2010 April » Hospital Dr

Archive for April, 2010

Calling on the GMC to re-define misconduct

JJ Oliver, Remedy - 30th April 2010 2:15 pm

The Remedy judicial review being heard on 11 May could drive a coach and horses through the meaning of misconduct, and the meaning of unfitness to practice.

Doctors who are involved in management will be anxiously awaiting the verdict, since they may find themselves personally liable for their managerial decisions in future. And appeal lawyers across the country will be looking to the judgement to see whether the GMC has opened the floodgates for them.

Doctors are always happy to whinge about their managers, but serious action against doctors in management is rare. The GMC has only taken action in a handful of cases. One such case was that of Dr Roylance - the chief executive caught up in the Bristol babies cardiac surgery storm.

The MTAS recruitment process was a unique disaster. Some of the superlatives used at the time still stand out; it was described as the “biggest disaster” in a generation, and the anger it generated has still not subsided. So when Remedy wrote to the GMC asking for the senior doctors responsible for it to be referred to a fitness to practice committee then they hoped that the case would be duly investigated.

But the GMC politely declined the opportunity to hold such an inquiry. At this point Remedy reached for their lawyers, and challenged the GMC to defend themselves in court.

The case raises significant issues well beyond the events of 2007. At the heart of it lies the prickly and complex issue of what constitutes unfitness to practice. What sort of actions outside the clinical arena will render a doctor unfit to practice as a medical practitioner? The GMC have defended themselves on the grounds that:

Whatever the conduct of [The Proposed Defendants] with regard to MTAS, I do not consider that it can sensibly be said to impinge on their fitness to practise as medical practitioners.

Yet this seems to be at odds with many previous rulings. There are many doctors who have been removed from the medical register for what has been referred to as “bringing the profession into disrepute” and for “conduct unbecoming of a doctor”. And if, for example, the doctors under investigation had knowingly breached the laws affecting international medical graduates then would the GMC still be arguing that this had no effect on their ability to work as doctors?

There has never been a case of deficient professional performance brought against a doctor for managerial issues. If Remedy is successful then this verdict will send a cold chill down the spines of medical directors and doctors working for health authorities - especially in an era of financial uncertainty.

The case is being heard in the High Court on 11 May - five days after the general election. Remedy has created a Facebook group for supporters of their case. If you agree with us, please attend court or, failing that, express your support.

This verdict is going to be studied by medico-legal bodies for many years to come.

Tags: GMC, MTAS
Posted in London Med Student | No Comments »

Call for doubling of A&E consultant numbers

By Mike Broad - 1:48 pm

The next government is being called on to more than double the number of consultants working in emergency departments.

The College of Emergency Medicine says every emergency department needs a minimum of ten dedicated consultants to deal with the growing number of patients presenting in A&E.

The current average is 4.2, while the number of patients averages 70,000 to 80,000 per year.

Increasing the number of consultants would guarantee their presence at evenings and weekends, and promote the highest standards of quality and safety.

The college claims that despite the increase in salaries the move would save money in the bigger picture. It would help reduce inappropriate investigations, unnecessary admissions and unsafe discharges.

Dr John Heyworth, president of the College of Emergency Medicine, said: “Emergency care is currently failing to deliver the service which the public expect and deserve. The single most important factor in providing a high quality, timely and clinically effective service to patients is care led by emergency medicine consultants.

“We are concerned that patient outcomes may suffer if this failure to invest in emergency medicine continues.”

The college has also called for a review of emergency care standards in its ‘manifesto’ A matter of emergency. The current target for all emergency care systems to achieve a target of 98% of patients being seen, treated and discharged within four hours is challenging due to understaffing and compromising patient care.

It also wants patients to have one-stop access to effective emergency care. The college supports co-location of the emergency department with other clinicians to provide unscheduled primary care, mental health and other key health services in one secondary care setting. It’s critical of walk-in or urgent care centres which are “largely unsupported by evidence regarding clinical and cost effectiveness. These initiatives have led to a fragmented system with duplication which evidence shows patients find confusing”.

