Category Archives: Political

STPs – plans being made about us, without us?

Jonathan Leach

Jonathan Leach

Jonathan Leach is a GP in Bromsgrove and Chair of the Midlands Faculty of RCGP. Jonathan initially pursued a military career for 25 years as a doctor before returning to the NHS. He is especially interested in supporting general practice at a time when it is under significant pressure.
Jonathan Leach

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NHS England is in the process of implementing the Sustainability and Transformation Plans (STP), which draws together Clinical Commissioning Groups, local authorities and providers to show “how local services will evolve and become sustainable over the next five years”. In each geographical area there is a STP board who are considering the nine “must do’s” which range from meeting access targets for A&E and ambulance waiting times, ensuring that referral to treatment targets are met, plus other treatment targets such as waiting time for patients with suspected cancer and mental health access targets. Included within the list is a “must do” to address the sustainability and quality of general practice but probably the biggest challenge is to move the whole NHS into financial balance on a backdrop that most provider trusts are in significant financial deficit.

Emerging information from STP boards is that plans are heavily swayed by the need to meet financial balance and to meet specific targets such as A & E access times. There is also concern that many STP leaders have conflicts of interest as chief executives of large provider trusts or local government organisations.

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“Plans are being made about us, but without us”

A recent joint LMC/RCGP workshop in the West Midlands looked at what engagement there had been with general practice. It was disappointing to find that many STP boards had limited or no input from general practice but probably the biggest concern that emerging plans did not take a whole system approach and in particular consider whether general practice and the wider community services has the current capacity to manage a larger patient volume as hospital services change. A separate question was about whether some of the patients would be better predominantly treated in a secondary or primary care setting. One delegate succinctly described matters as “plans are being made about us, but without us”.

The view from the West Midlands workshop was very clear that unless there is a clear plan to increase capacity in the community services as hospitals change, then patient harm will occur. These plans need to be greater than  “working at scale and integrate” as whilst economies of scale will help, they will not address sufficiently the overall capacity of general practice and the community services to manage more patients who are currently seen in a secondary care setting. There was also a significant concern that increasing the workload within general practice was likely to make current concerns about the retention and recruitment of primary care staff worse.

What is therefore key as STP boards make their plans is that they need to consider a whole system approach and incorporate the voice of general practice at a strategic level. This voice needs to understand and articulate the views of general practice and the wider community services with the requirement that system changes are only made once it is clear that these services can appropriately manage the greater number of patients in a community setting.

Time for the old guard to join the social media fray?

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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OLYMPUS DIGITAL CAMERAThe news is everywhere. I don’t mean this in the way that I might if I were a dewy-eyed aspiring journalist, seeing fascination and potential scoops in everything around me. I mean that news coverage seems to be literally everywhere; on the TV, on the radio, on the computer, on the phone in my pocket, on a big screen in Waterloo train station. It’s inescapable. And when it comes to health news, or more particularly doctor news, it never seems to be good news.

Headlines such as: “1 in 4 cancer cases missed: GPs send away alarming number of patients” (Daily Mail, 1st March 2011), “These overpaid doctors must stop whingeing” (The Times, 28th May 2014) and “Study reveals scale of errors on doctors’ prescriptions” (The Guardian 2nd, May 2012), are depressingly commonplace.

Even when we try to recruit the help of mainstream media it seems to get turned against us. The BMA tried to make the point that ten minute appointments are potentially dangerous for patients so that general practice might get the support it needs to provide longer appointments.  To convey this message the ticker feed of the BBC news channel informed the viewer that “GPs are putting patients in danger with ten minute appointments” as though it is out of sheer contempt for our patients that we refuse to give them any more of our time.

It’s not just us. The junior doctors were subject to The Sun’s ‘Moet Medics’ smear campaign and, when the consultant contract negotiations re-opened recently, the BBC obligingly ran a story entitled “NHS consultant paid £375,000 in overtime” to point out that it isn’t only GPs who are workshy and overpaid.

I thought it was just me making my wife feel uncomfortable by screaming at the TV in the evenings, but a recent study in the BJGP exploring why younger GPs are leaving the NHS found that 63.4% of them are also pretty miffed at this continual public abasement.1 Thus far, shouting at the TV seems to have achieved relatively little but there is an alternative. The junior doctors used social media pretty effectively to counter a lot of the negative media coverage during the last round of strikes. The noise on social media outlets revealed widespread public support for the juniors, which helped to strengthen their resolve and legitimise their cause.

Unfortunately, I suspect that many GPs, dare I say many older GPs, are wary of being too vocal on social media, with a hint of concern that opening a Twitter account is akin to giving your patients a key to the back door and painting a target on your back for the GMC to aim at.
This is a shame because social media is our best tool for getting across our side of the argument and it is also a fantastic way of opening up a dialogue with the public. These arguments would be well explored by the reluctant older generation of GPs who have earned experience and gravitas by passing through the mill of the NHS over the last few decades and who can spot the same cycles of mistakes re-appearing over the horizon.

Having a good rant on a blog is incredibly cathartic, I can feel myself relaxing as I type, but it is also a way to reach thousands, potentially tens of thousands, of people in a matter of hours which is exactly what some successful GP bloggers do.

Social media is an effective means to counter the denigrations of our profession and, so dependent has the mainstream media become on social media that, if we make enough noise, we might even begin to influence them. And that might even mean the occasional positive headline.

