Category Archives: Primary Care

The following article was first published in the Camden New Journal on 06 December, 2018

A private company being promoted
by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from the NHS, argue
Susanna Mitchell and Roy Trevelion

The sneaking privatisation of our National Health Service now aggressively threatens our GPs. In Camden and across London, we all need to be aware of the long-term harms this development will cause GPs and primary care NHS services.

Last year, a global multinational corporation called Babylon Healthcare – owned by a former Goldman Sachs investment banker and Circle Health CEO – established a “digital- first” business called “GP at Hand”.

Disastrously for the NHS, Babylon Healthcare Services Ltd can be traced back to a holding company in Jersey, the offshore tax haven.

GP at Hand is contactable through a mobile app which uses standard calculations as a symptom checker. Unfortunately NHS England have not provided our existing practices with this software.

Instead any patient registering with this commercial enterprise will be deregistered from their normal GPs. And, although the GPs employed by the company can also be accessed by video or phone, this process delivers no continuity of care or whole-patient assessment.

Continuity of care is a cornerstone of general practices. However, Matt Hancock, the health secretary says, “If we need to change the rules to work with the new technology then change the rules we must.”

In addition GP at Hand’s own promotion material actively discourages older people from registering. Explicitly these are those who are frail or living with dementia, or in need of end-of-life care. Pregnant women and those it describes as having complex social physical and psychological needs are also discouraged from signing up.

In other words it is “cherry-picking” young and healthy patients who will be more profitable to its shareholders. Its use of standard practice via information technology, and the easy access it offers, is particularly attractive to the young.

Of the 31,519 new patients who have signed up with GP at Hand over the past 12 months, 87 per cent are aged between 20 and 39 years, while patients over 65 now make up just 1 per cent of the population registered with the service.

All this poses serious problems both for patients and general practices. In the first place, our present primary care system consists of GP practices committed to whole-person and integrated care for everyone in their local communities. Healthcare services are organised around geographic areas to enable better co-ordination with hospitals and social services.

In contrast to this, GP at Hand fractures this fair and impartial community-based model, registering patients who live or work anywhere within 35 to 40 minutes of one of the clinics. In addition, should any of their patients require more complex care, they will no longer have their own GP to turn to.

Secondly, by picking the most profitable patients, GP at Hand drains money away from ordinary GP surgeries. Normal GPs are funded according to the number of people on their patient list and this funding is combined into a single budget to provide the services they offer. This means that funding from the roughly 80 per cent of patients who remain reasonably well helps to pay for the 20 per cent who are elderly, who are chronically sick, or have multiple illnesses.

But if the “capitation fee” of the young and healthy is scooped up by a for-profit company like GP at Hand, it will critically undermine the funding available to surgeries. This will leave practices to deal with the sick, the frail and the old on a much reduced budget.

Shockingly this commercial entity is funded by NHS England. It can be commissioned through our clinical commissioning groups (CCGs).

It’s expanding fast, and already has over 35,000 patients. Currently the corporation operates out of five clinical locations in London including one in King’s Cross. Plans for rolling it out nationwide are under discussion. It is also advertised widely, with the health secretary Matt Hancock recently announcing that he has registered with the company.

Future developments in information technology and artificial intelligence that can be useful to our public health systems should be funded directly towards our existing GP surgeries.

It should not be used as a vehicle for profit-making by private corporations at the expense of our NHS.
We need to make the dangers of adopting this business model clear to the widest possible public. We must encourage those who care about our publicly-funded NHS to boycott Babylon’s GP at Hand.

We need to bring public pressure to bear and end this attack on a valued and trusted institution that serves us all.

The NHS has always been for the benefit of everybody. It must be kept that way.

• Susanna Mitchell and Roy Trevelion are members of the Holborn & St Pancras Labour Party and of the Socialist Health Association.

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Nick Bostock reports at GPonline that:

Under-pressure GPs are delivering ‘remarkable outcomes’ on cancer

You can read the complete article here. Nick reports:

GPs ‘can take a lot of credit’ for marked improvements in early cancer diagnosis and reductions in the proportion of cases detected as an emergency, according to a cancer expert.

In the year to March 2018, the proportion of cancer patients who first presented at hospital as an emergency fell to 18.8% – down from 21% in the year to December 2012.

Over roughly the same period, cancers detected at an early stage increased significantly – rising from 46% in 2013 to 52% by mid-2017, according to figures from the National Cancer Intelligence Network (NCIN).

However: GPonline reported earlier this year on research showing that GPs were as good as consultants at making appropriate use of cancer diagnostic tests – and yet pledges to give GPs direct access to four key diagnostic tests – blood tests, chest X-ray, ultrasound and endoscopy – have not been delivered in many areas.

Isn’t it about time that GPs were also given access to the new technology for GP consultations via mobile and Skype? This is currently being ‘rolled out’ by GP at Hand. Here’s a transcript of the R4 Today programme 13 September at 6 mins to 9:00 am (I made this transcript and I believe it’s a fairly accurate job – but any mistakes are mine):

(Int) Interviewer

AP (Ali Parsa, CEO Babylon – parent company that runs GP at Hand)

RV (Dr Richard Vautrey, Chair GP Committee, British Medical Association)

SoS = Secretary of State

 

(Int): So Ali Parsa just explain to us how your App works.

