Category Archives: Doctors
Chief executive of NHS Confederation rejects health secretary’s claim that changes to GP contract in 2004 are to blame
There is no link between the crisis in hospital A&E departments and GPs opting out of out-of-hours care, a leading NHS figure has said – in a direct challenge to the health secretary, Jeremy Hunt.
Mike Farrar, the chief executive of the NHS Confederation, the body representing organisations commissioning and providing health services, questioned Hunt’s assertion that Labour was to blame for a public loss of confidence in alternatives to casualty by agreeing a new contract with family doctors in 2004.
As the political row deepened over overcrowded A&E departments – one that will get worse as ministers consider a number of closure plans – Farrar said: “We do not see a correlation between the changes to the 2004 GP contract and the NHS 4-hour waiting standard for A&E departments.”
Hunt has been keen to differentiate between blaming Labour and GPs themselves, but for days he has been citing the GP contract changes as a main cause of the problem. On Tuesday, he told MPs they had had “devastating impact and that pressures on A&E services were “direct consequences of the disastrous changes”.
The minister also said that last year’s GP patients’ survey showed “only 58% of patients know how to contact their local out-of-hours service, and said that 20% of patients find it difficult to contact their out-of-hours service, that 37% of patients feel that the service is too slow – problems that we are trying to address.”
But Farrar said: “In fact, for the vast majority of the last decade, A&E waiting time standards have been improving. It is in recent years where the pressures have started to bite, and there have not been any discernible structural changes to out-of-hours GP contracts during that time.
“It is clearly evident that there are rising pressures on the whole system. We agree there is a need to improve the co-ordination of out-of-hours care, and see how it can help take the pressures off A&E,” said Farrar.
“We believe real and lasting improvements to out-of-hours care are possible, but only if we put a greater level of investment in to primary, community and social care.”
Hospitals face rising threat of mortality as shortage of beds poses substantial risk to vulnerable patients, warns expert
• Jeremy Hunt admits pressure is mounting on A&E services
Overcrowding in hospital A&E departments in England could lead to more deaths and serious illness, MPs have been warned.
Mike Clancy, president of the College of Emergency Medicine, said there were not enough beds as more patients, many of them elderly, arrived for treatment after midnight. “If you were to look at the numbers of people multiplied by the length of time they are spending in emergency departments, that is what is increasing substantially,” he told the Commons health select committee.
“You should know that is dangerous. There is mortality and morbidity associated with overcrowding, we know that …We have to get rid of that overcrowding because it is a substantial risk.”
Clancy’s warning comes a week after his organisation said up to 30% of patients attending A&E should go elsewhere and advocated more GP surgeries being set up at hospitals to help keep them out of casualty.
He told MPs on Tuesday many departments had dropped the NHS’s four-hour target to deal with patients because of the pressure. The number of A&E patients who waited between four and 12 hours increased by 34,000, Clancy said.
The target is for hospitals to admit or discharge 95% of A&E patients within four hours. “The deterioration in four-hour performance, which is a process measure and not a quality measure, has reflected the pressure the system is under,” he added.
“What has happened is that organisations are now focusing more on how many people waiting up to 12 hours, and have in a sense parked the four-hour target because it is so difficult to manage. That is a reflection of the pressure the system is under.”
Patrick Cadigan, registrar of the Royal College of Physicians, said: “One of the big challenges here is out-of-hours care. And the problem is that A&E is the recognisable brand, and that’s where patients will go because they know they will see someone who is expert, often within four hours, and they will receive treatment.
“Patients will go where the lights are on, and in many of these alternatives the lights are not on after five o’clock in the evening and at weekends. And we have to face up to the fact that the services, other than the A&E department, are often run on a nine to five elective basis.”
Later in the Commons, the health secretary, Jeremy Hunt, again blamed Labour for the crisis, claiming the change in GP contracts in 2004, which allowed family doctors to opt out of out-of-hours care, had played a major part in causing it. He also cited Cadigan’s remarks.
Hunt, who acknowledged problems with the 111 NHS advice service and said more needed to be done to give confidence in alternatives to A&E, said: “Last year’s GP patient survey said that only 58% of patients know how to contact their local out-of-hours service, and said that 20% of patients find it difficult to contact their out-of-hours service, that 37% of patients feel that the service is too slow – problems that we are trying to address.”
During heated exchanges, he told his Labour counterpart, Andy Burnham: “Perhaps you should visit some A&E departments, talk to some A&E consultants, talk to some doctors, talk to some nurses, because they will say to you that those changes to GPs’ contracts, which you are saying have nothing to do with the pressures on A&E, have had a huge and devastating impact.”