Reference

1. Doran et al. Lost to the NHS: a mixed methods study of why GPs leave practice early in England. Br J Gen Pract Feb 2016, 66 (643) e128-e135

Brexit and statins: a tale of scepticism

christien-fortune-headshotChristien Fortune is a final year medical student at The University of Manchester and has interests in cardiology and medical education.

In the fabled land of post-June 23rd Britain and Northern Ireland, politics in the UK has been understandably dominated by the UK’s decision to exit the European Union. Vote Leave’s successful campaign, in part, utilised the public’s deep seated suspicion of the juggernaut that is the multinational political union of the European Union; one that in the eyes of the “Brexiteers” yielded little benefit despite its large cost to the UK. What was remarkable was the resonation of Leave’s message with the older population; according to YouGov poll over 64% of over-65s voted to leave the EU.1 The merits of EU membership can be debated until the end of time, but something which is unequivocally clear is that the older generation, in general, did not want to be part of the EU.1

As a casual observer of the UK political scene and avid viewer of the BBC programme, Question Time, I couldn’t help seeing striking parallels between the public attitude towards the EU and another juggernaut, this time of the pharmacological variety. To understand the aspersions surrounding statins is bewildering; at the time of writing, a Cochrane review of 19 studies assessing the value of statins in the primary prevention of cardiovascular disease revealed a marked reduction in all-cause mortality, major vascular events and revascularisation.2 Objectively, it seems unmistakably clear that statins have a major role to play in preventing our cardiovascular disease-baiting, overweight country. Unfortunately, the very nature of opinion does not lie in objectivity. In my admittedly limited experience, I have found a sizeable number of older patients sceptical about the benefits of statins. In broad agreement with my anecdotes, a study looking at adherence in secondary disease prevention for coronary artery disease in a US population revealed that consistent use of lipid-lowering therapy was 44%.3 The US does have other financial factors which will play a role in adherence, however, I’m sure that for certain healthcare professionals, this message will sound familiar. It is interesting that in the case of both the European Union and statins, scepticism seems to be the default setting of the UK’s older generation. Why is it that for a demographic, we (either Remain or medical professionals, take your pick) fail to convince them of a benefit which may be inconspicuous?

Although the older generation’s relationship with statins doesn’t pose quite as bigger problem to the future of our economy as the Referendum result will, it does still have important ramifications to an individual’s cardiovascular-related mortality. A failure to address the unhealthy relationship in those who are wary about the effects of statins has the potential to detrimentally affect the very lives we seek to care for. In a Scottish population, those who were compliant with statin use were more likely to have had the consequences of hyperlipidaemia emphasised.4 Tolmie et al also highlighted the need to a regular addressing of any concerns patients may have in order to prevent patients discontinuing medication without letting their doctor know.4 At the same time, there has to be some serious PR to promote the undoubted benefits of statins in the appropriate cohorts.

Interestingly enough, as was the case in the referendum, a major stumbling block in convincing the public about the benefits of their respective causes is the work of the tabloids. In a 15-day period, the Daily Mail published articles on their website with the following titles, “Statins ‘may be waste of time’…”,5 “Millions of people may be needlessly taking statins every day…”6 and “Don’t give up your statins…”.7 This startling contradiction indicates the type of mixed messages that the public is being told; it is unreasonable to expect the general public to be able critically analyse the underlying research and human nature means that the take home message will be the title in bold above the text. Naturally, this type of journalism creates the perfect conditions to promote widespread reservations about statin use. Therefore, it is up to healthcare professionals to combat the seeds of doubt surrounding statin use and provide a clear and coherent message about the advantage of using statins.

Now, the ship may have sailed across the Channel with respect to the UK’s membership but its sister ship containing some positivity about statins is still in the docks, albeit with increasingly frayed moorings. As doctors, we need to make sure that we shore up the public’s trust in statins; it is, of course, in their interest and that is something that it is easy to overlook.

References

1. Moore P. How Britain Voted. YouGov 2016 [Available from: https://yougov.co.uk/news/2016/06/27/how-britain-voted/.
2. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013(1):CD004816.
3. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113(2):203-12.
4. Tolmie EP, Lindsay GM, Kerr SM, Brown MR, Ford I, Gaw A. Patients’ Perspectives on Statin Therapy for Treatment of Hypercholesterolaemia: A Qualitative Study. European Journal of Cardiovascular Nursing. 2003;2(2):141-9.
5. Spencer B. Statins ‘may be a waste of time’: Controversial report claims there’s NO link between ‘bad cholesterol’ and heart disease. Daily Mail. 13 June 2016.
6. Spencer B. Millions of people may be needlessly taking statins every day: Study claims lowering cholesterol may NOT slash heart attack risk. Daily Mail. 20 June 2016.
7. Spencer B. Don’t give up your statins: Experts say warnings that made patients stop taking vital drug have put lives at risk. Daily Mail. 28 June 2016.

The blue pyjama brigade: primary care in Lesotho

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

IMG_2833Here at RCSI Bahrain our students wear blue scrubs to hospital attachments, but it’s a long time since I have been in scrubs. With some trepidation I had agreed to take four final year RCSI students to work for a fortnight in a small hospital in Lesotho.

Lesotho is a small mountainous nation, landlocked within South Africa. 40% of the population live on less than 1 US$ per day and almost a quarter of the adult population is HIV positive. You are 10 times more likely to die in an RTA than in the UK, and 50 times more likely to be murdered.

