Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

More people are waiting over 4 hours to be seen in A&E than ever before, according to government statistics. Only 84% of people were seen within 4 hours in October 2016, the worst performance ever recorded in October, and 5% worse than last year.

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12 hour waits in A&E tripled between September October in 2016  Credit: John Ferguson

Not only did A&E have its worse October on record, so did 999.  Only 69% of patients who stopped breathing, or had no pulse, had an ambulance arrive within the recommended 8 minutes. This number fell to 63% when other types of life-threatening calls are included (e.g. severe bleeds, strokes).

To top off a truly disastrous triad for the NHS as it approaches the annual ‘winter crisis’, delayed transfers of care took up more time than ever before. Patients spent over 200,000 days in hospital in October, not because they were ill, but because they couldn’t be moved out of hospital. Delayed transfers (horribly known as ‘bed blocking’) occur for  many reasons, the commonest being unable to find spaces in either care homes or other NHS facilities.

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 Delays in providing mobility equipment can delayed people going home, leaving them at risk to infections and other illnesses  Credit: Matt Sawyers

These three indicators (999 waits, A&E waits and delayed transfers) act as a proxy measure for the slack in the NHS. Good numbers in each mean patients are flowing in and out of hospital in a timely manner. Bad numbers mean the NHS is becoming increasingly bottlenecked, and pressure is building up with the system.

Given that all of these indicators typically worsen over the winter, it seems unlikely we’ll be seeing any improvements in the data in the upcoming months. In all likelihood, we’ll see the most pressurised winter in the NHS since records began. Maintaining quality of care in such an environment will be a Herculean task.

 

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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.

Corbyn and McDonnell join protesters near Downing Street in support of junior doctors

Corbyn and McDonnell join protesters near Downing Street in support of junior doctors

Jeremy Corbyn and John McDonnell joined hundreds of demonstrators who rallied around junior doctors on the day of the first ever full-walkout by doctors in the history of the NHS. They spoke to the crowd outside Richmond House, home of the Department of Health (DoH), having marched across Westminster Bridge from St Thomas’ Hospital.

During his four-minute speech, Jeremy Corbyn described a free health service as a human right, and said the Government were ‘more interested in attacking those who work in the NHS’. The Leader of the Opposition said Jeremy Hunt’s behaviour was ‘utterly contemptible’ and that the NHS was not safe in his hands. Other speakers included John McDonnell (Shadow Chancellor), Caroline Lucas (Green Party MP for Brighton Pavilion) and Johann Malawana (Chair of the BMA Junior Doctor Comittee (JDC)).

Dr Jayne Lim, who stood to be the Labour candidate in the upcoming Sheffield Brightside and Hillsborough by-election, said she was pleased to see her party leader join the demonstration and said: “This dispute has seen a lot of doctors realise they are in the same boat as other public sector workers.”

Dr Jeeves Wijesuraj, a member of the JDC, spoke from a picket line outside St Thomas’: “I think today is very sad. I, and my junior doctor colleagues, have never contemplated striking before. We’ve been forced into this position by a health secretary who is not listening to his own doctors, the Royal Colleges or the Patient’s association when they say the contract is not safe.”

Doctors have been maintaining a vigil outside the DoH for two weeks, offering Jeremy Hunt the chance to come and speak to them about the contract. Dr Carrie Thomas, an A&E registrar from a South London hospital, said she’d received unanimous support from the DoH employees she’d spoken to. “I think it’s horrendous in 2016 that Jeremy Hunt has introduced a gender pay gap into a profession where previously it didn’t have one.”

Dr Thomas was referring to the DoH own equality analysis that admits the contract ‘indirectly discriminates against women’ but that this is acceptable because is is for a ‘legitimate aim’. When asked about the safety concerns some have raised about the junior doctor strikes, Dr Thomas pointed out that her hospital today had 19 fully-trained consultant doctors in A&E when there would normally be 3 or 4.

