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    It is over 40 years since the Alma-Ata Declaration asserted the crucial role of primary care in the promotion of the health of people world wide. Since then global health policy has attempted to give effect to the Declaration with varying levels of success. The situation has been no different in Wales.

    The Wanless Review in 2003 re-emphasised this message. It stated “ …(t)he current configuration of health services places an insupportable burden on the acute sector and its workforce. This is the most expensive part of the system … (t)he primary care sector in turn is not sufficiently resourced or incentivised to keep patients out of hospital though it is hoped that the new General Medical Services Contract (under discussion at the time of this report) will create such incentives.”

    The publication of the final report by the Welsh Parliamentary Review on health and social care ( January 2018) shows that this still remains the main challenge. In response the Welsh Government has published A Healthier Wales and a Strategic Programme for Primary Care. Both these policy statements will have to be matched by a determined political will if they are to prove successful.

    In 2018 the Wales Audit office stated that “ (b)etween 2010-11 and 2016-17, total health board spending in Wales …. increased from £5.39 billion to £6.32 billion. However, over the same period, recorded spending on primary care as a percentage of total health board spending in Wales ….. reduced from 25% to 22%.This would suggest that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years is not being achieved.” No amount of smart or new types of working will be able to make up for this basic deficit. If primary care is to thrive it needs resources and investment.

    This has been highlighted in the number of GPs working in Wales. Between 2004-05 to 2010-11 the number of GPs rose from 1,800 to 2,000. However since then things have been more or less been static until there was a 4% decline between 2016 and 2017. By way of contrast the numbers of hospital consultants has increased by 40% between 2009 and 2017.

    However these headline figures do not tell the full picture. While there are now just under 2,000 GPs listed in Wales. Approximately 1,500 of the listed GPs were contractors with the remaining 400+ being salaried. However there is a concern that the official statistics do not present a fully accurate picture particularly in relation to the number of salaried doctors. And there are, in addition, a further 750 doctors working in system who are classified as locums or sessional GPs . This represents a 10% increase since 2016 when figures were first collected.

    Vocational training is central to securing a future workforce. The RCGP estimates that Wales needs to have 184 positions to be on a par with the rest of the UK. There has been an increase of 15% in posts over recent years with to 90% being filled but the overall numbers have still to reach UK levels.

    The Welsh Government therefore faces a major challenge to increase capacity in its primary care and general practice service. There is abundant evidence that GP workload is increasing both quantitatively and in its complexity. In response there must be an a substantial increase in the workforce as the Welsh Government itself acknowledges the service is not sustainable if it can only survive by the “heroic” efforts of its staff.

    Non-medical practice staffing levels has increased by over 7% in the last half decade with approximately 2,500 clinical and 5,000 administrative staff now being employed. Despite these increases the RCGP reports that there are still 20% of GPs do not have access to a practice nurse, 35% to a practice pharmacist and 50% to a physiotherapist. This is clearly not good enough.

    The challenge in recruiting and retaining GPs also looms large. Both the GPC and RCGP in Wales still insist that “.. (i)t is a fact that the independent contractor model is best for the patients of Wales and is the most cost-effective option for those who hold the purse strings in both Welsh Government and Health Boards. “ But with 20% of GPs already salaried and with almost twice as many more working as locums and sessional doctors there must an urgent need to review the way they work for and with the NHS.

    The Welsh Government acknowledges that the contractor partnerships will continue to be the cornerstone of general practice in Wales. But it also accepts that this model it is no longer a preferred option for many new doctors. They are not attracted to the business ethos, financial risks, administrative demands, inflexibility and investment costs which go with being an independent contractor. So while the concerns of independent contractors must be addressed there is also a need for a more diverse range of career options for future general practitioners.

    There are some interesting innovations taking place seeks to address this need. The Primary Care Support Unit in the Cwm Taf Health Board has been in existence since 2002. Social enterprise models for care delivery have been adopted in Bridgend and south Powys. But overall they are still too few to achieve the critical mass that is needed to achieve transformational change.

    Somewhat strangely the “GP establishment” seems to fear that health boards and the Welsh Government are rubbing their hands in glee at the prospect of becoming direct providers of primary care services. The reality is almost totally the opposite. There are now over 30 directly managed GP practices in Wales but in virtually every case local health boards have found themselves reluctantly obliged to get involved. This lack of enthusiasm for a public service general practice option must be urgently addressed.

