Dr Blogs

An open blog enabling commentators from across secondary care to share their opinions. To contribute email editorial@hospitaldr.co.uk

Charging is the only way to control demand

By Mike Broad - 1st September 2010 3:01 pm

I’m at a loss to understand how the NHS is going to meet rising demand.

Despite all the talk of efficiency and productivity, it’s going to be a tall order - and practically impossible if we want it to stick to its founding principles.

Several recent stories convince me of this. Hard evidence on demand comes in the form of a recent study by the Nuffield Trust which points to a “unsustainable” rise in emergency hospital admissions. There’s been an almost 12% rise in admissions over the last five years, costing the NHS an additional £330 million per year.

The government’s announcement that it’s disbanding NHS Direct, the 24-hour advice line, isn’t going to help. I’m no expert on primary care, but it appeared a useful service that helped take the heat off A&E and GPs.

If you believe the Save NHS Direct Campaign (with it being led by John Prescott, maybe you won’t) then the phone line fields 27,000 calls a day, or 9.5m a year. It’s staffed by 1,400 nurses, provides evidence-based information on its website and scores well on customer satisfaction.

Replacing it with a cheaper service, with fewer health professionals involved, is unlikely to help with demand.

Department of Health figures released this week suggest that GP referrals to secondary care are accelerating once more. Data on outpatient referrals and attendances show the number of GP referrals made from April to June this year increased by 169,000 to 3 million.

Referrals can be clamped down upon temporarily during times of financial crisis, but not when facing inexorable pressure.

It strikes me that there are parallels with global warming (largely because I’ve just ploughed through a weighty tome on the subject to assuage my guilt over reading Stieg Larsson on holiday).

There are loads of things we could do to help with the long-term sustainability of our health system. We should improve our approach to public health, deliver more preventative services, and so on. But, much like reducing our carbon emissions, it’s going to take too long. The NHS is going to be bankrupt long before then.

We have to do something now to deter the ‘time wasters’ from entering the system, and the only way to do this is to put a value on an NHS appointment. We need a simple system of charging for appointments. The usual groups would be exempted from charges and treatment would still be free (I’d even scrap the anomalous prescription charges system).

Jumping back to my rather spurious comparison with global warming, it’s the equivalent of investing in a quick technological fix rather than obsessing about the long game. My personal favourite is to mimic a volcano and pump some sulphur dioxide into the stratosphere to enact some global cooling.

It’s not something you want to do - and there’s always a risk of unintended consequences - but a dramatic approach like this is increasingly necessary, even if it compromises a few principles.

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Regulation of drug abuse is better than prohibition

By Dr James Bell, addictions consultant at the South London and Maudsley NHS Trust - 29th August 2010 11:26 am

Sir Ian Gilmore’s comments on “decriminalising” drug use while still regulating drug sales are welcome. I read the former president of the Royal College of Physician’s words this week between seeing patients in a south London drug dependence clinic.

The first patient was a young woman, barely coherent under the influence of prescribed benzodiazepines (anti-anxiety medication and sleeping tablets).

Next was an affable chap who has been on prescribed diamorphine for more than a quarter of a century, while running a successful business and leading an upright suburban life.

As pointed out in the 1970s by the American research of Norman Zinberg, the effect of drugs is determined by “drug, set and setting” - the action of the drug, the mindset of the person using it, and the social context. When discussing how to regulate drugs, we must clarify the particular problems that drug policy is seeking to address.

Some of the many faces of drug use were shown in the Channel 4 documentary series, Our Drugs War. Residents of a bleak housing estate claimed in the film that 60% of inhabitants were on heroin. Watching, it was hard not to nod wisely and conclude that deprivation, unemployment, and social and family breakdown have been the fertile breeding ground for heroin addiction.

This part of the series also interviewed people about the former “legal high”, GBL, revealing a different face of our drug epidemic. For the most part people using GBL are young, often privileged, employed people who use a range of drugs as part of their party lifestyle.

