The Budget 2017: three and a half ways it will impact healthcare

If you’re more sensible and more interesting than me, you probably haven’t looked through the thrilling contribution to world literature that is the Spring 2017 Budget.

For those who might still be interested in what our Government plans to do to healthcare spending but don’t have the time or inclination to read all 68 pages of figures, here’s a quick summary of the three healthcare related bits.

(1) £2 billion more for social care

While the NHS is struggling at the moment, social care currently looks like a Curly-Wurly being stretched between two hungry toddlers. Given that, the extra £2bn pledged over three years by Philip Hammond is welcome.

However, it’s estimated social care will need £2.8bn by 2019-20 so unless some more money can be found, or radical new policy solutions are found, social care is likely to be struggling for a while.

(2) £100 million for new facilities in A&E

A&E is in a perpetual state of just about managing, with January 2017 the worst month on record for waiting times. 15% of people had to wait longer than 4 hours to be seen, while the government target is 5%. Whether or not new facilities will stop people waiting longer, having £100 million of new buildings is nicer than not having £100 million to spend on new buildings.

Luckily, the idea proposed by the chancellor – having facilities for GPs to work in A&E – is not mandatory. While in principal having GPs in A&E to help triage patients is not a terrible idea, we don’t currently have enough GPs to fill jobs in GP practices. Transferring some of them to A&E and further exacerbating a community shortage doesn’t seem like the smartest move.

(3) £325 million for locally proposed capital investments.

The Department of Health’s latest wheeze is to get local NHS organisations to restructure themselves using ‘Sustainability and Transformation Plans’. Essentially, this means the NHS has been divided into 44 areas each with it’s own plan for how to make local services address local needs.

While local solutions are great and I’ll advocate localism as a solution for most things, they do allow Jeremy Hunt to say ‘well it’s your own plan’ when something goes wrong, which is probably the main reason they exist. Whatever the motivations, there’s going to be £325 million for local teams to bid for to build new facilities.

However, part of the criteria to receive the money is whether ‘the local NHS area is playing its parts in raising proceeds from unused land to reinvest in local services’. So effectively the policy is ‘sell some of your land, we’ll give you some money’ – which is an interesting way to encourage local creativity.

(3.5) 850 PhDs in Science, Technology and Maths

Not strictly a healthcare related bit, but additional funding for science PhDs is always a welcome thing. Investing in science and engineering always results in future benefits, and the Government has frequently said how much it values scientific research, so its good to see them putting their money where their mouth is.

 

That’s your lot. Nothing too horrendous, but nothing that’s going to radically change health or social care. Though Phillip Hammond has repeatedly said he’s going to make autumn the time when big money changes are made, so perhaps we’ll some more exciting things then.

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Parliament ‘sceptical’ about NHS England’s ability to deliver on mental health targets

An influential committee of MPs released a damning report today into the state of Britain’s mental health system. They found that only 1 in 4 people could access the mental health services they needed.

The cross-party Public Account Committee, in charge of making sure the Government spends money efficiently, said pressure on NHS budgets would make the Department of Health’s new mental health standards ‘difficult to achieve’ without taking money away from other services.

The Department of Health has pledged £1bn over 5 years to improve mental health provision but this is not ring-fenced. With the current financial pressures across the NHS, it will be tempting for NHS managers to use that money to plug short-term holes rather than invest in long-term  mental health provision.

Specific problems cited in the report include:

  • A lack of counselling in some schools meaning many miss the chance to have their symptoms identified early  – half of those who experience mental health problems do so before the age of 14 
  • Variability in the provision of services – in some areas 99% of people are seen in 6 weeks, in others it is just 7%
  • Lack of access to mental health care for current and former prisoners – 9/10 prisoners have a mental health problem, 7/10 have two or more

The Public Account Committee recommended, among other things, that the Department of Health and NHS England did the following:

  1. Figure out how much money they needed to pay for its mental health program, and which areas of spending they prioritised
  2. Join up services across government to improve continuity of care for those with mental health needs e.g. housing, social care
  3. Work out how many extra nurses and additional staff they would require to roll out their programs

Why these things were not done prior to rolling out new nationwide standards is not recorded. However, they do show a continuation of the Department of Health’s remarkably lax approach to planning ahead and gathering evidence, as shown by this argument from their lawyer in yesterday’s court case regarding junior doctor contracts.

