CQC (costing over £1million) following an inspection in January 2012 revealed pre-signing of the forms required in order to legalise an abortion. They found fourteen NHS hospitals where this was done, but in July the DPP decided that these hospitals would not be prosecuted as steps had been taken to improve compliance with the law.

In 1990 when the upper limit for terminations was reduced from 28 to 24 weeks a clause was also added to allow terminations in places other than hospitals. Despite research internationally that shows home administration is possible, the DH consider that unlawful and despite two pilot studies done in the community the requirement that women attend hospital persists. It is irrational and against the best evidence but appears to be a response to the furore that occurs whenever abortion is discussed in public.

The OAPA 1861 (itself based on the law first passed in 1803) has also been used recently to prosecute four women. Sarah Catt in 2012 was jailed for 8 years (reduced on appeal to 2½ years) for taking pills to induce labour at 39 weeks. She said the baby was stillborn but has not revealed where the body is. Natalie Towers was jailed for 2½ years in December 2015 for inducing labour at 32 weeks and delivered a stillborn baby at home. In Northern Ireland where the 1967 Abortion Act does not apply, two women are awaiting trial under the OAPA. One obtained pills from the internet for her underage daughter and appeared in court in June 2015 and the second referred herself to the police in January 2016 having taken the pills in 2012. Charge me or change the law was her message and she has been charged, unlike the 215 who wrote to the PSNI in June 2015 or the 100 who did so in 2013 asking to be prosecuted.

In the twenty first century it is extraordinary that women’s control over their own bodies should be constrained by a 19th century law and that women are being jailed for breaking this.

Doctors for a Woman’s Choice on Abortion believes that the woman should make the decision to terminate a pregnancy after consultation with her doctor, a position accepted by 70% of the population and that the OAPA 1861 which makes abortion a criminal offence and the 1967 Abortion Act should be scrapped.

The original purpose of these laws was to save women’s lives and the 1967 Act followed a decade where abortion had become the leading cause of maternal death. In the 21st century when abortion is very safe and available medically there is no place for

a 19th century law which exposes doctors acting in good faith to the risk of criminal prosecution. Prosecuting women who may need help with mental health issues or in the case of Northern Ireland access to legal abortion in their home country is wrong.

In November 2015 a High Court judge in Belfast ruled that the law in Northern Ireland was ’incompatible with human rights’. The EU Charter of Fundamental Human Rights  became binding on member states in 2009 and under article 6 “Everyone has the right to liberty and security of person” and Article 7 “Everyone has the right to respect for his or her private and family life, home and communications” I contend that women do have the right to bodily autonomy. Women do not take the decision to terminate a pregnancy lightly and they are in the best position to decide whether this is the right thing in the circumstances for themselves and their families. Safe abortion is available though the NHS and the requirement to obtain the agreement of two doctors is bureaucratic, outmoded and unnecessary. At the Lords stage during the passage of the 1967 Abortion Act, which set out the conditions for performing an abortion lawfully, a sentence was inserted to say that if “continuance of the pregnancy would involve risk greater than if the pregnancy was terminated” the pregnancy could be terminated. The risk to life is always greater for a continuing pregnancy than if the pregnancy were terminated before 20 weeks so this gives doctors the option of responding to the woman’s request.

It seems extraordinary that in 2016 women do not have control of their own bodies

We think the time has come for the UK to follow the example of Canada, which decriminalized abortion in 1988 without adverse consequences. Anyone who agrees could send a donation to Doctors for a Woman’s Choice on Abortion to help with campaigning-and if every woman who has had an abortion in the last 46 years were to send a pound we would be able to do so more effectively.

This was first published in the Hippocratic Post

 

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When you’ve been working in the same building every day for years, it’s easy to become immune to your surroundings.

All the clutter and mess taking over surfaces becomes part of the background, which means you’ll inevitably fail to see how unprofessional your business looks to outsiders.

Although this is understandable, it’s not a blissful state of ignorance you can let yourself slip into if you run a medical centre.

The consequences of poor space management

A cramped and shambolic practice doesn’t only create an inefficient workplace for your employees. It’s also likely to give potential patients a bad impression.

Every inch of your business, from the reception area to the waiting lounge and treatment rooms, should put them at ease and encourage trust. A tired, untidy and unorganised looking building isn’t going to accomplish that.

But when you can’t afford to start moving walls or adding extensions, how do you get rid of the clutter and transform your medical centre into an ordered, calm haven?