In university towns, this type of drug use is commonplace if not without risks, including overdose fatalities. I have seen charming, privileged and formerly hardworking young people who found themselves dependent on GBL neglecting friends, family and work commitments and experiencing severe withdrawal symptoms when they try to stop.

And then there is alcohol, with per capita consumption in the UK having risen over the last two decades - and with it, deaths from liver disease.

It is hard to avoid the conclusion that there is a high demand for drugs across the UK. So availability becomes a key determinant of consumption. Historically, alcohol and tobacco have been regulated by licensing and taxation.

Taxation is surprisingly effective; there is consistent data that even addicted people reduce consumption when the price of their chosen drug goes up.

However, successive UK governments have been reluctant to use taxation and licensing to restrict the harm associated with alcohol (and tobacco), justifying the position on the grounds that the use of alcohol is a matter of “personal responsibility” rather than an area for intervention by the nanny state. Yet they have been glaringly inconsistent in dealing with the use of other psychoactive drugs, regarding that not as a matter of personal responsibility but as criminal behaviour.

Prohibiting the use of certain drugs has proved moderately ineffective (GBL can still be ordered online for next-day delivery). Instead, this strengthens the link between crime and drugs, and breeds disrespect for the law.

Most aspects of modern life require a mix of personal responsibility and regulation.

Licensing laws and taxation are not “nannyism” but prudent measures to restrain excess. Similar regulation of other drugs may offer a more constructive approach than the current legal restrictions. Given the plentiful availability of black-market drugs, it is hard to imagine such a policy being worse than our existing regime of classification.

This article first appeared in The Guardian

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If you want to keep CEAs, you’ll have to speak up

By Mike Broad - 25th August 2010 10:39 am

I’m guessing that the 2010 round of clinical excellence awards is going to be the most hotly contested yet. Why? Because there’s every chance it could be the last.

CEAs are to be reviewed and the government has questioned their affordability. It follows a near halving in the number of national awards handed out in the 2009 round.

While the review will not be submitted until next summer, you don’t need the powers of Nostradamus to predict the ensuing proposals.

CEAs are set to become like any other modest bonus scheme. Smaller sums will be handed out to more participants and they will become time limited. It’s likely that consultants will have to compete with other health professionals to secure one in a broadened scheme. The big, national awards will be consigned to history and I’d be surprised if the ‘bonuses’ remained pensionable.

The main problem with this is, of course, that CEAs are not some financial frippery aimed at cheering up the odd hard-pressed consultant, but part of the essential terms and conditions of all consultants.

Without them, the government would have had to offer a higher basic salary for consultants in the 2003 contract.

This is what I told a researcher from Panorama the other week when they rang to discuss whether doctors should receive “big bonuses” at the public’s expense. They’re pulling a programme together on the issue of doctors’ pay and I doubt it’ll be supportive.

I also told them that scrapping CEAs will make the government’s job of raising standards in the NHS much harder. While no consultant embarks on a service- or practise-improving project because of the potential to receive an award, there’s no doubt it helps to compensate for the extra work this demands.

There’s also a real risk for the NHS that some consultants will seek to grow their private work instead. Consultants are currently facing a three-year pay freeze and having their SPAs squeezed. Pensions and CEAs are now both subject to high profile reviews and likely to be compromised.

Does the government really believe that a bit of talk about clinical autonomy is going to make up for this, particularly when it wants raised quality and improved outcomes?

The CEA system isn’t perfect but it’s a lot better than it was. It’s more equitable and transparent than ever. If the review concentrated on improving accessibility and ensuring that awards were better linked to ongoing performance then it might even receive professional support. But if it’s just about saving money then I doubt it will receive any (with the possible exception of those who haven’t received a CEA).

There’s an enormous challenge here for the BMA. Can they protect the contract they negotiated? It’s looking difficult. Not only are they going to have to be vocal and vociferous, but they’re going to need the profession to start raising their voices as well.

Who received a national CEA in this year’s round? Read more.