Ratings published every year will take into account safety, effectiveness and patient experience at GP practices
England’s 34,000 family doctors will face Ofsted-style inspections overseen by a new chief inspector of general practice to secure “safe and responsive care”, the health secretary, Jeremy Hunt, is to announce.
In March, Hunt welcomed findings of a government-commissioned review which proposed a fresh scrutiny regime and warned that there was “a clear gap in the provision of clearly presented, comprehensive and trusted information on the quality of care”. Last year it was estimated that 10% of all GP practices posed a “significant risk” to patients – and would require physical inspections.
In a set of plans designed to underline the health secretary’s pro-pensioner credentials, the health secretary will also say on Tuesday that every vulnerable elderly person will have a “named” NHS worker responsible for organising their heath and care needs. Keeping track of the myriad of care organisations and NHS appointments is a distressing experience and Hunt says older patients want to know who is responsible for their care.
A designated worker would help integrate health and social care as well as keeping the elderly out of hospital A&E wards, he says.
The ratings are likely to be run by the health watchdog the CQC, with which GP practices in England must register from 1 April, but overseen by a new chief inspector. Under an Ofsted-style plan the ratings, which will be published annually, would take into account safety, effectiveness and crucially patient experience. It is understood that this system will be in place before 2015.
The health secretary’s intervention comes as a leading thinktank calls for a fresh debate over whether wealthy pensioners should receive universal benefits at a time when public funding for essential social care is drying up. The King’s Fund warns that the government’s attempts to cap social care costs for the elderly “won’t solve the social care funding challenge”.
It says that since 1980 the number of council residential care beds has dropped from 140,000 to just over 20,000 in 2012. At the same time there has been a dramatic increase in private care home places from 80,000 to 240,000. With NHS long-stay beds also cut by more than half to a little more than 15,000 this means social care for elderly people is largely “privatised”.
How to pay for care, the King’s Fund argues, is now an urgent public policy concern. Local authorities’ spending will have fallen by £2.68bn by March 2014 – a cut of 20% over the current spending review period. The fund calls for a single budget for health and social care to respond to growing demands.
Liz Kendall, Labour’s social care spokeswoman, has repeatedly said the government’s reforms are being undone by a wave of cuts. “The government is in complete denial about the scale of the crisis that is now engulfing social care. We need a far bigger and bolder response to tackle this crisis and ensure a decent and fair system for the future,” she said.
“The King’s Fund is right to call for a single strategic budget for the NHS and social care – this is exactly what Labour has been calling for. We need a genuinely integrated care system which helps older people stay healthy and living independently in their own homes for as long as possible and which supports families to care for their loved ones.”
Controversially the fund outlines radical solutions for making up the shortfall. The thinktank says a flat-rate charge of £20,000 on estates worth more than £40,000 could raise £4.8bn. Alternatively only giving winter fuel payment and free TV licences to those on pension credit raises £1.4bn.
“With just 9% of the total devoted to essential care needs … [this spending has] been subject to ever more draconian rationing, compared with the large sums of public money disbursed through universal benefits – such as winter fuel allowances, free TV licences and public transport – to all regardless of their needs, income or wealth,” warns the fund.
On Monday night a Department of Health spokesperson said: “We recognise that the last spending review provided local government with a challenging settlement. But we prioritised adult social care by providing extra funding for local authorities to help maintain services. In order to make wider improvements to care and support, we need to fundamentally change the way that the system works, not just put in more money.”
Out-of-hours care provider Harmoni says it may need ‘a more attractive employment package’, after CQC review
A privatised out-of-hours GP service in north and central London does not have enough qualified, skilled or experienced staff to ensure it can meet patients’ health needs, a watchdog has found.
The verdict on Harmoni’s operations in part of the capital comes months after a coroner ruled that no individual or systemic failing by the company was to blame for the death of a seven-week-old boy.
The Care Quality Commission found the shortcomings during an inspection of care and treatment records in March, following a Guardian investigation into understaffing of the service. It found that Harmoni fell short on targets for triaging both urgent and non-urgent calls, and for making urgent home visits within two hours and routine ones within six hours.
The CQC found that 52 shifts had been cancelled at short notice between October last year and the end of December, with one doctor cancelling on seven occasions.
Harmoni, the largest private provider of out-of-hours GP care in England, has contracts with 110 GPs and uses agency staff to provide services in north and central London.
Harmoni told the CQC that difficulties in recruiting enough GPs played a part in the failure to meet the required standards, as did underestimates of cover needed for the bank holiday period. It said it may need “a more attractive employment package”.
The CQC said 22% of patients who responded to a survey in December said the service was poor or unsatisfactory, and in a survey in January the figure was 17%. Until the staffing issue was resolved, “there is a risk that delays could affect the care and treatment by patients using the service”, its report said.
