“Don’t bring in Keogh, bring in Holmes” Take Sherlock’s prescription

By drphilipbanfield at March 14th, 2014

There are, they say, “lies, damn lies and statistics”. The cross-border debate over hospital mortality rates, with the demand for a ‘Keogh-style’ inquiry into Welsh hospital mortality rates, is an obvious example where the same figures can be used to reach opposite conclusions. How?

We all would prefer life to be black and white, clear cut, not grey and murky. Similarly, we want the truth, not lies.  But life is rarely simple, and to expect the debate on hospital mortality rates to be straightforward misses the fundamental question – are we restoring the people of our nation to health? To answer this we must review how death rates are reported, how they are used and how attempts over the years to improve their meaning have always been controversial.  Finally, we would argue that they form one piece of the complex jigsaw that captures feedback and any concerns raised about our healthcare system in Wales.

The death rates so often in the news recently aren’t actually rates, but ratios. Mathematically, a mortality ratio is the proportion of deaths that occurred compared to the number that would have been expected if the population had had the same rate of deaths once all the causes have been taken into account, as happened in an agreed but ultimately somewhat arbitrary “base population”. It is conventionally expressed as a percentage. Thus, 100 represents the expected number of deaths.

An interesting insight into the historical context is given by Lisa Lezzoni: Henry VII (a Welshman) introduced a weekly ‘Bill of Mortality’ in 1532 to track infectious epidemics, which still forms tha basis for modern communicable disease surveillance and control to this day.  But the thirst for numbers and statistics really flourished in Victorian England. Florence Nightingale (with whom the Welsh nursing heroine, Betsi Cadwaladr had a spat in the Crimean War) and William Farr, physician and social reformer, were soundly criticised in 1863 for publishing misleading death rates for London and the Provinces, when they reported all deaths in London Hospitals over a year, divided only by the number of patients in London Hospitals on a single day and concluded a 90% mortality rate. One reviewer asserted that this was akin to calculating “a hundred apples, divided by fifteen red herrings”. It is unfortunate, because some important truths and messages then get lost in the ensuing argument over what figures MEAN.

Charles Dickens believed that the individual person gets lost amongst statistics and, as a social critic of his day, parodied the Victorian enthusiasm for numbers in his 1854 novel ‘Hard Times’, “In this life, we want Facts, sir; nothing but Facts”. And to a certain extent this was echoed by Sherlock Holmes, when he pronounced “Data, data, data.  I cannot make bricks without clay”.  Sound advice. Arthur Conan-Doyle was, after all, a medical man.

This is just as relevant today, if not more so, as we strive to look for more deaths that might be preventable or avoidable and more patients we can restore to good health.  An avoidable death is not necessarily preventable, for example, if a patient declines treatment or chooses a course he or she feels is more appropriate for them individually.

There have been many attempts to adjust for factors that bring doubt to whether different mortality ratios are directly comparable – apples with apples and not apples with pears. The population variables that become important  include age, the degree of social deprivation, gender and whether someone was expected to die (because they had a terminal illness) or not.  It is in this attempt to make the figures make sense that they end up causing dispute as to whether they make ANY sense at all. This is where Wales and England have diverged, providing a rich seam of slag to be cast back and forth that is confusing to the public.

Whichever counting mechanism is used (Welsh RAMI or English SHMI), both are very complicated.and subject to natural variation and bias.  In Wales, RAMI figures are published by a private firm, CHKS, so there is criticism from some clinicians that we don’t know exactly how the calculation is adjusted.  Similarly, the figures for England count certain patients and not others.  Any figure depends fundamentally on who’s counted (and coded by the hospital in a particular way) and who is included in the total population at risk – and this is also affected by local services, such a care home and hospice provision.

Instead of comparing apples with pears, it is much better to compare an apple with the same apple over time, to see how it is changing.