(AP): So, we have a very simple service. So, what it does is allow patients to check their symptoms whenever they want. To make an appointment with a doctor within seconds, to be able to see a doctor within minutes. In fact, I was just checking my App and it says that if I want to see a doctor I can see one at 9 o’clock today, in the next few minutes.

(Int): You mean ‘see’ over the phone?

(AP): Over the phone. And if you want to see somebody physically then, you can go see them that very same day. It is open 24hrs a day, 365 days of the year. And it is available for the same price the National Health Service pays any other GP. What we have done is to solve the problem of accessibility and the continuity of healthcare – using technology and what the SoS and the NHS is doing today is celebrating that and promising it for the whole country.

(Int): And Richard Vautrey, this is something which patients complain about again and again, isn’t it, access to their GP, so is this kind of App the solution?

(RV): We have real concerns, as well as patients do, about the inability of many practices to be able to offer enough appointments and that’s simply because we haven’t had the funding over the last decade to support the expansion of the health service to be able to meet the growing needs of our patients. What General Practices are doing right now is seeing thousands and thousands – if not a million – patients today offering, you know, face-to-face consultations and seeing them in their surgeries, so that’s when patients approach them today. So that’s happening right now. What we haven’t got is the resources to be able to offer some of the IT technologies in every single practice. And the SoS’s commitment to IT is welcome, but we need to see that commitment translated into resources provided to enable every practice to offer this type of consultation.

(Int): But could this kind of technological approach actually help some of the pressure on GPs because people would consult a doctor over the phone rather than going to the surgery.

(AP): Well many practices, if not most practices, already offer telephone consultations. What they haven’t got is the IT kit to be able to offer smart phone consultations, or Skype-phone computer consultations, any many would like to be able to do that, if the technology was provided to them. But the other big difference is that every Practice that is open today will see any and every patient who lives within their area, and we have concerns about the model of which GP Hand has been built, which is primarily about looking at some of the relatively mobile healthy patients and not accepting every single patient who lives within their area.

(AP): I’m afraid Richard that is simply factually not true. We will ask when patients started the service, to ask patients to seek advice if they want to change their GP Practice to our Practice, if they have any clinical issues. Most patients seek advice and join us – we look after them, young, old, sick, healthy, our patients are across the border, and we don’t do that just in Britain, remember we look after one third of the population in Rwanda, and we do so in the United States, we do this in Canada. . .

(Int): But specifically, on this idea of whether you cherry pick patients, it’s likely that patients who don’t have very serious health problems, and maybe younger, are more likely to want to use an App on their mobile.

(AP) . . . but, why is that? If the patient is not very mobile, if the patient is very old, if the patient can’t wait a few weeks to see their GP, they’re significantly more likely to use a service that is continuously available. Many of our patients have mental health issues – they can’t wait for a few days or a few weeks to see their GP. That’s why they switch to us. A thousand patients today will choose to apply to GP at Hand, and then switch their GP Practice – one every three minutes.

(Int): Richard Vautrey, some GP Practices are worried about the fact that if their patients sign up to GP at Hand they then lose that funding, don’t they?

(RV): That’s exactly right. And the way that General Practice is funded at the moment is a balanced mechanism, so those patients who use the service less, and there are many patients that use the service more, and that overall, that compensates one for another. What we have concerns about is that this would effectively replace a personal service with an anonymous call centre and patients don’t want that.

(Int): And finally, Ali Parsa, this was something that commissioning groups in Birmingham were worried about and that was clinical safety – isn’t it better to see a doctor the next day.

(AP): No, it wasn’t clinical safety, you do see a doctor, not a call centre, face-to-face on your mobile and then see one in one of our surgeries. We will open up across the country physical surgeries, their issue was not that. It was an IT hitch that doesn’t allow its screening to be done with your local hospital and that IT hitch has been fixed. This is the future, and I encourage more and more patients to join it.

(Int): Okay thank you both, we’ll leave it there, let us know what your think via twitter.

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  1. Pressure to not admit  people –  fair enough – but can be overdone and mean people are not admitted who should be
  2. Bad experience  esp for elderly frail in hospital, especially A&E,  so they wont go back even if that seems the best  course for them
  3. Lack of capacity in emergency social care – so people  have to be admitted as there is no where else for them to go
  4. Lack of community social care so people end up stuck in (sometimes dying in) hospital when they  would rather be out
  5. Slow response of  social care from council  so that  realistically most of our referrals for social care  are emergency ones
  6. Ambulance service overwhelm so that sometimes people  wait for  hours on the floor  or even with chest pain and  we get called to cover 999 calls they can’t get to
  7. Housing crisis- I  dictate  1-2  letters a  day re people’s  problems
  8. Stress and anxiety caused by benefits  reviews and assessments. We don’t have a great deal of input strangely now into the original benefit application  forms so we tend to only see the fall out eg the distress in anticipation or  after the assessment
  9. The common finding that at review benefits assessments are reviewed in favour of the claimant but financial issues common whilst in the process of assessment
  10. Consequent low morale in the medical ( and other associated professions ) associated with the sense of failure to deliver adequate care  when resources  do not permit ,but where provision of adequate care is seen as a personal / practice responsibility
  11. Increasing complexity ( age new treatments etc ) and increasing cohorts  with multiple morbidity /  age  – but no increasing resource to adequately serve that need
  12. Short sighted  cost cutting choices – eg  health visitor numbers  district nurse numbers  GP numbers – all below full complements –tendency for the loudest voices to be heard and consequent further entrenchment of the “ inverse care law”
  13. Removal / scarce resources for independent  housing/benefits  advice – bht are  good. CAB now very hard to get appointments  – but my experience is  successful benefits  appeals  need you to be very switched on or have  support from  an organisation with experience of what “ boxes to tick”