I had never been to Africa before. We landed at Johannesburg airport to meet up with a larger contingent from Action Ireland Trust (AIT), an Irish charity involved with development work in Africa. I drove our students across South Africa as part of the bigger party in in a convoy of mini vans. This is the one task I do feel prepared for – after the Middle East even driving in Africa feels OK. The hotel is interesting; nothing seems to work except my air conditioning, which sounds like a small lawnmower.

Together with an AIT doctor I am to supervise our students doing appropriate clinical work. RCSI goes out every year. The Lesotho Medical Council already has our details and copies of our documentation. The actual registration process normally happens on the first morning, when we attend in person with our passports and some cash. But this time the computer says no. Since the last visit the registration process has been “improved” with help from a grant from the EU. It took interventions from an Archbishop, an Ambassador and a government Minister to get us registered. My registration certificate from the Medical Council of Lesotho is now a treasured possession.

And so I became part of the blue pyjama brigade. Myself, my AIT medical colleague and our four students, resplendent in blue scrubs, descended on a small hospital some 30km from Lesotho’s capital, Maseru. The hospital serves a rural population of 200,000. Five GPs with nurse support provide 99% of the medical care for this population via the hospital and a handful of remote clinics. They run the hospital together with a fabulous Hospital Manager and a Nursing Officer.

In Bahrain 30% of the adult population has diabetes and these generate the chronic medical workload. In Lesotho it is HIV and its progeny, TB and PCP. We see new cases every day in packed open access clinics. We see Pott’s disease, TB lymphadenopathy, miliary TB, the list goes on. Having worked in South London I’ve seen many stabbings but now I see my first ever spear wounds (and more ordinary stabbings for good measure). Almost everyone is anaemic. We admit sick kids and serious adult pathology. We deal with broken bones and lacerations. The GPs look after the inpatients also – there is no one else. Only major surgical cases can be transported to Maseru. A close member of a hospital staff member’s family is murdered but she still turns up for work.

IMG_2485We drive to an outlying clinic. I thought the potholes on the main roads were bad, but now we are driving over unmade roads in the hills, eroded and rough. Driving across a ploughed field would be easier. Yet driving each day across the hills and plains of Lesotho is heart wrenchingly beautiful. Changing the inevitable flat tyre was not so beautiful. We were quickly surrounded by smiling faces and helping hands but the smiles disappeared when an unreasonable payment was demanded. I remembered the stabbings we had seen. We gave out some Rand and left quickly.

To say this was a humbling experience is a cliché, yet so true. General practice in the UK is well developed, stressful and increasingly dysfunctional. In Bahrain it is developing rapidly, it is stressful but functioning unencumbered by politicians and micromanagement. In Lesotho it is an immediate battle of life and death. Our five Lesotho colleagues are facing an unthinkable tide of pathology and trauma. Despite Alma Ata and the Millennium Development goals the inverse care law lives on.

Volunteering in the Calais ‘jungle’

calais and france 003

Niamh and Emily en route to Calais

Niamh Scally graduated from Norwich Medical School in 2013 and completed foundation training in Manchester. She is currently enjoying an F3 year before starting her paediatric training in London later this year. She has an interest in health inequalities and care of hard to reach groups.

Emily Player is a GP trainee on the Norwich VTS scheme. She graduated from Norwich Medical school in 2013 and has completed an academic foundation programme in Norwich. She has an interest in medical education and nutrition as well as migrant health and healthcare for vulnerable groups.

We are both junior doctors, feeling helpless and frustrated by the current refugee crisis we decided to travel to Calais to help in whatever way possible with this crisis on our doorstep. We used our annual leave and boarded the Eurostar for the one hour journey across the channel.

We arranged volunteering through the ‘Refugee First Aid and Support’ group on Facebook. We booked our accommodation in the local youth hostel where we met fellow volunteers, arranged lifts to camp and recruited more volunteers including student mental health nurses and dieticians to our medical team.

As undergraduates we had both volunteered in an orphanage in Kenya and later, on elective placements worked in developing countries providing healthcare at a basic level. Now we volunteer in France, there were no ‘grown ups’, and a distinct lack of authoritative presence, with the exception of the police vans which guard and intermittently blast tear gas across the camp.

The days go rapidly, like in the NHS there is not much time to drink or wee and for this we are grateful as we have seen the toilets. We mostly saw URTIs, wounds, scabies and were often confronted with the symptom ‘all over body pain’. We are still unsure if this is due to the cold and damp conditions people sleep in, the malnutrition, the fatigue from ‘trying’ all night or if it is somatisation of the mental pain they suffer everyday when contemplating their situation – this bottleneck they have arrived at here in Calais, twenty miles across the channel from their goal of a better life in the UK. ‘Trying’ itself is an incredibly dangerous activity; one refugee died ‘trying’ in the 5 days we were in Calais.

14259_0_supp_3_795wqtWe were seeing around 200 patients a day when all three caravans were up and running, which solely depends on volunteers. We referred a handful of patients a day to the Le Passe clinic; a service ran by the government hospital in Calais. MSF had been running a similar service until the beginning of March, when their contract expired and their main efforts were relocated to Dunkirk. Examples of cases we referred to Le Passe included febrile children, a non-weight bearing unaccompanied 16 year old child who incurred a police brutality injury, a head injury inflicted by a local fascist group that requiring suturing and a 65 year old Syrian man alone on the camp complaining of palpitations, clinically in AF with oxygen saturations of 88%.