Read the full manifesto.

Tags: A&E, Targets, Workforce
Posted in Hospital Dr News | 1 Comment »

Harnessing the benefits of the independent sector - a briefing

By Mike Broad - 11:57 am

NHS Partners Network, which represents independent sector health organisations, has launched a briefing document entitled Harnessing the benefits of the independent sector: priorities for the next government.

The document claims that the independent sector is uniquely placed to help develop innovative approaches to healthcare that drive quality and patient satisfaction up, increase productivity, and thus ensure that the unprecedented funding pressures on the NHS do not lead to a decline in quality.

But NHSPN demands that the process of market reform instituted during the Blair government needs revitalisation. The following is a summary of the changes that NHSPN believes are needed:

1. Publication of comparative quality data to support choice

All the main political parties are committed to improving patient information. NHS Choices website should be run by an independent organisation, and multiple sources of information should be encouraged.

The first published outputs from the independent sector’s data benchmarking project will be launched this summer. It is also important that data collected by the Department of Health itself is made fully available. It is wrong that data collected by the government, at considerable expense to the providers, should be withheld from the public and from analysts who can help the public make sense of it.

2. Abandon the preferred provider policy and require periodic competitive challenge

The government’s preferred provider policy is anti-competitive. The principle of value for money should be the overriding one guiding NHS commissioners. Any willing provider who meets NHS standards should be eligible.

There should be a commitment that, over appropriate periods of time, all NHS services should be exposed to competitive challenge so as to ensure that opportunities for maximising value and embracing innovation are not overlooked.

The provider market is still underdeveloped. This should be objectively recognised and reflected in practice, but not abused or used as an excuse for restricting the use of competition.

There will be circumstances when taking a broader view of alternative ways in which services can be provided may well result in there being a wider pool of potential providers than is at first apparent.

Commissioners need to be more aware that the surest way of demonstrating they have secured best value is by using open, non-discriminatory tendering processes wherever practical.

3. Create a level playing field

With increasing pressure on tariffs, and the likelihood of some form of renewed price competition in the future, resolving the major outstanding level playing field issues is a strategic necessity if independent sector and investor participation in the NHS is to be sustainable.

Independent economic analysis has established that the independent sector currently has to operate with a cost disadvantage of around 14% relative to public sector providers. The NHS pension scheme is the biggest problem. Unless this aspect of the playing field is levelled it is likely that over time the pitch will become unplayable for the independent sector.

A substantial part of the pension costs are carried by central government not by NHS provider organisations themselves. This puts the public sector at a competitive advantage over the independent sector.

To deal with this it will be necessary to ensure that public sector bidders are assessed on the basis of their full cost to the taxpayer. This might be done either by increasing the percentage of their pension costs which they have to bear directly or by applying a ‘shadow’ weighting factor which forces commissioners into making a truer comparison when assessing bids.

Internal accounting and cost allocation is weak within the NHS. Full cost allocation and accounting should be enforced.

4. Putting the NHS competition regime and the Cooperation and Competition Panel onto a statutory basis

The CCP has no statutory powers or legal teeth and can only make recommendations, and in recent months it has become clear that its rules can be rewritten by its sponsors.

The CCP needs to have teeth and become independent of political influence. A firmly established regime for managed competition has emerged as one of the vital reforms needed if investors are to be persuaded to the UK NHS market.

5. Establish proportionate, even-handed regulation

The Care Quality Commission must regulate the independent sector to the same standards and proportionality of all types of provider.

6. Build a new relationship with GPs

GPs will face an increasing conflict of interest. Inherent in the GP model is a perpetuation of commissioner-provider integration, rather than the split which is generally seen as beneficial for healthcare systems.

GP practices that scale up to carry out broader commissioning functions will become more dominant in their local markets, thus reducing patient choice, making market entry more difficult and further reinforcing their advantages. And the GP contract fails to incentivise them to drive change.

There will need to be a new GP contract which incentivises change and high performance, with corresponding measures of quality, thus recognising that the structure of primary care needs to move with the times.