To give you a helping hand, we’re sharing three top space-saving tips for better utilising your current practice. Take a look.

#1: invest in proper file storage

Upholding records for your patients is one of your biggest responsibilities, and if you don’t look after them properly, files and paperwork will soon start to pile up. Eventually, they’ll eat up all the free space in your medical centre.

You can digitise records but, with cyber-security a major risk, training your staff to do this properly takes time and money.

Instead, invest in a state-of-the-art medical records storage solution from the experts at Invicta. They’ve installed mobile shelving in lots of healthcare practices, so they’ll work with your budget to create space-saving storage tailored to your specific needs.

#2: reconfigure room layouts

Reconfiguring room layouts is one of the cheapest ways to free up space and can make a big impact on the general atmosphere of your practice.

For example, think about entryways and whether sliding doors would improve their efficiency. And pay special attention to your waiting room, making sure that there’s adequate seating for your average number of patients (too many empty chairs is an unnecessary waste of space).

But before you start getting people to move heavy furniture around, use a space management app to visualise potential changes and new set-ups first. It’ll help you find the optimal layout quickly and with minimum hassle.

#3: involve your staff

Involving your team in your centre’s redesign is the perfect way to encourage good housekeeping practices all round. After all, once they see how much effort you’re putting into transforming their workplace, they’ll be happy to put in a little hard work themselves.

Just make sure you give them the tools they need to be able to maintain your strict cleanliness and hygiene standards, even in behind the scenes offices and admin areas.

For example, it’s not expensive to invest in cable management systems or letter trays to keep desks tidy. Likewise, providing them with cupboards or lockers for storing their coats and handbags (personal belonging instantly clutter up workstations) isn’t difficult to implement.

Take these three space-saving tips as your starting point and you won’t have to break the bank to get your medical practice in fighting shape.

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The NHS is involved in a standoff with many of its locum staff -doctors, nursing and non clinical staff such as IT contractors.

There has been a change to tax rules, -IR 35 -which means that staff who are not regularly employed but are contracted with “off payroll” , -have to now pay the same tax and national insurance contributions as employed workers. This means their take home pay will drop -though most will still be paid a far higher hourly rate than regular salaried staff. for that job. The NHS didn’t make the tax rules but is having to deal with the consequences.

A number of staff, notably doctors, have abruptly withdrawn their availability for shifts, some at very short notice -less than 24 hours -unless the employer pays an increased rate to make up for the tax changes. This has meant that hospitals have had great difficulty in covering those rota gaps at short notice. And some departments such as A and E have been threatened with closure. In my own Trust, we have a heavy reliance on locum doctors to staff A and E as we have not been able to recruit permanent staff, so our A and E has been badly affected.
It was hoped that all NHS employers would” hold the line,” but some Trusts have agreed to pay the higher rate. So staff have moved to work with them, rather than the employer to which they had committed.

So, is this reasonable action by locum staff , who can sell their services to the highest bidder? The law of supply and demand is working well, one could say.
However, the medical regulator makes it clear that reasonable notice should be given if doctors are not available for agreed shifts.

The General Medical Council has warned that any locum doctors engaging in “unreasonable withdrawal” from work could exacerbate pressure on health services and potentially risk patient safety. This is against the professional code of conduct.

It remains to be seen if the action of some doctors will be judged to be “unprofessional. It depends on what you think is” reasonable notice”. It is worth noting that some of these doctors have a long term relationship with certain Trusts -they may be employed on an ongoing basis. What price loyalty?
And since when did we all expect our employers to increase our salaries, when there is a tax rise??

My hunch is that the Trusts will cave in and pay the higher rates, as they have to have continuity of safe services (the result being more strain on the budgets). But it is an unedifying tale.

“Unprofessional behaviour” seems about right to me…

www. drlindasays.wordpress.com

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The Welsh Health Cabinet Secretary (Minister) Vaughan Gething AM has identified three major priorities for primary care in Wales
* maintaining the sustainability of the sector,
* improving access to services and
* delivering more care in a community setting.

Central to delivering these are objectives are the emerging GP Clusters / Primary Care Networks. There are 64 networks or clusters in Wales with a population base of 30- 60,000 patients. It is based on promoting partnership and collaborative working.

The networks allow general practices and a range of other primary and community care practitioners to get together with their local health boards to shape community based services for their populations. However, unlike CCGs model in England, they are not involved in the commissioning of secondary care.

