NHS Phrases No longer in Use?

As the NHS and general practice continue to change and develop just like Britains lost railways there are phrases like railway lines in use say 20/30 years ago that are no longer in common use or whose relevance is no longer significant.

Convenience to Patients

GPs were once encouraged to provide appointments that were ‘convenient to patients’. This meant that appointments should be available throughout the working day. Whilst so called regular appointments might need to be at times when patients are not at work or at school, patients ought to expect to attend an urgent appointment at any time of the day. I recall one mother complaining that she had been offered an urgent appointment for her child at 8:45am – she said it was not convenient as she was taking her children to school. I assumed that the child’s health was less important than taking the child to school. Now is that a reasonable view of convenience!

Reasonably Spread Over the Working Week

The phrase ‘reasonably spread over the working week’ related to the spread of sessions Monday to Friday at a time when few GPs worked part time.  Many doctors still take a half day and close at lunchtimes. The half day has a long history that goes back to the Shops Act of 1911, which introduced the early closing day.  Nowadays many doctors work less than five days a week, although there is now some weekend working and sessions starting before 8.00am and booking appointments after 6.30pm.  In a patients eyes, however, is an appointment to see a practice nurse, a nurse practitioner or a health care assistant an adequate replacement for not seeing a GP? The Governments drive to have a seven day week seems to have lost steam  as the argument for weekend working is not convincing unless you work in an A & E Department of course.  If we are to have weekend working do we still need half day or lunch time closing?

Immediately Neccessary Treatment

There was an obligation written into the General Medical Services Regulations  that doctors should prescribe whatever medicines or drugs that were required for the treatment and care of a patient. Now you might be expected to buy over the counter medicines. I assume from this that the painkillers written up for me after a recent operation were actually not required, despite my pain and discomfort.  The serious question that arises is whether hospitals are failing to issue discharge medication and therefore cost shifting occurs, which instead of passing to the general practice is now passing to the patient. Something has gone off the rails!

Temporary Residents

Are we moving away from the principles of being able to obtain treatment and care when on holiday or away from home somewhere in the U.K.?  Practices receive little income for ‘temporary residents’ these days and I suspect that the rigeramole of completing forms, seeing patients and getting little recompense is leading to finding ways of cheating the system. New technology, fax machines and electronic prescribing systems are brought into play so that patients can pick up their treatment needs from a holiday location pharmacy without the intervention of a tourist town GP.  The problem comes with patients who have gone abroad and forgotten their medicines. Again what happened to the days when it took six weeks to sail to Australia and drugs would be provided for the journey. These days a temporary GP might give you one weeks supply if you are lucky and your own GP might limit you to 28 days.

Personal Medical Services

I often wondered what was meant by ‘personal’ medical services. The words ‘family practitioner services’ have fallen out of use. This had been an attempt by the government in the early 70’s to rename the local GP services that might become more familiar.  But ‘family practitioner’ was replaced by ‘family health’ and ‘primary care’ came to the forefront. What does that say about ‘family’? My take on personal medical services was a desire to provide services on a personal basis, that there be a continuity of care between the practitioner and the patient and that patients could become used to seeing a named and preferred doctor! Fine principles but are they now defunct and why?

Trusts, Foundations, Federations and Clinical Commissioning Groups

More titles, more paint for sign boards, more new headed paper. When will it end.  But what do patients make of all these primary care organisations. Do they know what they do. And there’s more with Urgent Care Centres, Walk in centres, and Minor Injury Units. Oh and there’s your local pharmacist. Now busy talking to patients instead of dispensing drugs. Can you see a points failure coming up fast. Is there going to be a disastrous train crash? Is the NHS going off the rails?

To be continued………

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Excuses not to collect charges from foreign tourists

Can you actually believe the extent to which NHS managers and clinicians argue that it’s not their job to collect charges from foreign tourists seeking free emergency or non emergency treatment. Many years ago in the 1970’s I came across a GP practice in the West Midlands that charged £25 per annum to register as a private patient the head of a household. The practice would not accept that person as an NHS patient. Working in a Family Practitioner Committee at the time we studied NHS Regulations very carefully in an attempt to find how this loophole. We could not find a law that had been broken and the practise continued.