So what can be agreed? There are fewer wealthy people in Wales than in England and we have a legacy of poorer health and chronic disease.  The English statistics can look superficially better because the larger number of richer people – predominantly in the South East – offsets the poorer health of their own deprived communities.  Thus, it makes more sense to compare Wales with similar populations – such as the North East of England – and we then find that Welsh mortality rates are generally lower. There is an uncomfortable North-South divide in life expectancy for people living in England that is lost in the all-England statistics.

Statistics obscure the individuality of patients and their families – both tragic losses and spectacular recoveries offer powerful opportunities to learn lessons about improving care. It is not only the approach to the comparison systems in Wales that needs changing, but it is the fundamental culture, rather than a response to statistics, that enables an effective early-warning system which prevents a “Mid-Staffs” disaster happening in a Welsh hospital.

We acknowledge the good progress that has been made in NHS Wales over the last year since we first raised concerns.  In BMA Welsh Council, we recognise that this is not just about the process (‘whistleblowing’) by which concerns and feedback are expressed in a manner that is listened to, but how these are valued and converted into improving care. We must demonstrate that our health service is making people better. Welsh Government, NHS managers and clinical staff are challenged to deliver a more open, transparent and listening culture supported by more meaningful statistics which, we suggest, must come from within.

Striving for excellence for every patient costs less in the long run and provides better care.  Our patients are individuals; infinitely variable and rarely the same, let alone ‘average’.  Trends in each institution are monitored and the data establish the expected variation in outcomes.  As care improves this variance falls and you can continue to strive to improve the outcomes by making changes on a patient by patient basis.  A central edict does not always work – hence the co-production and prudent model the Minister is so wisely promoting.  This relies of professional judgement and skill. It is the antithesis of production line mechanisms. Bring back professional leadership and let the indices take care of themselves.  But, meaningful and timely clinical treatment and care outcome statistics are vital or, as Sherlock Holmes might have said, “elementary, my dear Watson”.

 

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BMA Cymru Wales comments on the Written Statement by the Welsh Government on the NHS Pay Review Body and the Doctors and Dentists Review Body reports 2014-15

By administrator at March 14th, 2014

Chair of the Welsh Consultants committee, Dr Sharon Blackford said:

“The position regarding employed doctors’ salaries in Wales is unclear – indeed, the Welsh Government seems to have merely taken the English position and muddied the water further.

“Our reading of the situation is that the government have finally admitted that the NHS in Wales is unaffordable without picking the pockets of those dedicated professional staff who care for patients across Wales. This Fagin-solution is totally unacceptable to doctors.

“It begs the question ‘How can the Welsh Government even consider filling the significant gaps in doctors ranks when it can’t afford to pay for those it already has?’

“It is a massive disincentive to attract and retain doctors in the hard-pressed NHS in Wales, and will only further reduce their morale.”

Dr Charlotte Jones, Chair of GPC Wales said:

“We are bitterly disappointed that the Welsh Government is proposing to implement the DDRB recommendations in line with England, which equates to a 0.28% uplift to the GP Contract. This derisory amount is justified by arguing that practice expenses have fallen – whereas, feedback from our members suggests quite the opposite.

The reality of this “pay award” is to cause yet another real terms pay cut for GP practices in Wales at a time when:

1. Recruitment and retention of GPs in Wales is a growing problem, that will lead to difficulties in sustaining patient services particularly on the back of

2. The ever increasing workloads and demand placed on GPs

3. Welsh Government requires a sustainable GP workforce to develop its strategies

We strongly urge the Welsh Government to re-consider its decision with the view to applying a higher than recommended uplift, that would recognise the strains facing Welsh GPs, and honour the Welsh Health Minister’s commitment to see “our resources invested in primary care”.

 

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The risk of nappy sacks to children

By administrator at March 4th, 2014

Guest blog by Karen McFarlane, Children in Wales

Babies and young children can easily choke or suffocate on the plastic bags used for nappy disposal, and parents need more information on keeping their children safe. This is the subject of a new campaign launched by Children in Wales, Public Health Wales and the British Medical Association Cymru.