As healthcare professionals along with the refugee’s working as translators we treat numerous tear gas injuries, the dietician was able to give advice on refeeding syndrome to refugees on a hunger strike and together we refer on average 10 unaccompanied children to the youth team a day. The youth team, also volunteers, ensures the children have food, shelter and phone credit, they offer emotional support and a safe place to be during the daytime. They also provide information on staying in France and seeking asylum or expediting their application to the UK as vulnerable minors.

We couldn’t comprehend that there are children alone in the camp; other volunteers reassure us that there are often elders and friends looking out for them, but this doesn’t reassure us, this situation is not normal for anyone let alone a child. It is not normal to run away from tear gas. They are incredibly vulnerable to exploitation. More must be done by the EU governments to ensure these children are being protected. As one of the translators eloquently put, “we are living in the jungle but we are not animals”.

‘An eye for an eye makes the whole world blind’ – reflections on working with Syrian refugees

image Nikesh Parekh

Dr Nikesh Parekh

Nikesh Parekh is a GP trainee, a research fellow in ageing and part-time public health medical associate in London. Colin Tourle is a semi-retired GP in Hailsham.

There are 1.5 million Syrian refugees in Lebanon, of which the vast majority are hidden away in camps near the Syrian border. These are some of the most impoverished victims of the war in Syria, who lack the financial resource to travel further afield for safety.

With the support of Iasis medical charity (www.iasis.org.uk), we were privileged to travel to three refugee camps within a mile of the Syrian border in Lebanon’s Bekaa Valley to provide medical clinics.

The camps encompass vast swathes of land with back to back tents. Word would spread that doctors have come to offer free help and before long a mass of people, usually 75% women and children, would be gathered outside eager to be seen. Crowd control was nothing short of the chaos at a sporting event! It was hard seeing children queuing outside a dust filled tent waiting for us to see them when one could only feel they should be playing in a garden somewhere with a football or trampoline.

We had never quite anticipated how varied the presentations might be, from the expected urine and skin infections, to eczema, to renal stones, to muscle pains, to hypoglycaemic episode, to a likely bone malignancy. Recognising the likely bone cancer in a 7-year old boy was particularly moving. This child needed a haematologist and costly intervention. How on earth will this really happen – where is there a specialist hospital unit? Will the Lebanese doctor discriminate against the Syrian? Who will transport the child back and forth? Who will cover the costs? Who will look after the immunocompromised child if chemotherapy is the treatment of choicer? Is it too late anyway? These were all the kinds of questions one reflects on, and the unknowns are heart breaking.

Making a diagnosis is always a game of probability, but never really more so than in this resource limited setting, where health literacy of patients was minimal and gathering a good history was challenging even with translators. Attention was often diverted onto their painful stories of loss and despair in this prolonged war with no end in sight. The refugees just want to go back to Syria, the land where they grew up, where they had a living, where they had good memories with their families and friends, and where they were individuals as opposed to ‘refugees’. They certainly do not want to make a trip to Europe as far as possible.

Various pressures were on us and it is emotionally, physically and logistically intense – seeing as many people as wanted to be seen, being in a completely unfamiliar clinical setting where the concept of privacy in a medical consultation is non-existent, knowing that unless someone is life-threateningly ill you wanted to avoid hospital because patients knew that it was chargeable and would be reluctant to go. No one has money, and dignity is dying out fast.

There were some just excited by the opportunity to see some new faces in their camp. We knew they were not sick and they knew they were not sick but we accepted this and made a non-verbal deal; We would examine them and show off the stethoscope and they wouldn’t spend too long pretending to have a problem with every organ system. These sorts of cases made us both reflect on a question one inevitably has at the back of their mind but we didn’t dare ask for fear of the answer – how much of a medical difference am I truly making? – but we realised that we don’t need to answer this question because there was no doubt that the presence of a doctor to show care and provide reassurance without asking for anything in return was worth gold. It gave back some dignity, reminded these innocent victims that they are humans and that the world cares for them. They are not forgotten despite their isolation behind white plastic tent sheets labeled with the blue, bold letters ‘UNHCR’.

The Affordable Care Act and USA Healthcare: Reaping the Whirlwind

image1Professor John Frey III is now retired from the University of Wisconsin Department of Family Medicine and Community Health but is still an active teacher, research collaborator, journal editor and ‘faculty whisperer’ about career transitions at all stages of professional life (a free service but you have to buy lunch). He lives most of the year in Santa Fe New Mexico but also part time Madison Wisconsin.

United States presidential elections are ridiculously expensive, far too drawn out, and provide an enormous amount of money for the media consultants to try to convince voters – or more likely scare them – into one position to the other. It is hard to imagine what the initial Republican Clown Car full of candidates must have looked like to the rest of the world. Culling them to a single individual has not helped all that much. Why those who suffer adverse effects from social determinants of health such as poverty, social isolation, family dissolution and low educational achievement continue to vote against their own interests and are attracted to a jingoist real estate developer and ‘small government’ libertarians has been and will be a subject of continuing analysis. Twentieth century history had lots of examples of dangerous demagoguery and likely so will the 21st.

The current situation seems to say “experience and ideas and policy don’t matter, only generalized anger”. Health care always comes up in the Republican debates as “get rid of Obamacare” as I have mentioned previously, with nothing to replace it.[1] Donald Trump infuriates the Republicans by not following the party line on health care and seemingly wants not only to keep the Affordable Care Act (ACA) but improve it in some way that he seems reluctant to describe. But Trump’s daily policy swings assure only that whatever he says he would do will likely turn out to be something else. Health care is more central in the Democratic duo, framed as a ‘pragmatist’ who can get improvements to the Affordable Care Act done versus an ‘idealist’ who advocates a national health system run by government. Having worked hard to help create two Democratic Pyrrhic victories – Eugene McCarthy in 1968 which helped elect Richard Nixon and George McGovern in 1972 which assured a repeat victory by Nixon – I personally am not anxious to stick to the purity of progressive beliefs and bring the world President Trump. Despite different visions of progress in health care, there has been movement, with Secretary Clinton suggesting permitting some people who are still working to enroll in Medicare – the program for elderly and disabled – as an addition to the ACA.