The Health, Social Care and Sport Committee of the National Assembly for Wales is undertaking an enquiry to obtain a better understanding of how the cluster model is working in Wales. The evidence submitted to the enquiry provides an interesting barometer of the progress that is being made.

Where things are going well, a wide range of new services are bring provided, often using new models of care. Many of these more advanced areas areas want to move towards more formal structures. In the Bridgend area of the ABMU Health Board a social enterprise has been established to look a providing services. Elsewhere a number of networks see the formation of “federations” as the next obvious step.

There is not a single operational model for the networks with varying levels of professional engagement and breath of wider organisational involvement. Some networks are more active than others in their efforts to involve social care organisations, third sector bodies and the wider patient / user / public voice.

Clinical representative bodies (e.g. GPC Wales, RCN, RCSLT, Royal College of Physicians, Royal Pharmaceutical Society, Care Council ) highlight that involvement in the networks is time intensive with some concern about an over-focus on GPs and the lack of parity of esteem for other professional health and social care groups. But management evidence ( e.g various health boards, NHS Confederation, Directors of Primary, Community and Mental Health) suggests an awareness of these problems and that they are working to address them.

An important factor in improving the status of the networks and facilitating their work has been the Welsh Government’s decision to directly allocate funds to them. While most primary care funding still goes through health boards, £16 million of recent allocations have been directly earmarked for the clinical networks. This has been welcomed though some concern has been expressed that some health boards might dip into these resources in areas where the networks are making less progress.

The fragility of primary care overall and general practice in particular is a consistent feature of much of the evidence. This is in line with recent BMA survey evidence that 80% of GP respondents had concerns about the sustainability of their practices. The efforts of the Welsh Government to promote recruitment and the status of general practice were widely supported. But the factors under-pinning this fragility – patient need and expectation, system pressures and supply side issues such as resourcing and staffing levels must all be acknowledged and addressed ( Bevan Foundation).

While some individual submissions suggest that independent contractor status of general practice needs to be enhanced, overall most submissions acknowledge that this traditional model is no longer adequate on its own. Some sort of salaried GP service is required to supplement struggling practices, to staff directly managed practices and to provide out of hours care. As well the Bridgend social enterprise is looking at the option of directly employing GPs as a form of new service delivery. This is a welcome development as up to now, most Welsh health boards only saw salaried GPs being employed by independent contractors and regarded their own reluctant involvement in directly managed practices some sort of transitional safety net.

The need to relocate services to a community setting and to improve access is widely acknowledged across many submissions. Many illustrative examples are given. Some such as the use of pharmacists, better home physio and OT services and community re-ablement for respiratory and cardiac conditions builds on well established practice. But other initiatives such as Predictive Risk Stratification Model (PRISM) are being developed to support anticipatory care models while the Inverse Care Law Health checks (which was developed in the Aneurin Bevan and Cwm Taf University Health Boards) are being promoted for national roll-out in Wales.

Social prescribing is also gaining attention as a means for primary care to engage with primary prevention, health promotion and other activities to reduce the chance of becoming ill though the better use of non-medical community assets and to influence social determinants of health locally. Public Health Wales is working to create an evidence base to support this work.

While there is wide-spread support for the development of primary care networks, there are obvious issues that need to be addressed. There is uneven development and engagement both within networks and across networks and health boards. Hard pressed clinicians in areas of high need are most likely to find it most difficult to be fully engaged in these additional areas of work. Local Medical Committees, health boards and Public Health Wales need to carefully monitor the situation to ensure than this does not lead to an inadvertent widening of the health inequalities by ensuring that the areas with the greatest need are not left behind.

With some exceptions (e.g. ABMU HB, Care Council, College of Occupational Therapists) it is of concern that social care has not figured more prominently in the submissions. Social care is crucial to promoting and maintaining the independence and dignity of the most vulnerable in our community. However there are few submissions from the social care sector and there seems little awareness of the need to include social care as a key player in the management of people with multiple and complex problems.

But while there is little specific reference to social care, many of the submissions acknowledge the key role that multi-disciplinary teams (MDTs) will play in the evolution of primary care networks… both in terms of policy formation and delivery. These teams must not only embrace a wide range of primary care clinicians but also include social care. They should also explore ways to have a much more fluid interface with secondary care – as the RCP describes it, we need “hospitals without walls”. By implication, though it has not emerged in the submitted evidence, this would involve some primary care network participation in the wider planning of secondary health care services for their localities.