First published by the War on Welfare blog

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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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1) Holistic care:

Mental health and social prescribing services are doing their best in our practice area but are massively under resourced. Don’t forget the critical importance of valuing continuity and teamwork in the primary care team – really important for safeguarding, morale and retention of staff. See Watton in BMJ, especially around Health Visitors and District Nurses within practice teams. Same points apply re social prescribing / CSW / Health Trainers

Due to the clear correlations between deprivation, psychosocial problems and physical health, it is a false economy not to invest in mental health and social prescribing as ultimately patients fall back on more expensive NHS services. Many of our patients are illiterate or have poor health literacy and so patients often fall through the gaps of traditional appointment systems with letters and phoning back to make appointments even if they are in the correct age range (which many are not as they are too young or housebound). Many of our patients are struggling due to being victims of emotional, physical or sexual violence: their anxiety can be displayed as anger or addiction.

Improving Access to Psychological Therapies

It is fantastic to have IAPT counsellors in the building (as you know many patients do not attend other sites) but due to the constraints they are working under often our patients living in the most deprived area of Sheffield do not fit the criteria as they can be chaotic or ‘not ready’ for the emotional challenge of counselling.  I wonder if a more flexible type of approach could be taken, many of our patients need to build up trust with professionals over serial encounters before being able to engage – the IAPT triage service doesn’t allow for this, sadly. 

Groups or lectures are on offer around the city but our patients struggle on many levels to attend these due to poor self esteem, confidence and practical issues such as buses, school pick up and travel costs.

I also wonder if a ‘trauma therapy’ approach may be more useful for our patients as I heard about this from another Deep End GP in Glasgow.

In summary there are great counsellors and charities working in our area doing outstanding work beyond their resources but it is insufficient due to the massive need on the our, patients fall through the cracks and this perpetuates poor health and greater pressures on NHS services. Investing more to support mental health services and social prescribing feels right on a moral and financial level to reduce inequalities.

 2) Families and Children:

The links between early childhood experience and brain development has long been known and the field of epigenetics is emerging.

The local family planning clinic has been closed. We predict that unwanted pregnancies will go up in our area. We think investing in sexual health and contraception services, educating girls and women would help inequalities. Early years are crucial yet we have had the team dismantled – the overstretched health visitors are no longer in our practice. When I was a trainee in 2002 the health visitors knew all the families and who to worry about, came to all the practice meetings and we also debriefed over the kettle (a very underestimated source of support and sharing ideas and information!).  Not having the health visitors in our practice feels like a serious threat to safeguarding.

My suggestion would be to get the health visitors and district nurses back in the practices and integrated in the teams – we need more of them too! We need more support to provide contraception, sexual health services and parenting sessions.

3) Multimorbidity & Complexity: 

Again the links between deprivation and complex medical problems and multi morbidity at a young age have been proved and we need help to support our patients with these.

There has been a fantastic collaboration at The Whitehouse for many years between Prof Heller the diabetologist and the primary care team; once a quarter Prof Heller and his specialist nurses come for lunch and a cuppa at the practice and the Multidisciplinary team present our patients with Diabetes for a case discussion. These are complex patients who often won’t attend hospital outpatients. This opportunity of case discussion is so valuable on many levels. It builds personal relationships between primary and secondary care which allow a 2 way flow of information, education and morale essential to providing high quality care to patients. Our patients are not only suffering serious physical problems but the case discussion also allows us to acknowledge their complex lives and histories.

We have also been lucky enough to be part of a pilot with joint clinics between a Paediatric Registrar and GP trainee: this has been shown to reduce out-patient appointments and again develops supportive educational relationships.

We particularly need help with patients who have persistent pain and addiction to prescription drugs – experienced physiotherapists who are aware of issues surrounding deprivation would be a real asset to decreasing inequalities, as this could improve people’s chances of getting back into work and improve quality of life.

More educational cased based discussions between primary and secondary care specialists are fantastic educational opportunities and are invaluable to give the best patient care: Could we have more specialists coming to the practice like Prof Heller? It must be cheaper than running an out patient clinic and studies show that it does reduce referral rates and improve the quality of referrals.

4) Lifestyle: Smoking and getting more active.

We would like our stop smoking service back in the practice! Patients are reluctant to go to the ‘pharmacy’ for this, even though it is relatively close by.

We have recently been in discussion with SIV to see if our patients can have more support in our practice building to get more active and build confidence to going to other venues with someone they trust. The barriers to exercise are complex: one of my patients has flash backs to being raped by her brother and father when her heart rate goes up; another after being raped wanted to make herself obese so no-one would ever fancy her again.  Our patients need kind, broad shouldered, flexible and good humoured health trainers to overcome these barriers.

Health trainers working in house with physios would be really helpful to reduce inequalities.