Meanwhile, the ACA moves on to insure more and more people, with the percentage of uninsured now at its lowest point in history. Young people were supposed to be the low risk participants that would offset the high risk pool, and that has happened to a great extent, although not at the levels that the government had hoped. To their credit, young people realize that having health insurance actually frees them to experiment with jobs and careers that don’t carry health benefits. As a result they are busier than ever with entrepreneurial startups and small businesses which are the life blood of society. Not tying health insurance to a job has had a positive effect on what has been labeled the ‘gig economy’ – freelancing and session work controlled by the person rather than the company. If an insured young person in the gig economy breaks a leg, it won’t mean that they have to go live with their parents because they are bankrupt. There has also not been the predicted disconnect between work-related health care as a benefit which has been the foundation of US health insurance. Companies still offer it to most employees, in part because it is a large tax deduction that industry does not want to lose and also because there is renewed competition for workers as the economy speeds up. Private coverage was declining before the ACA was passed but appears to have leveled off. While a substantial victory for the forces of good, the ACA has exposed other problems with the way Americans think about health care and have infused our culture since the mid-20th century.

Two historic cultural problems:

Insurance companies are our friends and protectors

The reforms that had led to a five year leveling off of the cost of health care in the US are now starting to be threatened by two themes that are deeply ingrained in the US psyche: first, the belief that private insurance rather than the government works in the best interests of the people and, second, that getting something for ‘free’ will create an overuse of health services by patients. These two beliefs were sowed in the wind of public opinion back in the mid-20th Century and now the country is reaping the whirlwind. While the rest of the economically developed world adapts health systems to a changing society, the US remains stuck in 75 year old arguments.

The fact that private insurance companies compensate hospitals and physicians and pay for drugs for claims submitted to Medicare always comes as a surprise to the public – and sometimes to physician colleagues. Private insurance companies are contracted as ‘fiscal intermediaries’ for state and federal governments to manage programs like Medicare and Medicaid, for the elderly and the poor. The public has the image of an office building of government bureaucrats in green eyeshades and quill pens in Washington writing checks for over a trillion dollars to health care providers. But these contracts with private insurers limit the percentage of management fees the insurance companies can charge. Allowing ‘only’ a 4% overhead charge to manage Medicare may seem restrictive compared to the up to 20% overhead allowed by the ACA that companies can charge for private plans for the ironically titled ‘medical-loss ratio’ which treats payments for medical care as a ‘loss’ to insurance companies. But because there are more than 55 million of us on Medicare and growing daily, the billions of dollars that insurance companies get yearly to manage a straightforward program with minimal complexity is not so shabby.  But, despite a great deal of research to the contrary,  the public still feels that private insurance companies with high overheads and deceptive practices deliver better quality care than government programs. The Republican Party takes advantage of that belief to denigrate Medicare and Medicaid and the ACA and threaten to turn those programs to the private sector. (Sound familiar?) Not coincidentally the Republicans receive a great deal of money from insurance companies and present no alternative to the ACA other than ‘trust the insurance companies rather than the government’.

On the Democratic side, Senator Sanders picks up on one element of the progressive agenda which started in the late 1940s with President Truman and dwells on the ‘single payer’ mantra which, like so many other sound bites, is not really understood even by those who advocate for it.[2] The problem with ‘single payer’ is that, unless there is a rapid realignment of payment toward primary care and a change from the fee-for-service, production model which dominates US health care, it really would rapidly bankrupt the system. Ontario, in the Canadian single payer system, has moved most of its primary care to a capitated model and salaried service in part because of the strains of fee-for-service care but even with that change, continues to struggle with the right governance and accountability.[3]

In many ways, the whole debate for this presidential election threatens to be a war of sound bites, ‘single payer’ on the left vs. ‘end Obamacare’ on the right with neither party having the skills or the American people having the patience to actually understand what those phrases mean. And no one is discussing the 30 million Americans – the young, the low income families, and the undocumented workers who remain without health insurance.   While ‘universal coverage’ may mean what it says, it may have an asterisk next to it saying “except the 11 million undocumented workers who live here now and who we would like to ignore”. No one wants to have a serious conversation about immigrants at any level.

Being insured yet with ‘out of pocket’ expenses:

I have a photo from a collection from the National Archives of photos taken during the 1930s that shows a general practitioner sitting at his desk with a stern look on his face and a sign that reads ‘Consultations: Cash Only’. While one might be amused by the 80 year old photo, offices and hospitals are more subtle about it now but still demand payment from the patient, even if the patient has health insurance. ‘Co-pay’ and ‘deductible’ are the terms used these days for the portion of the bill patients must pay and are among the more maddening aspects of US health economics. Patients who have to make frequent visits may have $40 charges for each visit in addition to their insurance and so patients with chronic diseases which require frequent monitoring can quickly run up bills that keep them away even though they are ‘insured’. Drug costs are another example. I am on an anticoagulant for which I had a ‘co-pay’ of $15/month for the past year but my most recent refill said I had to pay $50/month for the same drug. The pharmacist gave me no reason and the health plan gave me no warning. All insurance products carry what is termed ‘deductibles’ which is the amount of money patients must pay before the insurance actually pays. The tiers of the ACA have decreasing deductibles with increasing cost of overall insurance. Patients still roll the dice when they are ‘covered’. A recent study reported that two thirds of Americans could not cover a $500 emergency and health insurance deductibles are ‘limited’ to $6850 under the least expensive plan in the ACA market! Such reliably conservative sources as the Wall Street Journal and Forbes have written about how the cost of health care for the average family is rising, even as more people gain insurance, and this cost is creating delays in getting care or receiving appropriate preventive screening. Bankruptcy from lack of insurance is being replaced by bankruptcy from deductibles. What is going on??!!