    The Strategic Programme for Primary Care confirms the Welsh Government’s commitment to delivering primary care services through 64 primary care or clinical networks based on populations of 50-100,000. These networks are tasked with bringing primary and social care services together along with the third sector to cater for the needs of their populations. There is a widespread support for this model both politically and across the professions. The Welsh Government has channelled much of its recent primary care investment through the networks to stimulate local innovation and service improvement. Their success to date is a bit mixed and in some cases they have an uneasy relationship with their local health boards.

    Innovation in primary care is also being actively promoted though the £4m Pacesetter / Pathfinder programme which began in 2015 with 24 distinct projects. The objective was to either develop new ways of working or to promote the wider dissemination of new ways of working. The programme received support from Public Health Wales and it is hoped that health boards would mainstream the practice of the successful projects. As these projects come towards the end of their initial phase this is recognised as being critically important. But it has also been appreciated that those areas where services are under the greatest stress are least likely to engage with the exercise.

    The Welsh Government has prioritised tacking health inequalities and asserts “..the fundamental Bevan principle that it is clinical need which matters when it comes to deciding treatment by NHS Wales.” In his annual report 2015-16 the Welsh Chief Medical Officer, Dr Frank Atherton, recognised this in stating “ … we make the case that one-size-fits-all health and care services in the traditional sense may not always be the best approach, as they can maintain, and sometimes increase, health inequalities. Instead we argue for an approach which is proportionate to the level of disadvantage which is often referred to as proportionate universalism.” But Welsh Government policy  is at its weakest it comes to outlining how this is to be achieved.

    Public Health Wales (PHW) has done a lot of work in identifying health inequalities across Wales and profiling populations to clinical network level. It shows that the difference in prevalence of good health between people living in the least and most deprived areas is already apparent at age 0-15. This gap then grows as age increases, peaking in males at age 65-74 (79% in least deprived vs 52% in most deprived) and in females at age 55-64 (84% vs 56%). And it is in these disadvantaged areas where we also find the greatest prevalence of patients with complex multi-morbidity.

    This work by PHW provides an excellent stepping stone for planning the promotion of health and well-being and the delivery of primary care services. But there is little evidence that this is happening on any scale. The Strategic Programme for Primary Care provides a lot of important one-size-fits-all advice for primary care but it only makes the most cursory of references as to how the new, transformed Welsh NHS will address health inequalities on the front line where 90% of health service contacts take place. This is its fundamental weakness.

    Welsh health and social care policy strongly argues for a new approach that will put a focus on prevention, which promotes a social model of health and well-being, seeks to address the social determinants of poor health and which will tackle the stubborn continuation of health inequalities. In many policy areas concrete proposals have been put forward to address this agenda. But there in health and social care the details still need to be outlined and put in place.




    Julian and I were chatting once about heaven and hell, as you do. He didn’t believe in either, but supposing he was wrong, he thought he might be allowed into heaven, not as a believer, you understand, but for good behaviour.

    Julian always wanted to be a doctor in a mining village, partly because his father had been a colliery doctor in Llanelli; partly it was the romance of mining practice as popularised in AJ Cronin ‘s novel The Citadel; but mainly it was the sort of community to which he wanted to belong.

    And belong he did. As Gerald Davies, one of his patients, said in a BBC documentary , Julian wasn’t aloof like the other doctors, the headmaster and the colliery manager. He lived in the village and shared the common experience.

    He wrote about it for medical students, “No one is a stranger; they are not only patients but fellow citizens. From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.”

    Julian loved his patients – not romantically, of course. The opposite of love in this context is indifference and Julian was never indifferent. He hated when bad things happened to his patients, especially when they could have been prevented. In his last 28 years at Glyncorrwg, there wasn’t a single death in women from cervical cancer.

    In his book A New Kind of Doctor, he described a man, invalided out of the steel industry after a leg fracture, aged 42. With no further use for his big muscular body, he had become obese, had high blood pressure and cholesterol, got gout and was drinking too much. 25 years later, Julian described how, after 310 consultations and 41 hours of work, initially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes. He described this as the real stuff of primary medical care.