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Demand has grown for the Ambulance Services by 35% since 2010. While the government announce that the budget has seen a 16% increase in budget since 2010 (National Audit Office, 2017), in reality matching inflation counts for 12% of this increase. This demand is not predominantly the ‘living longer effect’: while that of course does play a part, aging is largely a predictable variable and with effective planning could have been corrected for many years ago. The increase in demand comes largely from four areas: undifferentiated urgent care complaints; failed secondary care; mental health problems; and social care problems. All the above have occurred as a response to the cuts seen in Primary Care, Hospital, Mental Health and Local Council budgets. In this first of a series of articles, we will focus on the effect of cuts to primary care and the shift from GP provision to Ambulance provision as a result.

Ambulance services

Ambulances outside the Accident and Emergency Dept

During this article, I will refer to urgent and primary care interchangeably. This is because the classification for ambulance is ‘urgent’, where many of these patients should be managed in primary care. Many of the concepts of which I speak here are not the subject of research. I have linked to evidence where possible, but much of what I say comes from personal experience, and from talking to other ambulance clinicians around the country.

The Ambulance Services used to deal with, largely, emergency care. The perception of this remains, but it masks the true nature of today’s Ambulance Service. A mobile GP surgery, with none of the equipment, training or support. Older paramedics reminisce of days gone by where they only went to “genuine calls” – heart attacks, respiratory problems, road traffic collisions and cardiac arrests. Today, these make up only a small percentage of call outs. Today, we go to a variety of calls from mild belly ache, urine and chest infections to “baby won’t settle”, months-old complaints of back pain and other primary care conditions.

While this may appear on the surface as misuse, and therefore an issue of public ignorance towards the severity threshold for a 999 call, as many clinicians and social media users alike will propose, there are underlying processes at work that socialists must examine.

Many patients will talk on crew arrival of the immense difficulties they have undergone to try to get an appointment with a GP, only to either be instructed to call 999 as the surgery, under immense pressure themselves, are unable to assess the patient within a safe timeframe, or to be told the nearest appointment is in 3 weeks, to which many concerned relatives will see no choice but to seek a quicker assessment – and none are quicker than the ambulance service, despite increased waiting times. Others have been referred by the 111 service which has a notorious infamy amongst ambulance clinicians for referring a large number of false positives – and missing false negatives.

Some may reply that if Ambulances are sat around waiting for emergency calls, and GPs are overstretched, then we should be available to help. While I shall deal with the issue of the need for a ‘reserve’ within the ambulance capabilities later on in this series, it is also important to examine how we deal with these primary care cases.

At no point do Emergency Care Assistants, Emergency Medical Technicians, Associate Ambulance Practitioners or even Paramedics receive training in the management of urgent or primary care cases. Our guidelines make no provision for it either. Our assessment training only covers so far as to identify conditions that fall under the Emergency remit (Strokes, heart attacks, pulmonary embolisms etc.). Due to the lack of training, many do not have the confidence to make decisions on primary and urgent care cases, fearful of missing an atypical heart attack or other hidden emergency condition and such like. Alongside the perception of lack of support from employers and regulatory bodies (which does not always align with the evidence), this leads to an inordinate number of conveyances to A&E “just in case” – and not always in the patient’s best interest.

Our assessment equipment, again, is tailored to emergency situations – electrocardiograms, blood sugar tests (in case of an unconscious diabetic), oxygen saturation probes – and we lack the necessary equipment to make primary care decisions. For example, “Dipping” urine is a very simple skill, no more difficult than a litmus test or an old pregnancy test, such that relatives and patients are sometimes taught to use it. However, paramedics are unable to “dip” urine, with no explanation given (one can only assume a cost factor), needing for us to rely on District Nurses, GPs and A&E to conduct the urinanalysis, delaying diagnosis and treatment for a common elderly condition, which can progress to life-threatening sepsis if left untreated.

Not only this, but we carry only enough medication to prolong or save life in emergency situations – adrenaline, salbutamol, and morphine among others. Even if we correctly assess the primary or urgent care complaint, we have no management tools. We carry no long-term antibiotics (and maybe for good reason with a view to antibiotic resistance, but it has implications if we are to respond to these jobs). We can offer nothing for long-term pain management (only enough to move an in-pain individual to hospital). Again, with GPs unable to fit in appointments, this leads to a large number of conveyances to A&E as ambulance clinicians (rightly) view it as unethical to delay treatment, even if A&E are over-stretched.

The biggest problem caused by ambulance response to primary care is the lack of emergency reserve. I personally have heard so many calls from the Control Room pleading over the radio for someone to make themselves available to respond to hyper-time critical emergency events like choking, fitting or cardiac arrest, because the closest crew is 20 minutes away being drafted in from another city. Amongst other causes of increased demand (mental health and social care), this is because closer ambulances are dealing with primary care conditions. A major source of stress for ambulance clinicians is knowing you’re only a few minutes away from a time-critical emergency, but being unable to leave the primary care patient you’re currently dealing with.

However, there are advantages that are appearing as the ambulance profession absorbs primary care into its remit. An obvious example is care for patients who are unable to leave their home due to current or past medical conditions or their age. Traditionally dealt with by visits by their GP, these patients are left without care out of hours (except by out-of-hours GP visits) and struggle to ever be seen by health care professionals due to cuts to both in-hour and out-of-hour GP provision. A more detailed argument would be required by someone with experience in GP Primary Care provision dealing with whether home visits are an efficient and appropriate use of a GP’s time (as opposed to other HCPs). Ambulance clinicians are traditionally mobile and used to working in people’s homes, and are now used to dealing with some primary care complaints, could be one alternative. Before the Ambulance Service merger, Staffordshire Ambulance Service conducted GP Home visits on behalf of many surgeries, and provided the out-of-hours provision. This was backed up by training, good local working relationships, equipment and a more advanced management portfolio than the one provided to clinicians in the same region now.