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UK cancer fund not a victory for patients

The Lancet - 6th August 2010 11:33 am

The lead editorial in this week’s Lancet criticises the government’s announcement of an emergency cancer fund, saying that is not the victory for patient groups that some believe.

The new £50m fund will be available for six months from October, until the previously announced £200m cancer drugs fund comes into effect from April next year. The fund will enable a doctor whose patient has had funding for a drug declined because it is not approved by the NICE to appeal to their regional SHA panel. These panels will have the power to overrule NICE, and draw on their share of the £50 million to fund the patient’s drugs.

The editorial says: “This raises the spectre of appeals being granted or declined not on the basis of patients’ conditions, but because of where they live: either because their SHA has exhausted its share of the fund, or because their SHA is using stricter funding criteria. Scratch the surface, and it quickly becomes clear that what this fund represents is not the victory for patient groups that some believe. Rather, it is the product of political opportunism and intellectual incoherence.”

A report by national cancer director Prof Mike Richards provided a timely opportunity for the health secretary to announce this policy. The report compared treatment for various diseases in 14 developed countries. The UK ranked highly for providing drugs to fight heart disease and stroke, but was 11th for the provision of drugs for dementia, 13th for drugs for multiple sclerosis, and 12th for cancer drugs that had been on the market for less than five years.

Lansley appeared uninterested in the potential causes of the variations in drug use, and diverted £50m of Department of Health funds earmarked for the Personal Care at Home Bill to the emergency cancer drugs fund. The editorial says: “Presumably emergency funds for dementia and multiple sclerosis drugs will be announced in due course - anything else would be intellectually indefensible.”

The editorial condemns the policy for not only undermining NICE, but also it undermining the entire concept of a rational and evidence-based approach to the allocation of finite health-care resources. It concludes: “New cancer treatments clearly challenge the cost thresholds set by NICE, but innovative schemes have been developed to reduce the cost of drugs - notably bortezomib for multiple myeloma - by rebating costs in patients who do not respond to the drug in question. Lansley’s £50 million slush fund could reduce the incentive for drug manufacturers to engage in mutually beneficial schemes of this type. With ministers claiming that the coalition government is ‘more radical than Thatcher’, there is an increasing sense that a desire to force the pace of change is starting to cloud judgement.”

Read the full editorial.

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Are we seeing the rise of the supra-regulator?

By Mike Broad - 3rd August 2010 3:32 pm

There’s a quiet counter-revolution going on in medical regulation.

Anyone remember the Office of the Health Professions Adjudicator? What do you mean “no”? The OHPA was set to put the final nail in the self-regulation coffin. As an independent board, it was supposed to take over the adjudication process from the GMC next April.

The GMC would still investigate the fitness to practise of doctors, but the OHPA would pass judgement on the evidence. Well, not anymore. OHPA has been dispatched by the new government (and it’s not happy). The GMC will continue to pass judgement but has to learn how to do it more effectively apparently.

It’s not the only quango to suffer under the new government. Anyone remember the Council for Healthcare Regulatory Excellence? Oh come on, don’t you bother reading all this stuff we produce. The CHRE oversees the professional regulators and can review any decisions it doesn’t like: this effectively introduced double jeopardy for some unfortunate doctors.

Anyway, it has to become a self-funding body in the shake up and the regulators will have to foot the bill.

What does this tell us? It tells us that the drivers around professional regulation have changed with the new government.

Firstly, the paranoia surrounding Shipman, and the subsequent inquiry, is starting to fade.

Secondly, the coalition government appears far less antagonistic about doctors than the one it replaced. It’s early days, but doctors appear to be part of the solution rather than the problem. Health ministers no longer appear to be trying to put doctors ‘in their place’, making them accountable shift workers who operate under a draconian regulatory system.

And, thirdly, the government wants cheaper regulation.

It’s interesting to note what’s happened to the General Social Care Council (the GMC for social workers). The GSCC is to be closed with its responsibilities falling to the Health Professions Council. The regulator was moving to a self-funding model, but the government decided this could be done more effectively under the HPC. Social worker’s annual fees are still set to double.

