Category Archives: Doctors

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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One of the constant political backdrops in the months following the general election last May has been the junior doctor’s contract dispute. In essence this is a disagreement over pay and conditions between junior medics and NHS Employers, though it has expanded to become a fight between medicine as a profession and the Health Secretary, Jeremy Hunt. As the dispute has escalated so has the rancour, with some terse and- at times- less than professional comments on social media. For what it’s worth, which isn’t much, I agree with the doctors’ point that the contract seems to be unfair, especially in the way it redefines out of hours payments. I do, however, question some of the junior’s political nous and campaign tactics- which have seemed to lack a clear objective and focus. I’d also add that-since junior doctor’s leaders have been seen on picket lines with the Socialist Worker’s Party and appearing on Russia Today- win or lose, they are going to need a formidable exit strategy. In this current maelstrom, it is not surprising that some medics feel under attack and have begun to retreat into a narrative among themselves that seeks to exclude any outside challenges or scrutiny; in other words the echo chamber of confirmation bias.

It was we these thoughts in mind that I read Partha Kar’s post on his website titled Alternates. I want to explore and challenge some of the points Partha makes about the “uninformed” who seek to offer advice to doctors. Before I do that I just wanted to say that I have a huge amount of respect for Partha, he is one of a new breed of doctor who is trying to modernise his profession and he has done sterling work in transforming diabetes care in his area. With that disclaimer written, let’s move on to Partha’s blog post.

Partha starts his piece by dismissing those that spout “views without basic understanding”, well that’s them sorted! Except that the commentators and “hacks” that he so easily dismisses are- I suspect- policy experts, journalists, managers, patient groups and voluntary & community groups that have a far better understanding of how large systems operate and have the task of looking to the inter dependencies between various settings and organisations rather than just one clinical area. That’s not to say that doctors can’t develop a broad knowledge about the political and socio-economic factors that underpin delivering healthcare- many do- it’s just that it isn’t inherent to their skills and knowledge as medical professionals. In other words; policy makers and managers- among others- have to take a utilitarian approach to healthcare provision, while doctor’s focus on individual best practice. This approach, on the whole, works well and describing one group as “ill informed” is not especially insightful or helpful.

Partha then makes the superficially persuasive analogy between that of fans of a football club (patients) and its manager (the doctor). If only he had read Janan Ganesh’s piece on the rise of Leicester City in last weekend’s Financial Times he may have developed a more nuanced parallel; in the piece Ganesh highlights how a more modern approach to football- particularly in relation to redefining roles and responsibilities within the club- has driven the unfancied team to the top of the Premier League. As a fan of Liverpool F.C, Partha should also know that some football mangers are simply incompetent and it is often that voice of the fans that is instrumental in getting rid of them.

Partha then enters into a long discussion about the changing face of diabetes care in the UK over the past decade or so. I do bow to his superior knowledge here and he is right that policy makers and managers should directly involve clinicians- not just doctors- when developing initiatives in particular services. The success of the Stroke Strategy of 2008- which should be noted had no extra funding attached to it- is testament to this approach. In all his talk of cost and quality however, Partha never mentions the outcome of those two variables’ interplay; namely value.

The changing nature of society- especially the lack of substantial economic growth since 2009- means that we will have to look at the divisions of labour within healthcare and that may challenge some who are essentially rooted in a 1950s model of healthcare, which suggests that doctor knows best. Through all this the notion of value should be our guiding light.

As I have stated, anaemic growth has left us with the challenge of developing and providing high value public services. I believe Larry Summers- Bill Clinton’s Treasury Secretary- is correct when he says we are entering a period of secular stagnation in market based economies, characterised by low growth and shrinking investment. This leaves policy makers with challenges around the payment and provision of public services that will, I believe, mean we will have to pay more in our taxes if we want to see an increased level of spending on healthcare, for example. It will be easier to ask the public for more money if they believe that the NHS is designed to take into account the needs of patients and the public and is not subject to technocratic tribalism, from whatever source that arises.

Partha finishes his piece by warning of excessive arrogance and hubris in healthcare. We are both in accord on that.

First published on Medium

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