Another advantage is that paramedics are more regularly exposed to emergency patients than GPs, which gives them skills and experience that would assist GP assessment and to start the pre-hospital management of emergency care. One example of such a skill is that paramedics are fast becoming experts in 12 Lead ECG interpretation, and with this skill being almost routine, paramedics would be well placed in GP surgeries to provide an additional experienced opinion. Cardiac arrests are an uncommon occurrence within a GP surgery, and no matter how well a clinician knows the theory and has memorized the protocols, the management of this condition is difficult out of hospital, especially for clinicians who don’t have regular exposure to it. This is another example where ambulance clinicians who have a lot of real life, hands on experience with out of hospital cardiac arrest, would help primary care providers deliver effective care.

The two competing processes of dealing with urgent care and emergency care represent a tension that at times, such as winter, represents a crisis. In simpler terms, Ambulance Services struggle to provide a timely response to emergency care by being tied up in urgent care, and, as society’s last line, leave urgent patients without access to care due to dealing with higher priority requests (e.g. reports of elderly ladies left on the floor for hours).

So, what is the solution?

First and foremost, GP surgeries require sufficient funding to make sure no-one waits an unethical amount of time for an appointment. If Ambulance clinicians are to respond to primary care calls, clinicians should receive the correct training, equipment, management tools and support from GPs to provide the right care to the patient.

However, no amount of amelioration will resolve the contradiction. One set of resources balancing the two types of care will always be only one disturbance from crisis, no matter how well balanced it may appear.  What is appearing as the most fundamental requirement of any solution is that exclusive pools of resources to deal with each category of demand is required.

To achieve this, Emergency Ambulance Services should not take responsibility for responding to these primary care/urgent calls, and responsibility should pass to another group of resources. Possible splits could be for emergency care to pass to the fire service, or for urgent care to be taken up by the 111 service. It would also be possible for a split to occur within the ambulance service, much how the Patient Transport Service or the High Dependency service operates separately from Emergency care.

However, my suggestion is instead for non-emergency ambulances staffed by specialised urgent/primary care paramedics with the necessary equipment to be attached to individual GP surgeries, with a good working relationship with the surgery staff, that can carry out home and urgent visits at all hours. For clinical governance purposes, they could be managed by a national non-emergency ambulance organisation, while being paid and employed by the GP surgery.

The reasons I believe this to be the correct solution are:

  • Continuity of care for patients with acute exacerbations of chronic conditions, which is good for both the patient and helps clinicians make good decisions
  • Ambulance Crews are able to access a patient’s medical records to make informed decisions
  • A good working relationship between ambulance clinicians and GPs is difficult to achieve in many urban areas, due to the large number of regionally employed ambulance crews and the multitude of localised GP surgeries, however, one must only look to community paramedics based in rural villages and their relationship with the local GPs to see the increased benefit for the patient and the wider NHS.
  • A clear delineation between Primary/Urgent GP care, Emergency Ambulance Care and Secondary Care, where currently the lines are currently very blurred, allowing for correct training and equipment.
  • An embracing of the advantages of ambulance clinician primary care

The Socialist Health Association should oppose any attempt to load further primary or urgent care on to Emergency Ambulance Services – either directly, or indirectly through further GP cuts. The SHA should recognise the internal contradiction and its effect on patient care, and to call for primary care provision to return to GP services, allowing emergency ambulance services to have crews available to respond to true emergencies. However, the SHA should embrace the positives of mobile primary care response units and the unique experience of ambulance clinicians and call for ambulance clinicians to become more involved in primary care provision in GP surgeries through a number of possible mechanisms.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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Now the Labour Party’s objectives for the NHS are clearer, the real politics begins. If May’s government collapses, as looks increasingly possible, Labour will need to project its tactical policies for the NHS forcefully. The plausibility of how it plans to cope with the winter bed crisis will matter – what will the £500 million promised be spent on? How will a Labour Secretary of State for Health manage delayed transfers of care?

If May’s government survives Labour will have to live with Hunt Supremacy for a while longer, and will need some practical ideas. Two events in the last week offer some possibilities; the King’s Fund report and webinar on the development of an accountable care organisation in the Canterbury region of New Zealand, and John Appleby’s review of PFI in the NHS, published by the Nuffield Foundation.

Canterbury Tales

The Canterbury story was explained in the webinar by two leaders from the District Health Board and a large GP federation. They described the situation a decade ago in terms familiar to anyone in the NHS; clinicians trying to integrate a fragmented system but often inadvertently working against each other; hospital gridlock; and a common feeling that if only other people would sort themselves out, all would be well.