The absence of a rigid model for networks has many advantages as it allows clusters to develop at their own pace and in line with their own priorities. However the lack of an overall governance framework must create risks that will inevitably emerge as networks evolve and become more directly involved in care delivery.

The submissions to the Health, Social Care and Sports Committee shows there is widespread support and good will for the emerging primary care networks. The evidence suggests that they are evolving in a positive way. However there a are differing levels of maturity with differing levels of impact at a local level. The Committee will publish its own conclusions in time and hopefully its report will provide a further opportunity to consider how things should develop.

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The Welsh Government and the General Practitioners Committee (Wales) have agreed the details of a new contract in Wales

This follows from an earlier agreement between the Welsh Government and GPC Wales to to relax the Quality Outcome Framework requirements until the beginning of April 2017 to ease workload pressures on GPs during the high demand winter months.

 

 

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The defeat of the junior doctors was ignominious, and made worse by a failed legal challenge to the Secretary of State’s right to impose a contract. As the dispute collapsed, senior members of the medical Royal Colleges, who had tried to walk a fine line between supporting junior doctors and ensuring the health service could function, began to speak(off the record) about ‘Generation Me’ – entitled young people who want lots of money but not to work hard, and feel they should have it all. Some hospital managers who noticed how much more efficient their services were when consultants delivered them are wondering if having so many junior doctors is the best option for the NHS.

junior doctors

A new contract has been introduced despite being rejected by many thousands of junior doctors. Important concessions were obtained from the government, but no doubt loopholes will need to be closed and snags removed. Local, hospital level, bargaining will help tailor the new contract to circumstances, and local vigilance by the BMA should counter attempts to increase junior doctors’ hours. Already local payments have been made to juniors losing out under the new contract, and junior doctors’ complaints will be used to identify poorly-performing hospitals. Overall, however, the government achieved its desired re-categorisation of Saturday working as normal working hours, taking it a step closer to 7 day working. It seems unlikely that there will be any further national dispute over junior doctors’ working hours in the near future.

The pressures inside the NHS are building up, as cash-flow crises are averted just in time, and managers struggle to streamline services or just keep up with demand. This is a political dispute that may well overshadow the 2020 general election, but it is not amenable to industrial action within the health service by a section of one profession, and its outcome was never in the junior doctors’ gift. At first sight it seems remarkable that they thought it was. This identification of the needs of some doctors with the needs of the NHS as a whole, and of the public it serves, exemplifies LeGrand’s analysis of medical professionalism as a game of Knights and Knaves. In Knight mode the profession draws attention to its altruism, its central concern with the patient, and its willingness to go beyond the usual limits (including overtime working) to help others. In Knave mode it points out that its altruism will not be sustainable without more income. Much of the confusion in the junior doctors’ dispute arose from this dualism.

Debates on NHS funding will dominate politics up to 2020, but the other problems revealed by the junior doctors’ dispute will not go away, and there are many questions left unanswered. The tensions inherent in modern medicine are the province of the medical and surgical Royal Colleges, whose brief it is to define and nurture professionalism. At the very least systems of mentoring and support for doctors in training need to be invigorated and applied. There may also be a case for a wider debate about the effects of immaterial labour on medical, nursing and allied health professional workforces, all of which have problems of recruitment and retention of staff, and how to ameliorate them.

Do we have in the NHS a high-end precariat, becoming used to less secure employment than their predecessors? If yes, will this be a problem that a future Labour government could solve? Stabilising the medical labour market, perhaps even restoring the old firm system, might be possible, at a price. The price will need discussion, for trading off shorter working hours for less income security may become acceptable to doctors who are, after all, on their way to affluence.

Finally, there is the hapless BMA, defeated repeatedly by successive governments but now facing contract negotiations for hospital consultants and general practitioners. It was intoxicated by the energy of the junior doctors, only half grasping the impossibility of their aims. Now it is challenged industrially by the Hospital Consultants and Specialists Association, which has gained negotiating rights for hospital doctors, breaking the BMA’s monopoly. Will the BMA recover its power?

This is the conclusion of Steve Iliffe’s review of the junior doctor dispute, A tale of three disputes: junior doctors against the government 2015-2016, published in Soundings 64 winter 2016.  A fuller version is available at Health Matters.

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Dr Petra Hanson, of the University Hospitals Coventry & Warwickshire NHS Trust,  chair of the BMA West Midlands Junior Doctors Committee speaking at South Birmingham Momentum meeting 23rd April 2016 about the industrial dispute and the life of a junior doctor.

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