Doctors were not the only people making their voices heard in the demonstration against the Government. Paula Peters, a Disabled People against Cuts (DPAC) activist, was concerned about how the contract would be yet another change for the worse in the lives of disabled people. “For us, [DPAC] it’s personal. Jeremy Hunt has voted for every cut and attack on disabled people. An unsafe, unfair contract that produces tired doctors at risk will put my services at risks. I’ve lost 22 friends [to suicide] as a result of these cuts”

 

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Disabled People Against Cuts activists attended the march alongside doctors

The actions of Jeremy Hunt comes as no surprise to Aine Hall who campaigned  with the National Health Action party against Jeremy Hunt in the 2015 general election. “I was grief-stricken when he increased his majority. I have relatives who are junior doctors, and it’s so upsetting how this dispute is making them feel.”

The Department of Health was asked for comment on the story but did not respond. Two of its employees were spotted wearing BMA badges.

Five major NHS areas are missing their targets

Five major NHS areas are missing their targets

Much criticism of the NHS has been made over the years of ‘chasing targets’. Politicians from both sides have condemned chasing targets for the sake of targets.

The problem with this is that targets are targets for a reason. They  measure how well a system is performing, and should be used to indicate when problems are  going wrong. Unfortunately, the Department of Health seems to not paying attention, as five key NHS area are missing their targets.

1. A&E

A&E has just had their worst ever month. A&E departments have a target to see 95% of patients within 4 hours. In February 2016, the most recent month for which data is available, they managed just under 88%. Not only is this 7% worse than their target, it is the lowest ever recorded. Only 5 hospitals managed to meet the 95% target.

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133 out of 138 hospitals missed their A&E targets

 

2. Diagnostics

Diagnostics tests  can range from complex things like an MRI scan or a urine dynamics test to simple stuff like ultrasounds or blood tests. Nationally, it is expected that less than 1% of patients will wait over 6 weeks to get a diagnostic test.  This target was not met.

In addition, there were 863,100 people waiting for a diagnostics test at the end of February 2016. This is 6.1% more than at the end of February 2015.

3. Transfers of care

Transfers of care occur when people move from NHS (hospital) care to social (community) care. A common example would be an  elderly person who had a fall and and now needs daily carers as he or she returns home. There has been a 17% increase in delays to these transfers of care from February 2015 to February 2016. In fact, January and February 2016 are the two worst months on record for delayed transfers.

More of these delays came from the community than in 2015 – 32.2% compared to 25.9%. This comes after councils have had their social care budgets slashed over recent years.

 

4. 111

What used to be NHS Direct, 111 is supposed to offer people medical guidance in non-emergency situations. Ideally, calls are answered quickly, and if the correct information cannot be provided there and then, a return phone call is offered as soon as possible

Unfortunately, that is not the case. The percentage of phone calls answered in under a minute fell by 13.5% between February 2015 and 2016. For those that needed return phone calls, only 35% received them in under 10 minutes. That is the worst proportion ever recorded.

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Nearly three times as many people had to wait over a minute to have their 111 call answered in 2016 compared to 2015.

 

5. 999 

999 calls about life-threatening medical emergencies are categorised as Red 1 or Red 2. These include cardiac arrests and strokes. The target is that 75% are answered in 8 minutes or less. In February 2016, 68% of Red 1 calls and 60% of Red 2 were answered within the target time. These were the worst months ever recorded.

Both these measures have been under target for the past 9 months. In fact these target have been missed every month since April 2014, with the exception of March/April 2015.

Every missed target here is worrying individually. Put them all in the same system and its a recipe for catastrophe.Whether poorly-managed or under-resourced, the NHS is in a sorry state, and only seems to be getting sorrier under the Government’s noses.

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.

 

The letter that shows even Jeremy Hunt doesn’t believe changing junior doctors contracts will improve weekend care

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Jeremy Hunt’s most recent letter in which he never mentions junior doctor contracts. An omission or an admission?

Junior doctors have been saying for months that they already work 24/7 and changing their contracts won’t improve patient care. It now seems even the Secretary of State agrees with them…

Four days ago, Jeremy Hunt wrote a letter to a fellow Conservative MP, Dr Sarah Wollaston, trying to explain the ongoing media kerfuffle about the ‘7 Day NHS’, and why it’s so important it needs to be tackled.

This is all fairly standard behaviour. Jeremy Hunt is the Secretary of State for Health. Dr Wollaston is Chair of the Health Select Committee, and the most influential M.P. on health matters outside the Government. It makes sense that they would communicate on a fairly regular basis.