The OFT should look into the changing nature of the GP market and consider what changes might be appropriate to avoid excessive market dominance and reduce barriers to entry.

7. Simplify contracting arrangements

There is a need for simpler, more proportionate contracts for services that genuinely differ from the core NHS circumstances. Problems include disproportionate requirements, models perpetuating historic delivery patterns, undeliverable insurance requirements and failure to recognise the position of national providers operating across multiple trusts.

8. Promote the adoption of new technologies to provide advice and assistance to patients

Increased financial pressures on the NHS mean that it is important that individuals actively manage their health and adopt healthy behaviours. New communication channels need to be harnessed that can catalyse action in the public and private sector experience drawn upon.

Read the full briefing.

Tags: CCP, Pensions, Privatisation
Posted in Features | No Comments »

Medics face trainee registration fee rise

By Mike Broad - 9:01 am

A significant increase in trainee registration fees has been announced by the Federation of the Royal Colleges of Physicians of the UK.

The new fee for juniors in medicine wishing to pay a single payment for their core medical training will be £306, or £765 for specialist training. Both represent a 22% increase on the previous charge.

The new fees will come into force on 1 June 2010, and represent the first rise since 2007.

The federation blames the increased pressure on training budgets, which includes a reduction in Department of Health support for the JRCPTB. Also, there’s been the introduction of fees for using the ePortfolio, which the provider, NHS Education Scotland, formerly provided free of charge.

Trainees wishing to stagger payment of their fees, allied to collegiate membership of one of the royal colleges of physicians, will pay £153 annually. This was formerly £125.

For 2010/2011, trainees received a 1% pay rise.

Tags: Fees, Training
Posted in Hospital Dr News | No Comments »

Royal colleges speak out in favour of service reconfiguration

By Mike Broad - 29th April 2010 1:42 pm

A group of leading medical organisations have sent a letter to The Guardian in support of service change. They fear the debate is being misrepresented in the media. Here is the letter in full:

This is the most closely contested general election for more than a decade and health is one of the top priorities for voters and politicians. While we welcome the focus on the NHS, we are concerned that the political debate and its attendant media coverage tend to overlook the cogent arguments for service change that will bring long-term benefits for patients.

There has been a wealth of clinical evidence for many years that specialist clinical services, such as stroke, trauma and heart surgery, should be concentrated in fewer centres. This would allow the latest equipment to be sited with a critical mass of expert clinicians who regularly manage these challenging clinical problems, and are backed by the most up-to-date research.

The greater volumes of patients mean doctors are better at spotting problems and treating them quickly. Survival and recovery rates would improve markedly with many lives saved. As techniques and technology have developed over recent years, speciality rather than proximity has become the key for patient safety. So increased patient safety and improved care must be the major drivers of any reconfiguration.

Patients may indeed have to travel further for some specialist care, but if it is significantly better care then we believe that centralisation is justified. However, at the same time there is also strong evidence to support a large amount of more routine care, currently taking place in hospitals, being carried out closer to where patients live in the community with GPsplaying a crucial role in the delivery of services.

Delivering this requires strong leadership and brave decision-making from doctors, managers and politicians. Simply condemning change as bad and defending the status quo as ideal is not serving the interests of patients.

If the NHS is to cope with the financial pressures it is going to face under any government without resorting to indiscriminate and damaging service and staffing cuts, large-scale planned service redesign and reconfiguration based on clinical evidence will have to be at the heart of the strategy. This may mean, for example, A&Es, children’s departments and surgical units at their local hospital either closing or providing a different type of service.

Such a process can significantly improve patient care. But if it is to be managed well and properly provide the highest quality care in the best clinical environment, it must directly involve doctors, other healthcare staff and the public. This involvement should include a voice in the planning and strategy development for such services, thereby ensuring appropriate service reconfiguration driven by clinical evidence and not simply the need for financial savings.