Creating an integrated local health service required investment in general practice, starting with the organisation of out of hours services, and growing collaboration around care pathway developments, not structural changes. Resources were created for GPs to support their patients in the community more easily, and hospital admissions declined. Effort went into relationship building, influencing the private provider organisations (the majority) and letting go of history in which grievances were prized possessions. Making the process of change clinician-led and management- enabled stabilised the primary care workforce, avoiding the problems we currently have. The leadership of the changes avoided consultation, with its undertones of decisions already made elsewhere, and sought dialogue. Likewise, debates about funding and contracts were postponed because early exposure to them demonstrated that nothing could change. Realistic timescales were sought – no quick fixes. The integrated system works on the basis of not wasting people’s time (patients and professionals) and stressing its operational principles of “no wait, no harm, no waste”. The cancellation of a single elective procedure because of emergency care counts as failure.

PFI Revisited

John Appleby dissects the scale, size and costs of NHS PFI schemes, which vary enormously. He concludes that it is not necessarily the case that PFI scheme were poor value for money. Early schemes were not always good deals, but as the NHS gained more experience of PFI it negotiated better terms. Tees, Esk and Wear NHS Trust, which has paid off one PFI scheme, judged that its more recent schemes were good value and has left them in place.

A Labour Government could find ways to end PFI schemes early but the question is at what cost and opportunity cost? Would such repayments be money well spent, or could they provide more benefit if spent on something else? The drive for PFI has weakened. Seventeen new PFI schemes were expected to reach final construction in the NHS between 2011 and 2018, compared with 92 in the nine years from 2002. This may change again. Trusts needing to increase their capital budgets have been encouraged to open new PFI projects rather than borrow money directly. This will create some challenges for Labour, whether in office or in Opposition.

Appleby, J (2017) “Making sense of PFI”. Nuffield Trust explainer. www.nuffieldtrust.org.uk/resource/making-sense-of-pfi

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This is a discussion document not agreed policy.

The SHA is concerned that general practice under the Tories may go the way of dentistry and optometry. The SHA aims to eliminate the private sector except in exceptional and transient circumstances.

The SHA wants to see improved access to primary care for both acute and chronic care. We are keen to maintain continuing personal care. This will require significant increased funding for clinicians in primary care. The government’s proposals are too little, too late. They have resulted in immense frustration with GPs threatening industrial action for the first time. The SHA recommends reassessing many aspects of the current arrangements for general practice to reassure and energise primary care. This should include boosting numbers of clinicians and making the most of opportunities afforded by information technology.

The SHA does not support GPs being responsible for planning although they must be centrally involved, alongside other key stakeholders, in local planning decisions.

Independent Contractor status:

There are advantages and disadvantages to the independent contractor status. The SHA would recommend a trial of a mixed economy, where in some areas, primary care is salaried and in others as it is now, the benefits and risks to be evaluated. One option should include one of the current New Models of Care (NMC), that under which hospitals run some general practices. It is unclear whether this will lead to improvements or more problems and such a move needs evaluation before any decision about permanence.

In some areas where there are difficulties in sustaining general practice, we may need a directly operated model, employed by the NHS. The franchising arrangements for primary care must always include clear national standards.

Planning Primary Care

The SHA sees that primary care must be planned and managed rather than just administering it which is the present predominant model.. One of the outcomes should be a more consistent quality of primary care. How to best manage primary care must be discussed with primary care, but as with the rest of the NHS, we would expect national standards with local delivery.

The SHA recommends primary care workforce planning and joint multi-disciplinary training where appropriate.

We should have a large-scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care, for a single County or City. This should include social care free at the point of use. This could include GP practices collocated with other services, including hospital services; a strong focus on intervening in the social determinants of health. All to be under national standards.

Clinical developments

Care plans for all patients, jointly written and jointly carried out.

The SHA notes the connection between psychological problems in children and young adults and mental ill-health in later life, and supports investment in

  1. community-based programmes to identify and support children and young adults with depression, anxiety and other psychological disorders, and
  2. research efforts to identify the best approaches to reducing psychological distress in this age group.

The SHA understands the difficulties of changing the health of the population and so encourages Labour to commit to a long-term plan for health promotion, preferably coordinated by a national arm’s length health promotion agency. This needs to include ways of engaging ‘hard to hear” groups and approaches to healthy community development.

We would like to see Labour commit to:

  • promoting specialist medical and nursing care closer to home.
  • prioritising innovative ways of running ‘Hospitals without Walls’, where specialists and generalists work alongside each other in community settings to improve outcomes for patients, enhance generalists’ skills and contribute to specialist training.
  • prioritising the development of 24/7 ‘Hospital at Home’ services for admission avoidance, early discharge and rehabilitation, in parallel with all acute Trust hospitals.
  • investing in the expansion of community nursing services and other community-based specialist services to create stable ‘Hospital at Home’ services. Also investing in social services’ input to ‘Hospital at Home’. Decisions about clinical responsibility for ‘Hospital at Home’ services to be made at local level, but a budget to be provided for an expansion in the numbers of community geriatricians

The SHA notes the underdeveloped and underperforming state of falls prevention services in hospitals as well as in the community, and recommends investment in community-based programmes to identify people at risk of falling and encourage them to take up preventive services (like exercise promotion classes).Community care

The SHA wishes to see community care in both the health and social care sectors adequately funded and skilled.

The SHA does not recommend wholesale focus on community care as a means to avoid acute hospital admission. The evidence is weak. In the current climate of austerity, it becomes a way of cutting hospital beds even further. However, there may be a case in those areas where particular pathways make it particularly appropriate to shift hospital work into primary care.