He starts by explaining the 10 clinical standards that NHS England describe for 24/7 care. He explains that four standards are most important. These are:

  1. Consultant presence during initial treatment decisions
  2. Regular consultant review
  3. Access to diagnostic tests
  4. Consultant-led interventions

He then sets out his evidence for why these changes are important. He lists 15 studies that have apparently found worse health outcomes during the weekend than on weekdays. He lists a number of proposed reasons for why this might be, including the possibility of sicker patients being admitted at the weekend.

One group of people he doesn’t mention are junior doctors. Not even once. However he does mention their senior colleagues, the consultants. In fact, he mentions them a lot.

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The importance of consultant presence at the weekend is mentioned 5 times in one page alone.

 

 

With no less than 10 mentions in what amounts to 3 sides of A4, Jeremy certainly seems to think that changes to how consultants practise their jobs are necessary to stop substandard care.

He’s also quite keen to mention improved access to diagnostic tests (4 mentions) and to suggest improvements to community and primary care services (2 mentions).


 

For those of you wondering if Hunt mentions his ‘20% increase in stroke death at the weekend’ line, yes he does. He then promptly mentions that the implementation of Highly Acute Stroke Units (HASUs) has reduced this figure dramatically. In his words, ‘this clearly demonstrates the link between seven day services and reduced mortality rates.’

And in my words, ‘and it was all achievable under the current junior doctor contract, as are all your other suggestions to improve weekend care.’

Given that Mr Hunt clearly knows what needs to be done to improve weekend care (and its not junior doctor contracts), and has admitted as such, it’ll be interesting to see if he continues to peddle the nonsense that junior doctors don’t work: at all/enough/with enough ‘vocation’ (delete as appropriate) at the weekend when he pops back into the spotlight again.

Doctors of all grades and specialities want to help make all care, including weekend care, better. The implementation of HASUs shows that where problems exist, the NHS can pull together to change them.  What won’t change them is antagonising all the junior doctors to the point where half of them don’t sign up for speciality training, and quite a few of them never come back.


 

Click here to read the full text of Jeremy Hunt’s letter 

If you’re a junior doctor, medical student or anyone at all who cares about how the junior doctors who work in our NHS are treated, email jdcchair@bma.org.uk and make the subject “FAO: David Dalton & Clare Panniker”. The negotiating teams want to know your views and they want to know them ASAP!

 

 

 

 

 

 

 

 

 

 

 

 

Doctors trying to save lives – even if they are striking

 

first-aid-850489_640Tomorrow passers-by at London Bridge and the Southbank will be able to learn new first aid skills – courtesy of striking junior doctors.

Members of the public can learn the correct way to perform CPR on both adults and children, as well as deal with someone who is choking.

The event is part of a wave of public health events planned by striking doctors across the country. These include first aid training and blood donation.

While most doctors will just be giving up time, some are preparing to give up quite a lot more. Blood drives are taking place in Nottingham, Bradford, Warwick, Birmingham, Leeds and Brighton.

These blood drives have been welcomed by NHS Blood and Transplant: “We’re always looking for new or existing donors to come along. It’s a difficult time of year for donations. People are really busy, the weather is miserable, there’s bugs going around. All these things keep people from donating.”

The blood donations have been pre-organised with authorities to ensure that none of the blood collected is wasted.

People wishing to find out more about donating blood can visit www.blood.co.uk.


 

Birmingham – Sepsis Awareness, Blood Donation, HIV/AIDS Awareness
Bradford – Charity Fundraising, Child First Aid Teaching, Blood Donation
Colchester – CPR and First Aid Teaching
Hove – Blood Donation
Leeds – Child CPR Teaching, Blood Donation, Stem Cell Drive
Lincoln – CPR Teaching

Liverpool, Crosby – Child and Adult CPR Teaching
London Bridge – Child and Adult CPR Teaching
Lymm – CPR Teaching
Nottingham – Blood Donation
Oxford – Blood Donation, Child CPR Teaching
Poole – Charity Fundraising
Southampton – Stem Cell Drive
Southbank – Child and Adult CPR Teaching
Sutton Coldfield – CPR Teaching
Warwick – Blood Donation