 

Yorkshire and Humber School of Radiology to be ran by a radiographer; a bottle of red with lunch blamed

In very specific, but very silly news, The Yorkshire and Humber School of Radiology and Health Education England have chosen a non-radiologist, supposedly Dr Anne-Marie Culpan, as its head. She has no experience of radiology and isn’t medically qualified. She is in fact, a highly capable academic radiographer who has a PhD and is a senior lecturer in breast imaging at the University of Leeds. So no slouch, but definitely not a radiologist – a fact so concerning to the Royal College of Radiologists (RCR) that they are trying to urgently meet with the school to ‘explore how the damage caused by this ill-informed and ill-conceived decision can be limited’.

Now I don’t seriously believe the interview panel didn’t know the difference between the two, but according to the RCR, there was no radiologist on the interview panel, and an experienced and qualified radiologist did apply for the job, so it’s in play. For those unaware, here’s a simple guide that works for most situations –  radiographers use the scanners to do the test; radiologists look at the images to see what’s wrong.


As Anthony points out in the comments, the line between radiography and radiology can get a bit blurry. Some radiographers give radiotherapy treatments; others report on the results of tests in the same way as radiologists. The description above is not to be conclusive.


Now for why this appointment was exceedingly dumb.

  1. Head of Schools are responsible for delivering the training set out by the Royal College of Radiologists. Anne-Marie Culpan cannot even be a full member of this college as she is not a radiologist, leaving her outside of the loop when discussing clinical training.
  2. They are responsible for pastoral and training support of all radiologists in the Yorkshire and Humber area, including those in higher specialty training. Anne-Marie Culpan has not done even foundational medical training, leaving a question open about how much understanding and empathy she will have with complicated training problems.
  3. Anne-Marie Culpan would be responsible for any concerns raised about doctors. While I generally don’t hold much of a candle to the argument that only doctors can pass judgement on other doctors, I quite like those in senior positions to understand what the juniors should and should not be doing. It’d be extremely inappropriate for a radiologist to be in charge of supervising radiographers in training, it is no different the other way around.
  4. I do not know much about Dr Culpan, but her academic and radiographic work seems to have been very focused on breast imaging.  It seems hard to visualise how someone will go from being a very specialist research and teacher in one sub-speciality of a profession, to supervising 125 trainees going through generalist and sub-specialty training in a totally different profession.

While just one appointment, it does seem to part of a trend that doctors aren’t quite necessary under the people running the NHS. To expect a radiographer to understand what its like to be a radiologist and do so well enough to train consultants in that area is a ridiculous idea. It’s the equivalent of having a doctor train nurses or pharmacists, or in the non-medical world, a mainstream school teacher trying to train special school teachers. Let’s hope Health Education England don’t try such a dumb appointment again.

Private Medical Scans – My Experience of Alliance Medical

Private Medical Scans – My Experience of Alliance Medical

NHS England recently awarded a contract for cancer scans to a company called Alliance Medical. This came despite a rival bid from a group of publicly-funded NHS hospitals being £7 million cheaper.

(EDIT  FEB 2016: The contract award was made in January 2015; it has recently been doing the rounds on social media again. The message of this article still stands, however it is a mistake to describe it as ‘recently’ as I originally did. The piece is edited to reflect that.)

The fact that senior Conservative MP Malcolm Rifkind sits on the board of Alliance Medical would clearly have nothing to do with this decision.

The deal was handled by the NHS Strategic Projects team. They helped secure the deal to privatise Hinchingbrooke Hospital. This deal spectacularly collapsed last year amongst damning inspection reports.

All fairly normal for the murky world of NHS private procurement. But unusually, I can actually add something to this news story. I happen to have some personal experience of Alliance Medical and their scanning work. Here it is.

Meeting Doris

During my 2-week placement on a neurology ward, I met a lady, who I’ll call Doris for the sake of this post. Doris had come to our ward after a fall. She  happened to have lost her balance, was a bit confused, and generally seemed ‘a bit off’. This was with good reason.

A CT scan revealed, she had two substantial extradural haematomas, one on the right and one on the left. These are bleeds into the space between the layers that cover the brain and the skull. They are not good news. Quite frankly, it was a miracle Doris was doing as well as she was.