It seems strange that hospitals in particular either cannot or do not apply a similar principle. Collect a charge when the patient / tourist crosses the threshold. I was surprised to hear this morning that in the U.K there is no law that requires foreign tourists visiting the U.K. To take out a medical insurance. I don’t know about you but I find this ridiculous. I have an annual insurance which covered me on my Christmas trip to Cuba but if I had reached the age of 70 I would have had to pay another £70 on top of my £120. I took my insurance documents with me and although I was quite ill whilst away – I was waiting for an operation – thankfully apart from buying strong painkillers I did not need a medical intervention.

The tourist from Nigeria who was flying from continent to continent heavily pregnant has used up to 6 hospital beds for over five months at a cost of £500,000. Whilst considering it an abuse of our NHS who will pay, answer you and me. In recent years the whole attitude of the NHS has changed toward not charging and freely accepting all comers into our NHS. We must be the laughing stock of the world. I felt sorry for the man with his credit card machine trying to squeeze the last penny out of occupants of a hospital bed. The whole should be dealt with before the patient crosses the threshold. Perhaps border guards should be checking for health insurance rather than hospital staff ask how long have you lived here.

 

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The Prime Minister wants GPs to provide a 7 day service

How many times have we heard from the Conservative Government the call to General Practice to provide a seven day 8am til 8pm service. But is it possible? I for one do not want to wait 6 hours to see a doctor is an A&E but could my GP have helped me. On a recent occasion for me the answer would have been no, apart from referring me to see a colectoral surgeon urgently.

Yes, if there is a demand for a seven day service get it provided and provided quickly. It’s not a question of looking for premises. The NHS already pays GPs for surgery premises 365 days a year. But it’s the GP manpower that arguably is lacking. Why? In my view there are plenty of GPs. The problem is they are working part time. Few work full time. Whilst there may well be legitimate reasons for working less than 5 days a week there will be even louder and stronger arguments not to work over 7 days.

But it is not valid to work a four day week just because you want to. It is not valid to work one or two days a week so that a GP can lead a CCG. Family reasons are often cited as a reason to go part time and in these days of equality it would be difficult to argue against it. But in my view all part time working should be approved by NHS England. Admission to the Performers List should be for an agreed time commitment. I know too many GPs who have just taken it upon themselves to work a four day week without any real solid reason. The consequences of part time working has been the use of expensive locums.

All in all someone somewhere needs to take control again – stop unreasonable and unexplained part time working and stop the employment of locums, unless there are exceptional reasons, such as sickness or maternity leave absence or a singlehanded doctor needing a break.

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NHS in Crisis – What is the Solution?

4 Hours is a limit not a target!

During the first weeks of 2017, it is clear that the NHS is having problems coping and the blame is being laid at patients themselves, at the growth in demand due to the changing population, at NHS Managers for not managing or being afraid to manage.  But in simple terms why should a patient need to wait 6 hours to see a doctor in an A & E Department with no apparent offer of triage on entry into the Department. Answer – No one.

Constant Change Does Not Improve the NHS

Based on my own research and experience, I believe that the problems have been caused by political change and a constant reorganisation of the NHS which just has not worked. In 2004 General Practitioners were given even more independence to run their own practices with an allocated budget from the NHS. A quality driven payments system was added into the melting pot which allowed practices to earn significantly extra amounts. The responsibility for deciding how many doctors worked in a practice and how many sessions and days they worked was devolved to the practices themselves. Previously medical manpower was indirectly managed by the Medical Practices Committee who approved entry to the medical list in a specific location and the PCTs who might approve part time working. But as a consequence more and more GPs decided to work part time so that now a very small percent work a 5 day, 9 session week.

Part time working should be Approved not a right 

The change in the commitment of GPs to working part time rather than full time is attributed to amongst other things the workload created by growing elderly population, and growing ethnic communities. The result is a  lack of immediate GP appointments, and more and more GPS want to work part time whether they are approaching retirement or not.  The growing number of female doctors taking maternity leave and wishing to work a shorter working week is also cited. Whilst NHS Hospital Trusts can manage employed doctors in a hospital environment it is not so easy to manage self-employed GPs working in general practice.  Where singlehanded doctors work in small practices maybe with the help of locums the future of such practices is in doubt. Even where practices with a handful of GPs work unless the doctors are flexible with their sessions and days of work it is becoming almost impossible to manage smaller and even larger practices.