Professor Neil Douglas, Academy of Medical Royal Colleges, Professor Ian Gilmore, Royal College of Physicians, Professor Steve Field, Royal College General Practitioners, Professor Hugo-Mascie-Taylor, NHS Confederation, Professor Sabaratnam Arulkumaran, Royal College of Obstetricians and Gynaecologists, Professor Terrence Stephenson, Royal College of Paediatrics & Child Health, Professor Dinesh Bugrha Royal College of Psychiatrists, Dr Peter Nightingale, Royal College of Anaesthetists, Dr Neil Dewhurst, Royal College of Physicians of Edinburgh, Professor Andy Adam, Royal College of Radiologists, Mr John Lee, Royal College of Ophthalmologists, Professor Alan Maryon Davis, Faculty of Public Health Medicine, Dr Richard Tiner, Faculty of Pharmaceutical Medicine, and Professor David Coggon, Faculty of Occupational Health.

Tags: Election, Reconfiguration
Posted in Features | 2 Comments »

It’s time to make up your minds and cast that vote

By Mike Broad - 10:24 am

With 6 May fast approaching, I should probably be setting out the differences between the three parties on health and which one Hospital Dr thinks would be best for the NHS.

But, in truth, it’s impossible to say. For a start, this election isn’t going to be decided on health policies and they’ve barely been mentioned on the national stage. Our economic woes and the need to clean up politics have sidelined everything else, and the TV debates have thrown the focus on to personalities rather than policies.

And then there’s the problem that no one really knows what any of them are planning on health rationalisation. As the Institute of Fiscal Studies revealed, only a fraction of the required cuts in public spending have been outlined by any of the parties.

Despite lots of reassurances about protecting NHS funding and supporting frontline jobs, whatever they are, I’m sure there will be some nasty surprises following the election. We may be “bigots”, but the politicians are just peddling half-truths.

So, what have we learned? Well, ideologically there’s nothing between them. They all hate managers and bureaucracy, and the NHS will be far more efficient under each of their parties. They’re all keen to give more power to frontline staff. The private sector will become more involved in the delivery of NHS services. Waiting times around cancer will be shortened.

So, what don’t we know? Well, lot’s of stuff. There’s not been much about reconfiguring services, such as centralising specialist services, moving services into the community and taking a more preventative approach.

Darzi (remember him) was all about quality, and yet there’s been practically no discussion of the ongoing role of targets and regulation in supporting this. And what about the challenge to medical training posed by WTD? Yet more tumbleweed quietly blows past the hustings.

What did we learn from Swine Flu? Are our ‘dirty hospitals’ now clean? It seems that both the politicians and their voting public are quick to forget the big stories that have dominated the past few years.

More personally worrying has been the lack of scrutiny about demand. I’m not alone in questioning the longer-term sustainability of the NHS and what its role should be. Health economists have been banging on about it for years, but it appears to be electoral cyanide for all parties.

So, who will I (and Hospital Dr) be voting for? The Lib Dems as usual (or the Illiberal Democretins, as Jerry Nelson has re-christened them), but it’s got nothing to do with health policy.

Tags: Election
Posted in Dr Blogs | 1 Comment »

Reconfiguration will improve services, doctors say

The Guardian - 8:51 am

Many hospitals will have to shut their A&E units, children’s departments and surgical units to help the NHS fill a £20bn black hole, leaders of the medical profession have said.

In a letter to The Guardian, the senior doctors tell the main political parties that whoever forms the next government must be ready to press ahead with widespread rationalisation of hospital services which, although unpopular, would improve care and save patients’ lives.

Signatories include large sections of the medical establishment - nine of the 14 medical royal colleges, and three related medical faculties - including bodies representing GPs, hospital doctors, experts in childbirth and maternal care and specialists in children’s medicine as well as psychiatrists, anaesthetists and public health experts. Their public support for “large-scale” closures of hospital units is significant because together they speak on behalf of about two-thirds of all doctors.

The letter, which was organised by the Academy of Medical Royal Colleges, the colleges’ professional association, says: “If the NHS is to cope with the financial pressures it is going to face under any government without resorting to indiscriminate and damaging service and staffing cuts, large-scale planned service redesign and reconfiguration based on clinical evidence will have to be at the heart of the strategy. This may mean, for example, A&Es, children’s departments and surgical units at their local hospital either closing or providing a different type of service.”