Since 2001, at least 11 babies in England and Wales have died as a result of choking or suffocating on nappy sacks. If left around children, they can easily land on and cling to the baby’s mouth, where the child is unable to remove them, preventing normal breathing.

Nappy sacks are used for disposal of nappies when parents are changing their babies, but parents are often unaware of the risks.

 More and more parents and carers are using nappy sacks in every day childcare, but the risks are not well known, and there is a need to inform carers and professionals of the risks and to encourage safer use.

This is especially true as nappy sacks do not carry a choking or suffocation warning in the same way as other plastic bags. The new campaign focuses on getting carers to keep nappy sacks away from children.

Babies under six months are at the greatest risk, but nappy sacks also pose a risk to older toddlers, in the same way as any other type of plastic bag. Parents generally understand the risks posed by plastic carrier bags, but not of those posed by nappy sacks.

Nappy sacks are particularly dangerous because they are lightweight and smaller than carrier bags so can cling more easily to a child’s face.. They are also more likely to be kept near children in childcare settings and have an attractive fragrance.

Children in Wales, Public Health Wales and the British Medical Association Cymru Wales are working closely with parents and professionals to raise awareness.   A  poster has been produced to help with this.  This poster will be on display in every GP practice in Wales and  the organisations are also asking parents to share the information with family and friends. In particular, the campaign encourages carers to keep nappy sacks away children’s bedrooms, buggies and prams.

The poster is available for download from the Children in Wales website: www.childreninwales.org.uk/32896.file.dld .

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The Annual Report to the Conference of Local Medical Committees by Dr Charlotte Jones, Chair of GPC Wales

By administrator at February 19th, 2014

1 minute silence for Donna

Dear Conference,

Before I start my annual report I would like conference to have a minute’s silence in memory of Mrs Donna Martin – for those of you who never knew Donna, she was our committee secretariat for many years but sadly developed pancreatic cancer and passed away last year.  She was more than just the committee secretariat to many of us – she was a loyal, fun and engaging friend who always put the needs of her friends and committee above all else (unless Cardiff City were playing). Conference please stand…….

Thankyou.

Conference, I am honoured to be standing here in front of you after being in post for 6 months – it has certainly been an interesting and challenging 6 months trying to fill David’s shoes – the addition of a stiletto has only done so much

The situation we are facing today in Wales is unprecedented and despite patient satisfaction scores showing that patients are very highly satisfied with the care they get and complaints remaining low, we have a profession that is under strain, demoralised and not seeing any relief on the horizon.

We have spent time consulting and listening to GPs across Wales highlight what the impact that the contract and increased demand was having on them individually and their practice teams.

We heard them confirm that the constant tick-box style medicine, bureaucracy and micro-management of the GP contract and the never ending annual QOF changes was taking GPs away from managing the individual needs of their patients and reducing their enjoyment of the job they trained to do and the care they wanted to provide. 

We had confirmation that increasing patient demand and expectation had again led to an inexorable rise in consultation rates.

We have had confirmation from GPs that the constant shift left of care from secondary into primary care, and the relentless requests to medicalise social problems through form filling has led to their surgeries being workload saturated leaving no time / energy / capacity to consider strategic development of their practices.

We had confirmation that practices were anxious about the income streams coming into their practice – THIS WAS NOT about them wanting to increase their pay, this was about funding being cut through discontinuation of enhanced services and rising expenses all on the back of zero per cent pay uplift leading to concerns about how they could, as a business, continue to provide the same levels of service to patients.

We had confirmation that the predictions we had given Welsh Government about the significant recruitment and retention challenges facing practices were sadly coming true with many finding it difficult to recruit partners.  