Underlying all this is the peculiar US cultural belief that if you get something for nothing, you will both over use the service and not value it. When, in the 1980s,  Health Maintenance Organizations (HMOs) made it possible for visits for preventive care and chronic illness to be free, the use of services saw an 18 month uptick but then settled into a predictable pattern of use. Nevertheless, the country has been furiously backpedaling away from the idea of free-at-the-point-of-service care, adding co-pays and other costs to patients to try to steer them away from, for example, emergency rooms or certain medications. It reminds one of the airline industry where what appear to be inexpensive trips suddenly become expensive because of add ons like paying for bags, paying for a seat with leg room, or paying to get on early, all of which add billions of dollars of revenue that was not planned by travelers.

So there continues to be a dance that insurance companies, employers, state and federal government and citizens engage in that keeps health insurance from being simple to understand and that gives energy to the call for ‘single payer’ without having to deal with the insurance companies and their deductibles. The problem with that approach, sadly, is that the largest single component of the US Gross Domestic Product is unlikely to go through a radical change without resistance from those who stand to lose – including doctors, hospitals, Pharma and insurance companies. And if the NHS, with a long history of being widely accepted as the way to do medical care right, continues to struggle with history, economics and a changing world, one can imagine what lies ahead for the Affordable Care Act, which the Republican congress wants to undermine rather than fix.

A colleague, Paul Gordon MD MPH, a Professor of Family Medicine at the University of Arizona, is on sabbatical bicycling across the United States listening in small communities to people’s opinions and thoughts about Obamacare and writing and recording these stories. It is literally a ground level view of what is happening. (You can read Paul’s stories on his blog: https://bikelisteningtour.wordpress.com/ ) He reports the ambivalence and lack of clarity about the ACA that shows how far the country has to go to get it right. However, the percentage of people who see the ACA as positive is climbing and the percentage of those who are negative is dropping and the lines are likely to cross with the next presidency. But that may not happen if the forces of deception, greed and world class dissembling continue to dominate US politics. Paul Starr’s opening line from his landmark book on the history of American medicine, “the dream of reason did not take power into account” summarizes what lies ahead whatever happens in the US elections.[4] Perhaps a corollary to Starr’s comment is that the dream of reason did not take mindless demagoguery into account, either.

Footnotes

[1] Frey JJ 3rd. Is Obamacare working? Br J Gen Pract. 2014 Jul;64(624):360-1. doi: 10.3399/bjgp14X680653.

[2] Oberlander J. The Virtues and Vices of Single-Payer Health Care. N Engl J Med.2016 Apr 14;374(15):1401-3.

[3] Marchildon GP, Hutchison B.  Primary care in Ontario, Canada: New proposals after 15 years of reform. Health Policy. 2016 Apr 23. pii: S0168-8510(16)30087-2. [Epub ahead of print]

[4] Starr P. The Social Transformation of American Medicine. 1982. p 3. Basic Book Inc. New York

StarDocs: The Coffee Shop Model

PicturesJPGJim Pink (top) is a GP, father and songwriter with an interest in people, rather than patients. Jenny Coventry (right) is a fourth year medical student at Cardiff. In her free time she loves country walks and playing in the Cornish waves. Leo Duffy (left) is a fourth year medical student in Cardiff. He enjoys writing and rugby and is a full time Welshman.

The Apprentice: an assorted collection of wannabe entrepreneurs selling their souls in front of the TV cameras for the privilege of working with the self made billionaire Lord Sugar. As we sit in front of the goggle-box, unwinding from the day before, we learn about profit margins, innovation and “up-selling”. Back in the surgery, we reflect on what The Apprentice can teach us about running a GP surgery.

The economic reality that most surgeries are profit-making enterprises is lost to most patients, and indeed, some of our secondary care colleagues. There is a certain irony that whilst most GPs would resist the privatization of the NHS (to profit making organisations), those same GPs work tirelessly to maximize the profits of their own small businesses.

Up-sellling in general practice can mean two things. Even since before Stott and Davies1 described “the exceptional potential of each primary care consultation”, GPs were offering tidbits of health promotion to anyone who might listen, particularly amongst those with potential to improve their lifestyle. This practice of offering “a little extra” is now entrenched in modern UK general practice, so one can’t attend a GP with a sore throat without having a blood pressure check, and few people leave consulting rooms between October and Christmas without a flu jab, whatever they came for. Up-selling in this sense means offering a little bit more healthcare to patients for the price of one consultation, which in most cases, can be mutually beneficial to both patient and practice (not least, in terms of income).

Most will stop there, with the acceptance that if QOF points are maximized and as many people as possible are vaccinated we’ll have done the best for our patients and paid this month’s mortgage. However, what would Lord Sugar say? Perhaps he’d expect a little entrepreneurship in each surgery, particularly in a time where GPs are experiencing the double whammy of falling income and increased demand. He’d expect GPs to come up with a plan to fight back.