I guess the GMC must already know it has to be careful. The government sent it a clear message when it delayed revalidation for another year. It wants to support safe practise, but not at any price.

The GMC is due to spend £85.2m in 2010. Fortunately for it, doctors largely foot the bill. I’d still suggest it’s going to have to spend that money wisely otherwise we could see the rise of the ’supra-professional regulator’ as we have seen rise of the supra-inspection bodies.

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It’s not all about the big picture

By Mike Broad - 21st July 2010 10:48 pm

The government wants the NHS to do more with less (or, if a member of the media is within earshot, to do more with about the same). To achieve this, if indeed it is achievable, everyone is going to have to work a lot smarter.

And so we’ve got the White Paper, which shakes up primary care and once again seeks to usher in the private sector in pursuit of competition and efficiency.

But, efficiency isn’t just about the big stuff. Torching all the SHAs, PCTs and quangos before lunch and then shooting a few managers in the afternoon might grab the headlines but large scale re-organisations are often slow, expensive and rarely deliver the intended results.

Real progress - in both efficiency and quality - will be found in improved working practices and how services are organised locally. And that’s why we surveyed hospital doctors on how things could be improved.

Shift handovers are clearly a serious problem. If we don’t have the balls to modify the working time regulations, then trusts have got to adopt best practice and bring uniformity to the process.

It’s all very well for Sir John Temple to say every handover should be a well-planned and supervised learning opportunity (hang on a minute, when was the last time you attended a post-take ward round Sir John?) but the reality for many consultants is very different.

It’s also concerning that, according to hospital doctors, a lack of staffing and training resources are already compromising care. This is only going to get worse. At least the government appears to be tackling targets, another highlighted problem.

Our survey also offers some clear pointers for IT development. Time is regularly wasted finding medical records. Clinicians want to be able to access real-time electronic patient records.

How much public money has been spent on the NHS IT programme and yet we still can’t deliver this? It’s starting to make the Millennium Dome look like a successful project.

The message is a difficult one for a government with no money to stomach: you’re going to have to invest a bit more before you can make long-term savings. Having said that, scrapping the 48-hour week wouldn’t cost a penny…

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What’s happening to consultant pay in your trust?

By Mike Broad - 6th July 2010 10:03 am

I like my local hospital in Norwich. When I’ve accessed its services, I’ve been happy with the results.

However, I was disappointed by a recent communication. I received a letter and a glossy brochure asking me to become ‘a member’ of the trust.

By being a member I would receive regular updates about the work of the trust, be invited to events and be able to vote in governors.

Public engagement with health services is important, but there are ways and means. In this digital age, they shouldn’t be spending a fortune on paper-based communication with thousands of patients.

A different department in the hospital is currently leaning on consultants to compromise their pay. Consultants are being asked to drop half a PA in pay, while still doing the same work, or accept a 5% pay cut for a year.

They’re just proposals at the moment but it’s surprising how many consultants appear willing to consider it.

I’d tell the management to get stuffed until they stop wasting money on recruiting ‘members’ and the like. I’m sure potential members would agree.

Elsewhere news is filtering through of other tough measures. The level of Clinical Excellence Awards is to be frozen until 2013. As they’re pensionable, this is another blow to consultants’ long-term financial security.

And there’s lots of conjecture around pension reform and whether consultants will have to pay a one-off levy to maintain their current benefits.

Is it fair that while consultant pay is frozen for three years local trusts try to guilt their doctors into accepting additional arbitrary cuts? Surely the answers lie in more efficient services.

And it’s so self-defeating when it comes to productivity. One imagines that many consultants, who may never have done any private practice, are considering it now.

Depressing times. If it is to be resisted, we need to start collating what is happening around the country to consultant pay and benefits.

If your trust has made controversial proposals take the opportunity to name and shame them below - you can post anonymously.