Lawyers for the parents of Axel Peanberg King, who died last November after a cold developed into pneumonia, believe the criticism supports their contention that the service was not staffed properly and therefore could not provide the care it should have done.
In February, Shirley Radcliffe, the coroner who investigated Axel’s death, delivered a narrative verdict, which did not apportion blame. She concluded that Harmoni’s overall systems were safe and rigorous, although she concluded that the performance of the last doctor who had been in contact with the family had been inadequate.
That doctor had taken one minute to investigate Axel’s condition in a phone call and made “wholly inadequate” notes of the consultation in between seeing patients, booked at a rate of five an hour, at a Harmoni clinic where he was on duty, the inquest heard. By downgrading Axel’s case from urgent to routine, there was a delay in him seeing a doctor the day he died.
Ellen Parry, the lawyer at Leigh Day representing Axel’s parents, said: “This report supports our belief that the out-of-hours service run by Harmoni was not staffed properly and therefore did not provide the service it should have to our client and her baby boy, Axel.
“Harmoni must realise that the safety of the service is directly linked to both adequate and appropriate recruitment and the service cannot be considered safe until they have solved this issue. If they cannot ensure adequate staffing, by good doctors, then I believe that the service is not fit for purpose and should be taken out of private, profit-based ownership.”
NHS Direct staff 1,200 smaller in number than in 2009-10, resulting in 120,000 more hospital referrals in the past year
The NHS Direct health advice service referred an extra 120,000 patients to accident and emergency departments in the past year, compared with the final 12 months of the Labour government.
The increase in the number of calls to the 0845 service that were considered to require “urgent or emergency” assistance came as staffing levels dropped significantly. More than 1,200 fewer people worked on NHS Direct in 2012-13 compared with 2009-10, according to figures from the service. The numbers appear to offer an explanation for at least some of the huge increase in people attending A&E departments and a crash in performance there in the last year.
Of the 143 trusts that have large A&E units, only 18 have hit the target of treating 95% of patients within four hours, with the goal being missed by a widening margin in recent months.
Jeremy Hunt, the health secretary, has claimed that this is due to an extra 4 million people a year attending A&E compared with the numbers under the last government. He has blamed doctors’ contracts in 2004 allowing GPs to opt out of offering out-of-hours services for pushing people into hospitals. However, the figures suggest that other factors are at work. The coalition has been running down the NHS Direct service, about 40% of whose staff were nurses, since announcing in summer 2010 that it was to be replaced by a 111 helpline run by private call centres.
However the 111 service, introduced nationally on 1 April, has been beset by major serious problems, with many patients unable to get through for hours or being given poor advice and arriving at A&Es in frustration. The figures revealed today show that, as the NHS Direct service has been winding down, it has been pushing more people to hospitals. The proportion of calls referred to A&E in 2009 was 24% of the 4,864,035 calls, up to 36.5% of 3,585,954 calls in 2012. Suresh Chauhan, of the campaign group 38 Degrees, who obtained the figures, said he feared the 111 helpline, run by staff who lack medical training, was sending more people to A&E than NHS Direct, compounding the problem. “The real cause of this crisis is a policy decision made by this government when it came to power in 2010,” he said. “They decided to dismantle the NHS Direct service which triaged out-of-hours calls for medical aid.
“This service, called the 0845 line, had been working for a few years then and had an impressive record of processing the calls by listening to actual problems and giving appropriate guidance.” Alan Milburn, who negotiated the GPs’ contract changes in 2004, said it was “complete nonsense” to claim that reforms introduced nearly a decade ago to improve GP recruitment were hitting performance levels in emergency wards today. Milburn, an adviser to the coalition on social mobility, said ministers needed to explain why performances in A&E departments had improved in the latter part of the Labour administration, only to worsen since 2010.
“It’s complete nonsense and totally spurious to claim a deterioration in accident and emergency performance which only took effect in the last 18 months can somehow be tracked back to a GP contract change from 2005,” he said. “Jeremy Hunt is blaming the wrong government. He has to explain how the NHS managed to improve accident and emergency performances despite an increase in the numbers of people attending up until 2010, but has since failed to do so.”
Maggie Boyle to leave post months after operations at LGI children’s heart unit were suspended over high death rates
An NHS trust at the centre of a row over death rates for children’s heart surgery is to replace its chief executive.
Maggie Boyle will leave Leeds Teaching Hospitals NHS Trust (LTHT) next month, ahead of a management shakeup which follows fears over high mortality figures.
Operations were temporarily suspended earlier this year after concerns were raised over death rates at the children’s heart unit at Leeds General Infirmary (LGI).
Boyle is not believed to have tendered her resignation.