 

Obvious Bleeding

A couple of hours after I’d seen Doris, and after she’d been sent to surgery, I was called into an office by the professor in charge of her care. He showed me a brain scan, not the one I’d seen earlier, and asked me what was wrong with it. Like Doris’ scan, it was an extradural haematoma and, happily for me, I noticed this.

That’s the thing about massive extradural haematomas (or any massive brain bleed/injury). They are a bit obvious.

To prove this to the non-medics reading this, see if you can see what’s wrong with this scan:

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A fairly obvious extradural haematoma.                                                                           Credit:MedPix

Even without the helpful arrows, I’d hope you can notice the massive white blob on the left side of the left picture. Even if you couldn’t say what it was, you’d probably say: ‘That doesn’t look like it should be there, I might tell somebody about it.’

Whoever worked for Alliance Medical and looked at the scan did not think that. They didn’t notify anyone about the massive extradural haematoma, and as a result, that patient went out into the world without being treated.

That patient was Doris. She’d had a CT scan a week before I’d seen her, for a reason I’ve now forgotten. I’m not sure it really matters. Whatever it was, doctors had not thought it serious enough to wait for the report of the CT scan.

That CT scan had been sent to Alliance Medical where three equally bad options await us.

  1. No one looked at the scan in the week leading up to me seeing Doris
  2. Someone looked at the scan and didn’t notice the massive bleed that was obvious enough for a 3rd year medical student to spot
  3. Someone looked at it, noticed what was wrong and didn’t tell either her GP, or the hospital who commissioned the scan, that their patient had a potentially fatal injury.

Actualy, we don’t have three options. It was the last one. The scan had been reported correctly, but no one at Alliance Medical thought it important to tell someone Doris was very, very ill indeed.

As a result, Doris spent a week with a bleed in her brain that could’ve killed her. She then fell and developed a second one.

Unneccessary Harm

Happily, Doris left hospital alive and well. However, it could’ve finished quite differently. She was exposed to a week of serious harm completely unnecessary.

She could’ve easily died if she hadn’t had the ‘luck’ to fall and be ill enough to require a second CT scan.

In this incident Alliance Medical, which  through incompetent management or lack of clinical judegemnt, failed Doris. They failed the NHS, which was required to pick up the pieces of the failure of private healthcare. They failed the British taxpayer who pay them handsomely to look at non-urgent scans so stretched NHS doctors don’t have to.

I imagine my experience is a one-off. I hope it is for the sake of patients like Doris and the NHS as a whole. Otherwise, it seems very unlikely that Alliance Medical will be able to provide a service that’s worth paying an extra £7 million for.

 

Glasgow bin man hid his medical history before last year’s tragic accident

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Mourners for the victims of last year’s bin lorry tragedy in Glasgow.   Credit: Michel (Flickr)

 

A Glasgow bin lorry driver could have avoided the deaths of six people if he had: “told the whole truth” about his medical history.

Harry Clarke, 58, lost consciousness at the wheel of his vehicle on 22 December 2014. It then careened out of control into 23 people, leaving six dead.

At a fatal accident inquiry (FAI) at Glasgow Sherriff Court, Sherriff John Beckett pointed out eight ways the tragic accident could have been avoided, all of which related to his hidden medical past.

Clarke was found to have suffered: “an episode of neurocardiogenic syncope”, one of the commonest causes of fainting.

Syncope is just one of a long list of conditions that drivers may need to inform authorities about including diabetes, epilepsy and anorexia.

Drivers are supposed to notify the Driver and Vehicle Licensing Authority (DVLA) if they have a medical condition which could cause them to: “become incapacitated at the wheel.”

Matthew, a 21 year old with Type 1 diabetes described dealing with the DVLA: “It’s pretty easy, it’s just a case of sending a form off and getting a new license a few weeks later. Though it’s frustrating to need someone else’s permission to drive.”

Sherriff Beckett suggested that doctors could be given greater freedom to tell the DVLA about patients who may be driving unsafely. He even suggested that Parliament could give doctors a legal obligation to tell the DVLA.

The General Medical Council (GMC) said that their guidance already allowed doctors to breach patient confidentiality if they felt their patient posed a risk to the public, without fear of disciplinary action.