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Stepping up to the mic at the BMA conference

By Mike Broad - 30th June 2010 4:25 pm

A lot of voices get heard at the BMA’s annual representatives meeting but, when it comes to the media, only the GPs and consultants tend to get any coverage.

So, in the interests of balance, it’s worth giving some of the views of juniors’ and the SAS doctors an airing.

Dr Shree Datta, chair of the JDC, stuck to her line that the problem with the working time regulations is their implementation rather than a restricted working week per se.

“Half-hearted compliance leads to half-filled rotas,” she insisted in her conference address.

She added: “It is time for employers to take up Temple’s challenge, and engage with junior doctors to create realistic rota solutions that balance training and service to our patients.”

Where all the additional ‘manpower’ will come from to fill these rotas she didn’t say. Maybe she feels, like Sir John, it’s up to consultants to fill the gap.

Training will clearly continue to be this year’s hot potato.

She said: “The many streams and rivers of NHS money are being diverted and dammed. The NHS prides itself on its highly trained workforce. But the quality of senior doctors in future depends on the quality of training now. The whole profession must unite against any suggestion of haphazard cuts to our training budgets.”

Dr Radhakrishna Shanbhag concurred. The chair of the SAS committee told the conference: “My job is not an easy one. It is no secret that the SAS grades include many varied and sometimes challenging needs and aspirations. We are a diverse group but that should be our strength. We need to improve access to training (for those that want it), provide some formal recognition of our competencies and skills and ensure that with this, the SAS grades are seen as a positive career choice for highly skilled and motivated specialists.”

But it’s not just about money, Shanbhag is after a bit of respect too. He complained about the slow implementation of the ‘new’ SAS contract. “Two years since it was introduced, I’m shocked that there are still many SAS doctors waiting for assimilation. I believe that this is a damning indictment of the lack of respect that employers have for our grade. We have continually pressed NHS Employers and devolved administrations to move things along and will continue to do so.”

And did I detect a desire for a bit more respect from within the ranks of the BMA?

In summation, he asked the conference to “take ownership of this grade, celebrate their achievements, acknowledge their vital role and let them be spoken to and about in the same breath as other senior medical professionals. Let us stand up for SAS doctors.”

While the slogan of the conference might have been ‘standing up for doctors’ - a line that the chairman of BMA council repeated at least 742 times - the real message was more one of ‘sticking together’, possibly alongside other public sector unions, to see out the gathering storm.

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Spirit of co-operation could falter over pensions

By Mike Broad - 28th June 2010 12:00 pm

I’m at the BMA’s Annual Representatives Meeting in sunny Brighton. It’s a beautiful day and there’s a stunning view over the beach and the pier from the press room.

However, the 500 or so faithful members who’ve turned up are dutifully sat downstairs in a rather gloomy conference hall.

From my elevated position above the promenade I can see the odd one making a break for the beach but they’re being surprisingly dedicated to the cause.

That’s probably because there’s much to discuss - not least the threats to doctors’ pay and terms and conditions. As you’ll be aware, last week, Chancellor George Osborne pledged to freeze public sector pay for the next two years in his emergency budget.

Dr Hamish Meldrum, chair of BMA council, gave his big speech earlier. A key theme was the new spirit of cooperation between the coalition government and the union. He agreed with the government’s decision-making on the revalidation postponement, on seeking to reduce bureaucracy, cutting waste, streamlining management, and saying they want to put doctors in control.

However, while promising to be “reasonable and responsible in our pay demands”, he warned that doctors would “not be made the scapegoats for failures of speculators and marketers”.

In a direct message to the government Meldrum said “don’t underestimate us when it comes to protecting doctors’ jobs and pensions. On these, I will not be reasonable if, being reasonable means accepting cuts in the number of doctors or reneging on the recently agreed, revised pension arrangements for staff”.

He pointed to BMA research which suggests cuts are already being made to staffing numbers round the country. He described this as “madness”.