A trust spokesman would not confirm whether her departure was related to the heart surgery fears.
Boyle, a former nurse, issued a statement through the trust in which she expressed support for managerial change and the implementation of a “clinically led” structure.
“It has been a pleasure and a privilege to be chief executive at LTHT over the past six years,” she said. “I believe the move to new management arrangements which will see a clinically led, managerially supported structure being established is absolutely the right thing to do and will have enormous benefits for patient focused care delivery.
“I would like to wish the senior leaders and all of their staff all best wishes for a successful future.”
The trust found itself at the centre of a public outcry when Sir Roger Boyle, the government’s former heart tsar, raised fears about high mortality rates at LGI.
He presented data to NHS medical director Sir Bruce Keogh, who suspended surgery at the hospital’s child cardiac unit for eight days while an investigation took place.
The decision – which meant 10 children had to be transferred to centres up to 120 miles away for treatment – was widely condemned. Experts claimed the information that led to the unit’s closure was incomplete.
But health secretary Jeremy Hunt said suspending surgery was “absolutely the right thing” to do.
Boyle resigned from his role last month.
A trust spokesman said: “Arrangements to cover the chief executive post until a substantive appointment is made will be advised shortly.”
The report calling for an overhaul of accident and emergency services is right. Misdiagnosis nearly cost me my life
I’d always assumed that if you were involved in an accident or became suddenly and seriously ill, A&E would be the best place to go. The doctors and nurses there had seen it all before, would know what to do and of course had the support of an entire hospital if needed. So when, over a matter of just a few hours, I changed from feeling perfectly fine at dinner to being in the worst kind of pain I’ve ever experienced by midnight, A&E was obviously the place to go.
My wife almost had to carry me from the car into the A&E waiting room – being a Friday there was nobody available to help her. I had searing pain in my neck and lower back, nausea, light sensitivity and the worst headache I’d ever had. As no chairs were available my wife agreed with me that it was probably best I just lay on the floor. Goodness knows what I looked like – shivering, covered in sweat while wearing sunglasses with a T-shirt wrapped around my eyes. I was taken through quite quickly and hoped this meant they recognised how serious my condition was. Unfortunately, nothing could be further from the truth. The young-looking junior doctor seized upon my admission that I suffered from migraines in my early teens (I’m now in my 30s), then demanded my wife take me home and stop wasting their time. Tired and in pain, I reluctantly agreed and went home, hoping sleep would do the trick.
Three hours later and the pain and nausea were worse still. Back we went to A&E to find yet more chaos, more patients and seemingly even fewer doctors. Again we were seen fairly quickly, this time by a different junior doctor. So as not to concern my wife, I waited until she stepped out for a moment and implored the doctor to at least consider the fact that I had almost all the known symptoms of meningitis. This was rejected out of hand and to make matters worse I was told not to come back under any circumstances for 24 hours – a point they forcefully made to my wife as well. Back home again, still in pain, I lasted another three hours until I could take it no longer. You often hear that in busy times, ambulances won’t come and get you if you have an alternative means of transport. So my wife did the only thing she could – called 999 and falsely claimed I was unconscious, which wasn’t far off the truth when they arrived.
With the arrival of the paramedics, we had our first dealings with experienced medical professionals. The senior paramedic recognised me from A&E, and demanded to know why my wife had taken me home. He then diagnosed meningitis in less than two minutes. An hour later I was in an isolation room and the treatment I received was first-rate until I went home a week later. A senior consultant visited me every day, apologised for the misdiagnosis and promised me that steps would be taken.
What surprised me was that the hospital didn’t try to cover it up or make excuses. They actually asked me to make a complaint – something I was uncomfortable doing. What became clear to me then and the recent report by the College of Emergency Medicine (CEM) appears to support, is that those in A&E know the system is broken and want something doing about it.
The CEM report has said up to 30% of A&E cases could be seen by GPs or other healthcare practitioners at hospitals, but crucially not in overcrowded A&E departments. People will often want to go to a hospital full of doctors, knowing if their condition quickly becomes serious they’re in the best place. The CEM has recommended the introduction of GPs and urgent-care centres at hospitals. This would allow people to still go to hospital but without causing congestion within A&E departments. Additionally, the number of hours senior consultants are in A&E would also increase if the new proposals are introduced. Perhaps if this system had been in place when I was ill, an experienced doctor would have been able to assist their junior colleagues, who in turn would’ve had more time to consider the possibility I wasn’t yet another patient who should not have been in A&E.
Doctors undeniably provided the treatment that saved my life that day, but without the quick thinking of a senior paramedic the first two visits to A&E would have been my last. Without the persistence of my wife, I would probably have died from an illness that should never kill a healthy adult.
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