We heard about the impact that the consistent negative reports on an almost daily basis by Westminster, media and others denigrating our profession has led to many reconsidering their future in General Practice.  One particular example of this is the widely publicized reporting that the A&E problems are as a direct result of the GP contract……… Conference, we see over 19 million patients / year in Wales alone, if we accepted the reports that 10% of their attendances in A&E were due to a lack of GP access, and we all know that the reality is significantly less, but even based on these wildly inflated figures that would mean an extra…….wait for it conference …… 2 patients / week – I think we could cope! However, it doesn’t take away from the moral sapping effect that these reports bring.

Given the above, GPs were further disappointed that the problems and issues being experienced within General Practice were not recognized by Welsh Government as we were not allocated any of the additional monies given to Welsh healthcare in the Assembly budget round this year – General Practice simply saw the maintenance of the Enhanced Services funding.  Again, I must reinforce this is not about increasing GP pay – it is about having fair access to the resources needed to provide care to patients. The RCGP fairer funding campaign has confirmed that the NHS in Wales has had a significant drop in real terms over the last 5 years and the % spend on GMS care now stands at 7,87% from a high of 10.27% in 2005.  This reduction in investment goes totally against Welsh Government strategic policies of providing more care in the community – how can this be done without investing in General Practice? All the evidence clearly demonstrates the value of investing in primary care and how effective we are – in these times that need prudent husbandry of resources, not investing in General Practice just does not make sense.

So conference, as you know, that is the reality of the situation facing GPs across Wales.

Focusing on what needed to change, together with Government civil servants who are prepared to listen and negotiate in the true sense of the word, we managed to come to a negotiated agreement on the contract which should go some way to alleviating some of the problems around workload. Most of you in the room will be aware of the details of this but in summary, we have:

  • Removed 344 points from QOF
  • Moved 300 of those into the global sum at full QOF point value without 6% OOH deduction – We believe it is better for practices to have more resources in core funding than in QOF and definitely safer in Wales to have it in core funding rather than in Enhanced Services – this also fits with our no new work without new resource mantra. I must stress that this does not mean that GPs and their teams will not stop providing clinical care to patients in areas where QOF points are removed – they will of course continue to do so but when the individual patient needs rather than against set pattern.
  • Did not include any of the proposed NICE indicators for 2014/15 other than wording change for LD domain
  • Agreed a process to protect the outliers when MPIG removal starts in 2015
  • Removed the QOF QP domain 116 POINTS and replaced it with the GP cluster programme with the addition of 14 points – this programme will develop over 3 years
  • Used 30 points to resource completion of the Clinical Governance Self Assessment toolkit to enable GPs to demonstrate that the governance in place in surgeries, identify areas for development and be prepared for HIW inspections of General Practice
  • Agreed no changes to seniority
  • Agreed to participate in a working group to look at publishing GP earnings but not gross earnings – these will be on net GMS income, based on a 37.5 working week to enable like for like comparisons
  • Agreed inclusion of annual CPI adjustment in SFE which will ensure the value of a QOF point is increased annually in line with increases in average list size

The impact of the contract changes will be to:

  • Reduce administrative and bureaucracy within the practice
  • Reduce GP, practice nurse and admin workload
  • Enable GPs and practice teams to manage the individual patient and not be chasing targets
  • Enable practices to determine length of appointments and how they configure services

We believe these changes will be good for patients and good for practices in enabling them to get back to doing what they do best – determining how best to meet the needs of their patients.

I believe it is important to focus on the MPIG redistribution.