Reintroduce Management Controls

In my view controls need to be introduced to manage the approval of part time working and added to that the employment of locums needs to be controlled. Locums are an expensive draw on the funds of a GP Practice to such an extent that in reality they are unaffordable. Perhaps if a practice is in real difficulties caused by maternity leave or sickness the local CCG or the NHS Area Team could both give approval to the employment of a locum and ‘funding’ within reason. My major concern, for general practice, however, is that the advent of Care Quality Commission inspections has probably contributed to the demise of smaller less efficient practices, where no doubt good doctors have been in practice, but their management and organisational skills have been lacking. I think it is also true to say that practices managed by local health organisations who employ salaried GPs also seem to fail. There are practices that have closed due to lack of funds i.e bankruptcy. This is not a way to run a health service. There must be essential small practices that should receive additional funding to survive.

Start to Ring Fence New Funds

My main concern though about offering any extra funding to so-called independent general practice is that the recipients of extra funds don’t regard the money as their profit or their pay rise. Any extra funds given to resolve real problems in practices that deserve help must be ring-fenced and only spent on resolving the problem. I feel the same about practice staff pay. There are those that argue that the independent nature of general practices gives practices the right to pay their staff whatever they want. What an attitude. Practices too continue to find ways of reducing toe cost of GPs by employing cheaper nurses, nurse practitioners and health care assistants. In their defence I have to say that some posts should be funded by the NHS and generally have not been. This includes phlebotomists. In my view an essential practice based service.

So to me the solutions to an ailing NHS lie in directing funding at real problems to deserving practices and regaining management control of the number of GPs working in general practice along with managing their days and hours of work. Lets stop this practise of deciding to work a four day week or less, and to employ other types of staff to replace GPs without good reason.

Robert Campbell

January 2017

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2017 – A Third World NHS?

So It is November and I have been in pain for three weeks and eventually  get a GP appointment. Admittedly a very quick diagnosis and instant referral but a three week wait for an out patient apoointment. A diagnosis and appointment for operation given. No advice on pain control.

December 2016

Over the Christmas week the pain and discomfort become worse. Difficulty sleeping and eating. A pharmacist gave pain relief advice and strong painkillers.

January 2017

A call to 111 produces a GP out of hours appointment almost 6 hours later. No different pain advice. Felt like a wasted four mile journey.

The first day after the New Year Bank Holiday I chase the operation appointment and confirmatory paperwork as none received. The hospital switchboard openly answers after three attempts but the Outpatient Department does not answer.

I find my original outpatient appointment letter and an appointments line number to ring. After a tirade of instructions to use the internet to cancel an appointment I get through. Yes I am on a waiting list but no confirmation of operation date. I am given two phone numbers for the consultants secretary. I try both. Both have answering machine messages about the working hours of the secretary. Neither work today. Try again tomorrow.

Still in pain and discomfort – it’s getting worse. A private operation can be done in two weeks costin around £3,000 as a day case.

I make an appointment to see my GP – first appointment is in 2 days. Have to wait over 30 minutes beyond allotted appointment time. Good history taking and examination. Referred to A and E but that hospital does not have colectoral surgeon. Go to one that does by car. It’s 12 noon. The waiting room signs say three hours to see a nurse and six to see a doctor. There is no obvious triage. I check the latter which is confirmed at six hours. No way could I sit for one hour let alone six with no guarantee of seeing the surgeon. Went home instead to rest.

In the meantime, I  phoned the consultants secretary again and leave a message for consultant about attending A&E with little hope of seeing anyone.

The A & E toilets were disgusting and patients were being sick in the cramped waiting area. Patients were being seen by nurses on the corridor.

Today I chase up my repeat prescription. It was due to be ready yesterday at 4pm. I call at the pharmacy only to be told it was not ready and I would have to wait until 4pm as stocks were not in. I asked for my prescription back. The response was we will do it in ten minutes. Very annoyed I left in a huff.

This is our wonderful NHS. Someone has to get it the neck.

To be continued!

 

 

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