We want to see resilient out-of-hospital solutions for the care of older people, including increased recruitment of GPs, District Nurses and Health Visitors. One example that needs evaluation are Older People’s Assessment Units and extended primary care.

THE MYTH OF THE DEMOGRAPHIC TIME BOMB

The SHA rejects the concept that an ageing population results in unacceptably high costs. On the contrary, we are proud that we have an increasing number of older people whom we value.

Older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years. Increased life expectancy means more years lived in good health.

Older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

It is not age but nearness to death that accounts for health expenditure. Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

It is those dying between the ages of 50 and 60 who cost the most.

Old age dependency has fallen substantially in the UK and elsewhere, when measured using remaining life expectancy. It is likely to stabilise in the UK close to its current level.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ If the cost of death declines with age then an ageing society could lead to lower health care costs.

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’

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The latest idea from NHS England has got doctors really angry – and it takes a lot to do that these days, given the familiarity of relentless attacks on the profession and the health service itself.

NHS England are to ask CCGs to put every referral from a GP through a new vetting process before they reach the specialist they were intended for, according to a leaked memo of the secret plans. The term for this is ‘referral management’ (there are a few exceptions to this scheme, like urgent or suspected cancer referrals).

Since 1948 GPs have been at the front line of NHS healthcare. Every UK citizen has the right to register with an NHS GP and that GP is the first port of call if you are unwell or feel worried about your health. Often your GP would undertake further tests or investigations to try and diagnose the illness you presented to them. Sometimes it isn’t possible to confirm a diagnosis and your GP would decide to refer you on to a hospital specialist for their opinion, further investigations and / or advice and treatment.

So why is NHS England saying that all such referrals now have to be second-guessed by a panel who haven’t even seen the patient – with the suggestion this scheme could reduce referrals by up to 30%?

In today’s NHS these referrals have pound signs attached to them. Every GP referral is seen by NHS England as another burden on the NHS budget and they are now looking at ways to reduce those referrals to hospital doctors. NHS England focuses on the pound signs but seem to forget that behind those referrals are real people with real problems who have already seen their GP, often many times, and in need of the help of a hospital specialist.

The former head of the Royal College of GPs, Maureen Baker, said in responsethat she is “concerned about the patient safety implications of referral management” and asks “what – if any – risk assessment has been done?”

Hospital doctors are also deeply concerned, with the President of the Royal College of Physicians saying “Vetting GP referrals to hospital is disempowering. There must be better ways to reduce outpatient attendances.”

The BMA spokesperson, Dr Andrew Green, is similarly scathing: “We are used to seeing un-referenced claims such as ‘could reduce by up to’ in adverts for anti-wrinkle cream and I am surprised to see such language in an official document.” And he adds “It is important to be aware of the lost-opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce, GPs we don’t have.” 

But the loss of GP time in vetting the referrals is also lost on NHS England, it seems.

We live in a country that is the 5th richest in the world  and has an NHS that is the envy of the world despite funding shortfalls that have pushed it close to collapse.

Usually restrained commentators are now raising concerns over this new scheme. Jeremy Taylor, CEO of National Voices, a coalition of health and social care charities, tweeted “Has NHS England consulted anyone? Eg have any patients or patient organisations had any say in this?”

Rather than face up to the criticism, NHS England seems to be hoping that if it fudges things enough, the storm will blow over. NHS England have their own ‘media’ twitter account (@NHSEnglandMedia) to highlight issues and rebut adverse publicity. On 29th August, the media account was concerned enough to tweet on this hot topic.

Alongside a shot of the Daily Mail front page headline ‘GPs told to slash hospital referrals’ the NHS England media account  claimed that it was‘Inaccurate nonsense from tomorrow’s Daily Mail’. In another sign of their sensitivity about this issue they even managed to get a rapidly published ‘clarification’ from the Daily Mail – something that some might see as harder than getting blood from a stone. The article published just 2 days later read:

Clarification

But this claim feels like a frantic fudge from NHS England’s PR team. Despite numerous requests (including from myself and other high-profile experts), NHS England themselves have pointedly refused to explain publicly how GPs will ‘retain final responsibility’, overturn decisions if there is disagreement, or avoid delays. Many have pointed out that the experience of GPs in areas where ‘referral management’ has already been introduced, is that whatever the spin, these schemes do, in reality, override the GPs decisions.

Dr Steve Kell, former co-chair of NHS Clinical Commissioners is one of those expressing concern. He tweeted “Making schemes mandatory is new – we’ve never had one. Lots of twitter noise but no actual guidance yet. Hope someone is watching.” In response to his question “So can we refer BEFORE the referral is reviewed?” NHS England Media account merely replied “We will check for you. Please can you DM your contact details”. Kell is still asking questions, including “what about…right to a second opinion and confidentiality?” so we can assume he’s not satisfied.

The foundation of the centuries old doctor patient relationship is one of trust and this is why doctors remain one of the most trusted professions in the UK. For patients to find out they have been denied treatment will make them wonder about the reasoning for this. As Professor Martin Marshall, Vice Chair of the RCGP, said in a statement “our concern is that these schemes can undermine the important trust that exists between GP and patient.”