As conference will know, for many years, the negotiating team have been under pressure to agree to an MPIG redistribution.  A number of factors have influenced this agenda – the current Health Minister believes it exacerbates health funding inequities and the Wales audit Office recommended its removal in 2008  – the Govt is required to act on its recommendations or justify why they have not done so. The team have faced criticism over the years from those practices who do not have a CF who have received less funding / patient than those with a CF. The reasons for a practice having a CF are multifactorial. These reasons were clearly highlighted to Welsh Govt both verbally and in a written paper at the time this was raised as part of this years negotiation round. The potential unintended consequences of removal of CF were clearly highlighted again verbally and in writing. However, it was made extremely clear to us that this was a non-negotiable area – the question for us as a team was whether we walked away and risked imposition OR we accept the inevitability of this and work on mitigating the losses as far as possible. As 54% of practices would gain from CF redistribution then they would certainly not have been happy for us to walk away and lose the other benefits that a negotiated agreement would bring. The additional benefits of QOF proposals would also advantage those practices losing from the CF changes. Thus, we decided to work on getting as fair a process and as good a deal as we could. To be fair to Welsh Govt they were willing to look at an income loss cap of 15% of the CF % of GSE. Whilst any loss to practice income is a strain and we know that this income loss is on a background of reducing monies coming into the practice including Enhanced Services being decommissioned BUT the harsh reality is it was going to happen. The average loss per affected practice is £5k per year for the next 7 years – this is hard and tough but could have been much worse without the protection for the outliers.

Moving onto networks and why these are being incentivized in this contract round. Conference, we have a one off opportunity for GPs to rise to the challenge, change the rhetoric and seize the agenda to get the resources primary care and patients need. The network development plan is a 3 year programme with year one being the foundation to build upon. We need to get the message out there that if we don’t engage fully and this opportunity is lost then the future is bleak for General Practice.

The network proposals offer practices the opportunity to support each other and learn from horizontal integration. They offer the opportunity to deliver services consistently across a population area and re-ignite inter professional dialogue. It affords the possibility of sharing staff / backroom functions / federating or merging where practices want to do so and I stress – where practices wish to do so. General Practice has served its patients well since its inception but to continue to deliver effective care it needs to modernize.

All sounding rather motherhood and apple pie but this work requires a significant mind set change from the Health board and in particular finance directors:

The deciding point will be whether finance directors will truly delegate a proper budget to networks OR will they keep back a contingency fund and thus nothing will change.

So, if WG truly want these networks to deliver, then they need to under write this risk – my challenge to Welsh Government is to demonstrate commitment to this agenda and put the necessary resources and support in – this will not happen without central direction.

That is enough about the contract because conference, the major challenge facing the profession at the moment is workforce – both recruitment and retention. GPC Wales has been working very hard on getting the various organisations in Wales to wake up to the fact that there is a crisis across Wales. I would like to specifically reference the highly publicized problems being faced in mid Wales, west Wales, the Lleyn peninsula and OOH organisations.

Primary care workforce planning has been in the too difficult or low priority box for far too long. We are now seeing the impact of this and none of us want to see our warnings of “too little too late” come true. We have to have a workforce that is fit for the future and recognizes the needs of the population and the wants of the professionals. The two can marry up but requires innovative thinking and progression of solutions to attract and retain GPs in Wales.

GP training numbers have remained static despite many representations to increase the numbers. Wales currently has 136 training places available – if it is to keep pace with England it needs 200 trainees. We need to ensure those that take a break can return to General Practice quickly and easily.  Returner placements need to be appropriate to the needs of an individual GP – after all, these GPs have already proven their competency to do General Practice already.  Why are they standardized 6/12 programmes? Do all GP returners need to do the AKT, a simulated surgery and a 6 month supervised placement – I would challenge this assertion and say no – some simply need a brief orientation in the NHS. 

NHS Wales needs to consider the wants of the professionals coming through training today– we need to ensure the independent contractor status is understood and invested in as the main bedrock of primary care with other models complimenting this via salaried /portfolio or sessional working depending on the individual GPs wants and the network needs.

Welsh Government needs to look at mechanisms to retain GPs in the workforce – with the pension changes and ongoing complexity of work, increasing demand and stress within the GP why would a GP stay in practice unless they had to? We need to ensure they, and all GPs, feel valued and respected. Maintaining seniority is just one of the options – Welsh Govt urgently needs to keep these experienced GPs in the workforce so additional solutions need to be looked at.