Sir David Nicholson, the NHS’s chief executive, has said the service must make £20bn of “efficiency savings” between next year and 2014.

Centralising services which are currently provided at many hospitals, such as stroke and trauma care and heart surgery, would improve the quality of care and patients’ outcomes because medics would handle larger numbers of cases, the doctors say in their letter.

Public confidence to rise with revalidation

By Mike Broad - 8:21 am

Seven out of ten members of the public say they will have more confidence in their doctor once revalidation is implemented, a GMC survey shows.

The poll, of more than 2,000 people, suggests that the revalidation process should provide further assurance to patients - more than 70% of those who were not confident in their last doctor agreed revalidation would increase their confidence.

Even those who were confident in their last doctor said revalidation would increase their confidence further, with 69% of those who were quite confident and 63% of those who were very confident agreeing it would make a difference.

Revalidation would require all doctors in practice to demonstrate that they are up to date and fit to practise on a regular basis, although doubts persist on whether the system will be implemented as outlined due to funding cuts.

The vast majority of people surveyed reported a high level of confidence with 86% saying they were confident in their doctor’s skills and knowledge, although 14% said they did not have confidence in the last doctor they saw.

One of the proposals is that the checks on doctors should include feedback from their patients - 95% of those surveyed agreed that this should be taken into account in reviewing a doctor’s practice.

Niall Dickson, chief executive of the GMC, said: “We know that patients in this country justifiably trust their doctors and that is vital for good medical practice. But many also think that every doctor is already subjected to regular checks, and this is not the case - what this poll shows is that they would welcome further assurance.

“We believe the new system of revalidation will achieve that by showing that their doctor is up to date and fit to practise. It should become an integral part of high quality care throughout the UK and if we get it right we will lead the world.”

The GMC is currently consulting on how revalidation will work and is encouraging doctors to contribute.

Tags: Revalidation
Posted in Hospital Dr News | No Comments »

Surgeon struck off for wrongly removing testicle

BBC Health - 28th April 2010 9:02 am

A surgeon who cut off a patient’s testicle by mistake has been struck off the medical register.

Dr Sulieman Al Hourani was only supposed to take out a cyst but removed the whole right testicle instead. The blunder happened at Fairfield General Hospital in Bury, Greater Manchester, in September 2007.

Dr Al Hourani, who has returned to his native Jordan, was found guilty of misconduct by a GMC fitness to practise panel.

The locum surgeon was struck off in his absence and refused to engage in the proceedings.

Medical notes made it “perfectly clear” the procedure was to be “excision of right epididymal cyst”, a disciplinary hearing was told.

The hearing was also told that in August 2006, Dr Al Hourani had injected himself with two milligrams (mg) of midazolam, a powerful sedative, which was meant for a patient.

Hospital staff said the doctor, who was on call, appeared unsteady on his feet and was later found in the doctors’ mess room “deeply asleep” and taken to A&E.

Dr Al Hourani was issued with a final warning over that incident but was eventually dismissed by his employers, Pennine Acute Hospitals NHS Trust, in October 2007 over allegations he stole two boxes of dihydrocodeine tablets.

Bowel cancer test could save many lives, study claims

BBC Health - 8:56 am

A five-minute, one-off screening test could prevent thousands of people dying from bowel cancer every year, a study published in The Lancet suggests.

There are now calls for the test to be rolled out across the UK after results from 200,000 people aged 55-64 found it cut deaths by 43% over 10 years.

Cancer Research UK described the results from the Imperial College, London, study as a “rare breakthrough”.

The independent bowel cancer screening committee will discuss whether it would be cost-effective to incorporate the procedure - known as sigmoidoscopy - into the UK’s screening programmes.

Scientists from Imperial College, London, who carried out the research, argue the costs would be outweighed by the savings generated through reducing the incidence of the disease, the UK’s second biggest cancer killer.