As things stand now if your GP feels you need a consultant opinion they will sort this out for you and an appointment will eventually arrive on your doormat. Under the new system the GP will not be sure if their referral will get through the ‘vetting process’. Highly trained GPs with years of experience will have to cross their fingers that their referral gets through the system. They will not be able to say to you in the consultation that you will definitely get an appointment. Its yet another stress and burden for GPs – many of whom are leaving their profession in droves. The stress for patients will be evident too and it will raise suspicions by the patient if a GP says ‘I don’t think you need to see a specialist for this problem’. If your referral is knocked back will you wonder whether your local NHS is trying to save money from its already stretched budget?

And in the long run the measure is likely to be entirely counter-productive. As Kailash Chand OBE, honorary Vice President of the BMA, says “if people are denied hospital treatment, then their health will invariably be compromised…In the long term, this measure will therefore end up costing the NHS more money and waste further time”.

GP and assistant medical director of NHS Wales Sally Lewis agrees, blogging that these ‘referral panels’ will “create a laborious bureaucratic exercise” and “be completely ineffective at managing demand into secondary care” and concludes: “In the final analysis, all referrals are generated by unmet patient need. Let’s figure out how to meet that need properly and not just put up the hand. Computer says no.”

GPs need to speak out about this latest idea from Whitehall and patients need to write to their MPs to tell them they want the NHS to be funded adequately for the care they need and stop inventing new ideas to prevent their necessary care.

More and more cuts to care are occurring and we must fight back or the NHS as we know it will be lost for good.

This was first published by Our NHS

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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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The Public Accounts Committee report on patients’ experience accessing general practice medicine says the Government is pushing ahead with extended hours plan without real understanding of issues.

Concerns persist over patient access to GPs

In March 2016 the Committee reported concerns that patients’ experience of contacting and accessing their general practices varied significantly between different groups of patients and between different practices. One year on, these concerns persist.

The Department of Health (the Department) and NHS England have objectives to improve and extend access, and have made some effort to understand the demand for this extended access, but they are moving ahead in rolling out extended hours without really understanding the level of access currently being provided or how to get the best from existing resources.

Overall number of GPs reduced in last year

Last year they also expressed concern that staffing in general practice was not keeping pace with growing demand. Despite the government’s target to recruit 5,000 more GPs, the overall number of GPs has reduced in the last year, and problems with staff retention have continued.

Health Education England has increased the number of trainee GPs recruited, but still did not manage to meet its recruitment target last year. NHS England and Health Education England have several initiatives in place to boost recruitment further, to make better use of other staff groups, and to ease workload and encourage staff to stay. However, they are pursuing these discrete initiatives without a credible plan for how to develop a cost-effective, sustainable workforce.

Full report

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Wales was the first health service in the UK to abolish prescription charges in 2007.  The NHS in Scotland and Northern Ireland subsequently adopted the policy.

The following article, written by Welsh Cabinet Secretary for Health Vaughan Gething, initally appeared in the Western Mail newspaper:-

 

 

This weekend we marked the 10th anniversary of free prescriptions being available in Wales.

 

When we took the decision to abolish prescription charges back in 2007 it was in light of evidence that some people with serious chronic conditions, such as high blood pressure or heart disease, could not afford their prescriptions so chose to have only part of the prescription dispensed.  This reduced the cost but meant some people were going without medicines they needed to keep them well.

 

It is for that reason we chose to make a long-term investment to improve people’s health, and since then, prescription medicine has been provided free in Wales.

 

All patients registered with a Welsh GP who get their prescriptions from a pharmacist in Wales are eligible. But the GP is just one of a number of frontline clinical experts able to prescribe medication. Others include pharmacists and nurses: prescriptions issued by these are also free of charge.

I’m proud that we were the first of the home nations to take the step to introduce free prescriptions. I’m delighted that both Scotland and Northern Ireland followed our lead.

 

We firmly believe by providing people with the medication they need helps to keep them well and out of hospital, thereby reducing the overall cost to the NHS.  It should never be the case that people with serious chronic conditions can not afford to collect their prescription.

 

Some have called for the reintroduction of prescription charges, but I simply don’t agree that is the right way forward.  That said, our free prescription policy does not mean people should expect to have whatever they want prescribed by their GP; clinicians must make the right decisions about when and when not to prescribe.  Where a medicine offers little or no clinical benefit it should not be used, this isn’t about free prescriptions it’s about good clinical practice.

 

Prescription charges and the system of exemptions which persist across the border in England are poorly conceived, illogical and manifestly unfair to some groups. 

 

The re-introduction of charges would require the development of a new, fairer system.  To maintain such a system would require a costly framework for determining who should not be charged, who may be exempt from charges and who may be entitled to full or part remission of charges

 

The costs associated with administering this fairer system and then safeguarding that system against misuse would reduce significantly any potential income derived from the re-introduction of a charging regime. 

 

It would also negate the very real health benefits we believe Welsh citizens gain by removing ability to pay as a key consideration when an individual takes their prescription for dispensing.

 

So let’s be clear, the Welsh Government has no intention of reintroducing prescription charges.

 

Ensuring patients have the medication they need not only improves their own health and wellbeing, it also benefits the health service as a whole by reducing hospital attendance and placing fewer demands on general practitioners.

 

Free prescriptions are progressive and an integral part of our health services in Wales. I believe it is socially irresponsible to charge people with serious chronic conditions for the medication they need.

 

Health Secretary Vaughan Gething

 

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