    At a seminar in Glasgow, we asked Julian what happened next. The man had died, of something else, a late-onset cancer I think, but when Julian told us this, there was a tear in his eye. His patient had become his friend.

    This was Dr ‘art, without an “H”, as known to his Glyncorrwg patients. None of this explains why Dr Julian Tudor Hart became the most famous general practitioner in the history of the NHS.

    In 1961 with large numbers of very sick people, huge visiting lists and a nearby colliery that was still working, the Glyncorrwg practice was extremely busy. His initial base was a wooden hut. It took five years to reach a stable position.

    He was the first doctor in the world to measure the blood pressures of all his patients. Famously, Charlie Dixon was the last man to take part, had the highest blood pressure in the village but was still alive 25 years later. Julian became an international authority on blood pressure control in general practice and wrote a book about it which went to three editions and was translated into several languages, with a companion book for patients.

    What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years he showed that premature mortality was almost 30% lower than in a neighbouring village – the only evidence we have of what a general practitioner could achieve in a lifetime of practice.

    It’s said that behind every great man there is an astonished woman. Behind Julian, was a great woman. When Deborah Perkin was planning her BBC documentary, the Good Doctor, (which we keep showing to medical students and young doctors), I said to her, there is something you have to understand. There’s two of them. Mary was his partner and anchor every step of the way.

    Glyncorrwg was the first general practice in the UK to receive research funding from the Medical Research Council. Mary and Julian had both worked with Archie Cochrane and his team at the MRC Epidemiology Unit in Cardiff where they learned a democratic type of research in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. And so, in Glyncorrwg, there was the Shit Study, the Pee Study, the Salt Studies and the Rat Poison Study, all with astonishing high response rates.

    Julian counted as a scientist anyone who measured or audited what they did and was honest with the results. Brecht’s The Life of Galileo was his favourite play and he often quoted Brecht’s line, “The figures compel us.” Julian didn’t pursue scientific knowledge for its own sake. His research always had the direct purpose of helping to improve people’s lives.

    He had a talent for the telling phrase. His Inverse Care Law stated that the availability of good medical care tends to vary inversely with the need for it in the population served, or more simply, People without shoes are clearly the ones who need shoes the most.

    When Sir Keith Joseph, a Conservative Secretary for Social Services, announced that
    “Increased dental charges would give a financial incentive to patients to look after their teeth,” Julian commented, “The government has not yet raised the tax on coffins to reduce mortality, but Sir Keith is assured of a place in the history of preventive medicine.”

    Julian’s friend and fellow GP, John Coope from Bollington in Lancashire, admired Julian’s nose for what mattered in the published literature. In his book The Political Economy of Health, that magpie tendency was on display, the footnotes comprising one third of the book and worth reading on their own. A Google search could never assemble such a mix. Goodness knows what readers made of it in the Chinese translation.

    He lectured all over the world – in the US, Australia, Kazakhstan, Italy and Spain in particular. Julian could deliver formal lectures but for brilliance and exhilarating an audience he was at his best in impromptu, unscripted exchange.

    When principles were at stake, Julian could argue until the cows came home. In his younger years he took no prisoners. A famous medical professor reflected that he had been called many things, but never a snail.

    Dr Miriam Stoppard arrived in the village to interview Julian for her TV programme, determined to cast him in the role of a doctor who made life or death decisions concerning his patient’s access to renal dialysis and transplant. They battled for a whole afternoon, Stoppard trying to get Julian to say things on camera that fitted her script. He defied her, ending every sentence by mentioning how much dialysis and transplant surgery the cost of a single Trident missile could buy. She went away defeated and empty-handed.

    I was surprised once at Paddington station to see him with a copy of the London Times. He was no fan of the Murdoch press. On boarding the 125 for South Wales, he laid out the newspaper as a tablecloth and over it spread a messy, aromatic Indian carry-out meal. If businessmen in their smart suits wanted to sit next to us, they were very welcome.

    Standing for election to the Council of the Royal College of General Practitioners, Julian topped the poll. What he offered GPs was a credible image of themselves as important members of the medical profession – alongside specialists, not beneath them.