Niall Dickson, Chief Executive, said: “Doctors carrying out their duty will not face any sanction.”

The Crown Office responded to the report by saying: “There are no findings in the determination that undermine the decisions not to prosecute the driver.” The DVLA said they are: “carefully considering the recommendations in the report.”


This piece originally appeared on Westminster World

Patients still want unnecessary antibiotics, even with superbugs on the rise

E.coli bacteria. Credit: NIAID
E.coli bacteria. Credit: NIAID

Patient satisfaction drops when GPs don’t give them the antibiotics they want, according to a new study.

Despite antibiotics being ineffective for most coughs and colds, GPs are still under huge pressure from patients to prescribe them.

The General Practice Patient Survey asked nearly three million adults and found that a 25% reduction in antibiotic prescription would cause a GP practise to drop by six percent in national rankings.

Patient satisfaction is taken into account when determining a GPs performance-related pay. A GP practice’s rankings also affect the amount of funding they get, meaning a drop in patient satisfaction could result in a substantial budget reduction.

The researchers from King’s College London were keen to point out that any drop in patient satisfaction from antibiotics could be made up for in other ways.

Listening to and carefully examining a patient was enough for GPs to offset the upset caused by not giving out antibiotics.

This study comes at a time when GPs are under a variety of pressures to reduce the amount of antibiotics they give out.

In August 2015, Prof. Mark Barker of the National Institute for Health and Care Excellence (NICE) said regulators needed to deal with overprescribing doctors who failed to change their ways. The Royal College of General Practitioners (RCGPs) described Barker’s comments as: “counter productive and unhelpful.”

More recently, samples of E. coli, a bacteria that commonly causes food poisoning, have been found in Denmark and China that are resistant to an antibiotic called colistin.

Colistin is one of the last lines of defence against antibiotic-resistant bacteria. Credit: FedEx

Dr Christopher Thomas, Professor of Molecular Genetics said of the discovery: “It is just a matter of time before worse combinations of resistance genes are likely to appear. Since colistin is one of the last resort antibiotics this is therefore very worrying.”

Colistin is a member of group of antibiotics called polymyxins and is unpopular due to its toxic effects on nerves and kidneys. However it remains in use as a last-line of defence against the so-called ‘superbugs’, bacteria that are resistant to all other antibiotics.


This piece originally appeared on Westminster World

 

What Health Professionals Should Pay Attention To In Parliament This Week

Like all weeks in Parliament, there is quite a lot on. Even massive nerds like me struggle to care about most of it, but there are always a few nuggets worth paying attention to. Here are the things healthcare professionals should be paying attention to.

Monday 30th 

The Health Select Committee will release their report on childhood obesity. This report will make uncomfortable reading for Health Secretary Jeremy Hunt, given the recent furore over the proposed sugar tax and the ongoing crises of junior doctor contract talks and NHS finances. The report will probably generate an ‘action plan’, health professionals will be interested to see if it’s up to snuff.

Tuesday 1st

The Health Select Committee will interview the potential new head of the Care Quality Commission (CQC), Peter Wyman. He has held a few interesting roles over his career. A bit of digging reveals the following:

  • He is a senior advisor to Allbright Stonebridge Group – a company that advises multinationals on business strategy, or in blunter terms, a lobbying group.
  • He is a member of the board of Companies House. This group oversees businesses in the UK.
  • He was previously president of the Institute of Chartered Accountants, and a senior figure at PriceWaterhouseCoopers.

It is a little surprising that the Government’s preferred candidate  to oversee the quality of healthcare is a man with ongoing interests in business. Hiring Wyman would open them up to further criticism about their desire to further the links between the NHS and private business interests.

Friday 4th

A bill designed to make off-patent drugs cheaper will get its second chance in Parliament. It will take a miracle for it to even be talked about as 11 other bills have to be voted on before it. It has such a late position as it was blocked on its first day by Alistair Burt, Minister for Social Care, who spoke for nearly half an hour to stop it passing.

 

To be honest, a lot less of interest to healthcare professionals in Parliament this week than most weeks. Though the upcoming junior doctors strike, and the ongoing NHS financial crisis, will ensure health and politics don’t stray too far apart.