Over a mid morning beverage and snack, we had a brainstorm; it hit us. Why not turn the waiting room of our surgery into a coffee-shop? (Selling life insurance or funerals, although no doubt profitable, were rejected on account of insensitivity.) Imagine the scene at the front desk, “I’ll have a skinny, decaff latte with soya milk, a flapjack and a cervical smear please?”

Sadly, not all of us can always run to time, so there are often waiting rooms full of ill, tired and sometimes understandably grumpy patients. Surely a cup of something warming would help? Also, we all know of a patient or two who consider a trip to the surgery as a social outing, so why not make the environment more conducive to this, with newspapers, comfortable furniture and a selection of hot drinks and snacks. Whilst waiting for their coffee to brew, they could either have a natter with other patients, comparing the severity of their ailments, or simply just relax in a quiet corner browsing on their iPhones using the complimentary WiFi. Profits from sale of beverages could be re-invested in to the practice, to improve the service provided and employ additional staff.

Clearly, there are a few potential pitfalls with this plan (not least that not all receptionists are keen to retrain as baristas) but the change of perception of what a GP surgery should look like is worth considering. The future will tell us what role private providers will play in primary care provision, but they will surely not share most GP’s moral reservations about making money from patients.

The strength of NHS general practice is delivering personalized healthcare in the heart of a patient’s community. As such, why should the building not be a community hub? The walls could be decorated with art from the local school and sell local produce in the cafe. Charities offering support to patients such as Age Concern, Citizen’s Advice Bureau and Macmillan could be offered a platform. The building could be used in the evening for exercise classes, book clubs, stress management classes etc.

The inspirational Bromley by Bow Healthy Living Centre have adopted this holistic approach to great effect, with healthcare provision being provided alongside projects to improve skills, lifestyle and support people back into work. Not all surgeries can hope to emulate their approach, but if we strengthen the links to our communities, we may just be able to resist the private healthcare companies that are circling overhead waiting to pounce on our patient lists.

Our vision of the future of General Practice is caffeinated. Whilst patient-centred, individualized healthcare would be the base, we could also add a steamy layer of partnership and engagement with local charities and sprinkle on top the utilization of the practice premises for health improving activities out of surgery hours. And we could sell coffee. We think Lord Sugar would approve. We could call it StarDocs…..

Reference

1.     Stott NCH, Davis RH (1979).The exceptional potential of each primary care consultation. JRCGP,(29), 201-5

 

Junior doctor dispute: The politicisation of a generation

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

I am a junior doctor. I went through medical school, foundation and speciality programmes with relative ease and multiple accolades.  I married a guitar playing, Aston Villa supporting historian I met at university who entered policy work.  I would scoff at his insistence that politics was important – I truly believed that I was doing the only true and noble job in the world. Politics was beneath me.

Experiencing the furore of our contracts dispute I now realise how completely and naively politically illiterate I was.  To disengage with this process and say it does not concern us for we are public servants has proved detrimental.  If the health secretary has done nothing else, he has at least caused a political awakening amongst our generation and I am not ashamed to say that at times this has been thrilling.  I have attended marches, canvased local support, given interviews, written and appeared in newspapers and journals and signed numerous group letters to various news outlets.

Social media has played a central role in this. Facebook groups have allowed us to feel connected to almost every other junior doctor in the country in some way, answer queries, debate responses and celebrate victories. The twittersphere, has enabled rapid dispersal of information and opinion.   Both these have helped nurture and spread the message of an essentially grass roots campaign, like #meetthedoctors, to fight the imposition of a contract that is unsafe for patients and unfair to us.

The unravelling of this dispute in the media has strengthened the resolve of many of my peers to become more politically active.  Many believe that the media have to take responsibility for their role in exacerbating this dispute – you may recall the now retracted 1998 Wakefield study and subsequent rise in incidence of measles as an example.  Indeed the online national survey by Gan et al1 to explore the ‘Hunt effect’ suggested that in the months after reporting of Jeremy Hunt’s irresponsible interpretation of the Freemantle epidemiological study2, there were patients presenting later than they would have to emergency services, afraid the weekend care would be suboptimal.  Patient care was potentially compromised as a consequence.

By engaging with the press, we are able to project our concerns whilst also being able to hold them accountable to what they write – my peers have written letters to the Independent Press Standards Organisation (IPSO) and a complaint about a report on our pay was recently upheld by the BBC.  This increased engagement between our media and the scientific community can only be a good thing, hopefully leading to an improved relationship long term.

As we enter the next chapter of this dispute with a clear mandate for industrial action it is life affirming to realise that we are not alone.   Many patients, allied health professionals and other emergency staff understand the nature of this fight and stand with us.  Becoming politically aware does not have to mean just engaging with politicians and the status quo.  It is also the way we connect on a meaningful level with those around us to make our immediate and extended social, cultural and economic environment relevant and bearable.

Although I am yet like a child taking my first steps in this new landscape, my feelings of political apathy are diminishing and I sense that change is possible.  I’m aware that our contracts debate will take many months to resolve.  But I am hopeful that our political awareness and social responsibility will survive the crest of this campaign post crisis, whatever the outcome.