    Julian was humble in himself but ambitious for his ideas. He accepted with ambivalence the honours and sentimental treatment that came with age but he never lost his edge, and if we are to celebrate his life it should be by holding to the principles he held dear.

    The work of a general practitioner is immeasurably enhanced by working in, with and for a local community, for long enough to make a difference.

    Everyone is important, the last person as important as the first, and the work isn’t done until everyone is on board.

    Julian was the “worried doctor”, anticipating patients’ problems, not waiting for them to happen, and then avoiding them by joint endeavour.

    Drawing on his reading of Marx, he saw health care as a form of production, producing not profits but social value, shared knowledge, confidence, the ability to live better with conditions, achieved not by the doctor alone but by doctors and patients working together. Patients were partners, not customers or consumers.

    The NHS should never be a business to make money but a social institution based on mutuality and trust – the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In re-building society, co-operation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.

    My daughter Nuala met Julian many times. Losing him as a person, she said, was like the Mackintosh Building at Glasgow School of Art, burning down. We lost someone dear, a big part of our lives, an institution, a one man “School of ‘Art”, full of life, light and creativity.

    Julian’s gift to us today is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the present challenge of how we follow and give practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us do.


    Professor Graham Watt
    Emeritus Professor
    General Practice and Primary Care
    University of Glasgow


    Last year I told you about a group of 7,000 health professionals who had spent 7 years fighting for their trade union to be recognised by their employer. That campaign has now lasted 8 years. See:

    The Boots pharmacists were the first workers in any sector to challenge an employer through the ballot process described in that earlier article (above).  The law requires not just a majority, but that 40% of those eligible to vote, known as the “bargaining unit”, must vote “Yes” to make a difference.  The result was 87% of those who voted (2,826 pharmacists) voted Yes and that constituted 41% of the bargaining unit in favour.  This passed all the legal tests and the blocking agreement with the “sweetheart” union that the company was using to keep independent trade unions out, was ended by order of the Central Arbitration Committee.

    To emphasise what an achievement that is, if you measure the BREXIT referendum in similar percentages, of those eligible to vote it was just 37% vs 35%, so getting over 40% of eligible voters to support anything is no small achievement. Despite the clear result, the employer has continued to resist pharmacists’ efforts to secure an independent voice at work in the largest community pharmacy multiple chain.  However, in February 2019 the 7,000 pharmacists can vote again in a further postal ballot and this time it will force the employer to recognise the PDA Union

    One of the big issues for pharmacists is the company’s approach to performance management and the union have been hearing from pharmacists about what it means to them.  These quotes from pharmacists illustrate what the PDA Union are trying to fix so that these health professionals can get on with caring for patients.

    “In regards to its pay structure and market based pay it should be ashamed. It should be ashamed for its performance review where no person I have spoken to has any idea what it means to be above performing and where the pharmacy advisors, the people on the front lines get no bonus at all unless they are above performing.

    Nobody knows what exactly they need to do to be “above performing”. Even if you hit all your targets and are green on the scorecard despite those targets being an increase you are performing.”


    “I worked under this regime and it is a terrible way to work. The constant threat of a ‘non-performing’ rating is so demotivating and demoralising and it sometimes felt like a personality contest. I challenged it many times (probably another reason I would never win a corporate personality contest) and was told that even if all targets were met/exceeded you could still be classed as non performing so what’s the point!”

    Ballot papers will be mailed to pharmacists on Monday 18 February and completed ballots must be returned by noon on Monday 11 March in order to be counted.

    Boots directly employs well over 10% of all pharmacists in the country and has many more working occasionally as locums, so this is a significant story for pharmacy, but sadly under reported by the media.  Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

    The PDA Union was established in 2008, it is the only independent trade union in the UK which is exclusively for pharmacists.  It received a certificate of independence in 2010.  PDA Union is a member of Unions 21 and affiliated to the Employed Community Pharmacists in Europe (EPhEU) organisation and a member of Health Campaigns Together.  You can follow the PDA on Twitter, Facebook, Instagram and LinkedIN

    Written by Paul Day, National Officer at PDA Union.

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    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.


    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

    Comments Off on Are GPs referring too many patients? If so, why?

    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.

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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 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.’


    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:


    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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