Rumours abound that doctors’ pensions are going to suffer following Osborne’s claim that public sector pensions will be reformed. One rumour is that doctors will have to pay a large one-off levy - in the region of £20,000 - next year to maintain their pension benefits.

It’s widely believed that the government will put back retirement age to 66 by 2016.

The BMA, however, feels that the NHS pension is in better shape than others within the public sector, such as the civil service and military. They claim doctors contribute more and retire later, and the NHS scheme should provide the model for other public pension schemes to follow.

Meldrum said: “Only two years ago, we reached agreement which raised the age of retirement to 65, capped the contributions of the government, increased contributions by the higher paid and put the NHS scheme on a sensible and affordable footing for the future.

“I am not someone who easily resorts to threats, but I warn the government - in a spirit of cooperation and being helpful - if you really want a crisis in the NHS, start meddling with the NHS pension scheme.”

I knew the love-in with the coalition government wouldn’t last long.

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Am I alone in thinking the honours list is sinister?

By Mike Broad (note the lack of title) - 15th June 2010 11:10 pm

Another year, another set of gongs. And there are some pretty distinguished names included on the Queen’s birthday honours list this time round for ‘services to medicine’.

The following all received knighthoods: Prof Marc Feldman, Professor of Cellular Immunology, Kennedy Institute of Rheumatology; Prof Ian Gilmore, president of the Royal College of Physicians; and, Prof Peter Rubin, chairman of the GMC.

So, how do you get on the list? Well, anyone can nominate anyone. Then there’s a series of committees, blah, blah, blah. But, the detail of the process and decision-making remains shrouded in mystery.

I find this a deeply disturbing anachronism. As the walls of most of our ‘secret societies’ are slowly dismantled, either voluntarily or through freedom of information requests, the honours list remains opaque and surprisingly unquestioned.

I’m sure these guys - sorry knights - are all fine doctors, and will look great on horseback in chain mail, but I start to worry when I see Department of Health ‘spin doctors’ on the list.

(I only met Sian Jarvis, the DoH’s director-general of communications once but it was memorable. I received a long and rather condescending lecture at Richmond House about how my magazine was too questioning of government policy. My reply - “Er, durr, that’s my job” - didn’t seem to help.)

If I were offered a knighthood for services to journalism, or jam making, or whatever, I would definitely turn it down. And I’d really enjoy writing “thanks, but no thanks”. It’s just another way of reinforcing privilege. It would be interesting to know how many doctors who’ve received knighthoods are male, white and from public school. I certainly didn’t notice many long-serving, immigrant hospital porters in the list.

I’m always surprised that more people don’t turn them down. Lot’s of people denounce them, and their like, but when push comes to shove the desire to join the club proves too strong. Just look at Prezza.

It’s sad but in a profession that is becoming steadily more elitist, I can’t remember hearing of a doctor who’s turned one down.

And, how do they stomach the accolades without feeling bilious? This is from the GMC’s chief exec on their press release - yes, press release - on the subject: “I am sure everyone at the GMC joins me in congratulating Peter. This is richly deserved and is recognition of a highly distinguished career in medicine and research, as well as a great contribution to medical education and regulation. It also reflects well on the GMC and what Peter has achieved in the years he has served this organisation.”

It’s all starting to sound a bit like an Oscar acceptance speech.

And then Gwyneth Paltrow, sorry Prof Gilmore, on a separate press release (yes, press release) tries the old trick of suggesting he’s only really accepting it on behalf of his organisation: “I am delighted to receive this honour, which I believe acknowledges and reflects the tremendous efforts made by the Royal College of Physicians to improve health and healthcare in the UK and beyond. This is done through setting standards, educating doctors, and promoting an environment where people can make choices that promote health and wellbeing.”

You’re not fooling anyone Prof - we know this one’s for you.

I think I may now have officially blown my chances of being knighted but, should opportunity come knocking for you, please strike a blow for equality and transparency and write a beautifully crafted letter turning it down (and do it before your spouse comes home and forces you to accept it).

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