 

References

1. Gan HW in response to BMJ 2015;35:h4596. Available online:  http://www.bmj.com/content/351/bmj.h4596/rr-52
2. Freemantle et al., Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351:h4596

Junior doctors’ dispute – learning from previous experience

The First Cut Author photo 2Peter Sykes is a retired surgeon and author. His latest light hearted novel, entitled ‘First do no harm’ is set against the industrial action that beset the NHS in the 1970s. His website is www.petersykes.org.

Recently junior doctors voted overwhelmingly in favour of industrial action. It is a situation that they will not have encountered previously, indeed one that many will wish they didn’t have to face. They have many factors to consider when, as individuals, they decide just how militant they are prepared to be. No doubt they will weigh the pros and cons carefully. They may be helped in coming to their decision by considering the lessons learned during the last major dispute with the Government when, as now, junior doctors took industrial action.

In the 1970s, a situation arose that was remarkably similar to that at present. The juniors were negotiating with a Government whose main priority was to reduce public spending because of a burgeoning national debt. Harold Wilson and Denis Healey, Prime Minister and Chancellor respectively, were in the embarrassing situation of having to go ‘cap in hand’ to the International Monetary Fund for a loan to keep the country afloat. A strict wages policy was in place. In the weeks before the ballot, as now, there was relatively little coverage of the dispute in the press though the general public were thought to be broadly sympathetic to the juniors’ plight. Protest marches had been held and representations made to the Minister of Health, Barbara Castle but the Government remained unyielding and a ‘stand-off’ resulted. The mood was one of frustration and anger that genuine concerns were not being heard. There were strident calls in some quarters for a complete withdrawal of labour to force the Government to capitulate. A ballot of junior hospital doctors (JHDs) was arranged.

The ballot paper asked a number of different questions amongst them ‘Are you personally prepared to engage in industrial action and sustain this until the government provides extra money?’ Meetings of juniors were held up and down the country and there was a lively debate in the correspondence pages of medical journals. Some doctors were represented by the British Medical Association, others by the Medical Practitioners Union but a significant number had joined the more recently formed Junior Hospital Doctors Association which was significantly more militant. It rapidly became apparent that many doctors held extremely strong (though widely differing) views on the way forward and the advice they received from the three representative bodies varied enormously.

In deciding how to vote, juniors had many uncertainties to consider. Would it bring doctor into conflict with doctor; some in favour of action, others against? In fact it did; indeed before the result of the ballot was known, a vote of no confidence was passed in the Chair and Executive of the BMA’s negotiating group who were forced to resign from office.

What form should the industrial action take; would some doctors be willing, others unwilling to break the Hippocratic Oath? Who should decide on the form of action? A few spoke of complete withdrawal of labour; others argued that there should be no disruption to the service at all. As it transpired, it was left to individuals to decide and in practice, action was patchy. No one actually ‘went on strike’ and withdrew their labour completely. Some declined to take any action at all, others reduced their hours to 40 per week. Since the average number of hours worked was approximately 80, this had a profound effect and where this policy was implemented, all elective work ceased.

Then there was the question of patient safety; what safeguards would be put in place and who would monitor the situation? In the days before clinical governance, this was left to the conscience of the junior doctors. In the event, there were no reports of disruption to the care of accident and emergency patients.

A major concern was that doctors would damage their career prospects by taking action against the wishes of consultants, some of whom were keen to remind their staff of the hours they had worked when they were juniors! At this time, many consultants were refusing to sign the ‘overtime claims forms’ to sanction payment for work undertaken even though the juniors had a contractual right to such payments. This became a major issue between the juniors and the government who believed that the number of hours of overtime claimed, represented the amount of overtime worked.

A further complication was the major disagreement amongst the juniors as to whether the dispute was about pay or about the principles embodied in the proposed new contract. Is the present dispute principally about pay or is it about safe medical practice? The vote in favour of industrial action, published in November 1975, was 7355 to 5336 (the nature of the action was undefined).

When industrial action began, many failed to anticipate the close examination the press then gave to the junior’s pay and working conditions. This was a time of national financial crisis and support was not universal; some considered that everyone should make sacrifices to help the country through its economic difficulties. Similarly, they were unprepared for the criticism that resulted when patients suffered – as they inevitably did. In 1975, the number of patients treated in hospital was 4% lower than in 1974. The number of patients waiting for admission rose by 12% to the highest level since the NHS began and out-patient attendances were down by 7%. The reputation of the junior doctors was tarnished.

In that previous dispute, there had been no prior agreement of exactly what the government would be required to concede for the industrial action to be withdrawn. In fact, action was discontinued when a contract based on standard pay for a 40 hour week was agreed and an understanding reached that the rate of overtime pay should be determined by an independent body; the juniors therefore returning to normal working before they knew what the financial settlement would be. It was also agreed that the department of Health and the BMA would work jointly to reduce JHD’s excessive hours.

There are lessons to be learned from the JHD’s previous dispute with the Government and it would be wise to heed them. It is hoped that the Department of Health and the junior doctors will resume constructive dialogue so that industrial action, with the inevitable harm that will cause to patients, may be avoided.

Sources

Archives of the British Medical Association
Archives of the Royal College of Nursing
Archives of Confederation of Health Service Employees
Hansard
‘The Castle Diaries 1964 – 1976’ Barbara Castle
‘Fighting all the way’ Barbara Castle
‘The Red Queen’ Authorised biography of Barbara Castle. Anne Perkins
‘The Junior Doctors Pay Dispute 1975 – 1976 Susan Treloar
‘A history of the Royal College of Nursing 1916 – 1990’ Susan McGann, Anne Crowther and Rona Dougall
Lord David Owen Personal Communication