For OOH GPs we have lobbied hard to get cover from the Welsh Risk Pool in recognition that the substantially higher indemnity premiums levied by many of the indemnity organisations has led to many GPs saying they can no longer afford to work OOH or increase shifts when organisations are struggling to fill rotas. Welsh risk pool cover is not enough on its own – we caution all GPs to ensure they maintain additional cover to protect / support them in the event of a criminal or regulatory body hearing.  We welcome the move from the Welsh Risk Pool to extend cover to GPs working oOH as this may well enable individual GPs to reduce their premiums and we are hearing reports that the workforce has increased. We would like to see it extend beyond April 2014 else we are concerned that the workforce problems will worsen.

To those who believe that investing in the GP workforce is money ill spent and that there are cheaper options, I would like to remind them that no other healthcare professional can do what a GP can nor are they trained in the same way – that is not to denigrate their contribution to health care but to suggest they can replace GPs is something that we must strongly disabuse – they can do some but not all of our role.  The cheapest option is not always the most cost effective.

Other achievements of the team in the last year:

  •  Worked with WG to ensure clear transparency of use of HB funds – this is critical going forward in this financial climate. This work has seen HBs working closer with LMCs and being more open re: finances / allocations – this will improve trust and certainty that GMS monies are being used appropriately and properly
  •  The principles of equitable access to remediation and resources has been written into the proposed remediation framework and guidance as well as ensuring that processes map across to agreed performance procedures for GPs.
  •  From an IM&T perspective – we have worked with NWIS to widen the use of IHR for safety of patients being admitted to acute medical intakes, GP2GP starts in Spring, worked through issues relating to systems of choice migration, negotiated 50% reimbursement of asbestos survey cost and actively participated in the data quality system procurement exercise which means that GPs continue to have a data extraction tool they can have confidence in.

We have got agreement for an exciting collaboration with the SAIL database to get information on deprivation – GPC Wales would urge all practices to sign up to this as this could potentially help us prove the need for additional resources into primary care. Conference I wish to assure you that SAIL is not like care.data – it is distinctly different and safer – practice information is split into two before it leaves practices – i.e. clinical data goes one way and demographic data another and they are never married up in a way that could identify the patient. Thus it is safe.

  •  We have worked with WG to ensure that any QOF losses from data migration to new systems of change or QOF point losses from services not available or the late production of business rules does not adversely affect practices – HBs have had guidance to adjust end of year QOF out-turns where it is needed.
  •  For sessional doctors we have negotiated: free seasonal flu vaccines for GPs which is continuing, developed an affiliation scheme for GPs who aren’t part of a sessional group and feel isolated or want to be linked to a practice to access some of the governance work of a practice and got the issues of need for each sessional GP to have their own individual email addresses and prescribing numbers back on the active agenda.
  • We have had lots of “interesting” discussions around the inclusion of the community pharmacists in the flu programme and impact / issues that have arisen from this – there are many motions relating to this in the agenda today but suffice to say, we remain unhappy at the uneven playing field that we have compared with community pharmacy and the fact that nobody will be monitoring whether they have followed the specification they were contracted to provide.
  • The Welsh version of 111 i.e. Phone First has GPC Wales engagement in each workstream and, again, seems to be a sensible approach linking into OOH organisations. It is important that despite Welsh Govt stating the service will be in place by July 2015 that it gets the right solution – not just any solution.

This isn not enough and we are not resting on our laurels– our focus for the next year is on:

  • Workforce – this remains top of agenda for reasons outlined before
  •  We will be supporting networks and driving forward the changes needed to enable networks to have budgets, manage community staff and realise the benefits that these networks can bring to patients and the profession
  •  We want stability for practices so will be looking at the potential for a 2 or 3 year negotiated agreement next year
  • We are working through some solutions to resolve the unintended consequences from CF redistribution and some of the specific issues that rural practices experience
  •  We are involved in ensuring that any inspection of General Practice is appropriate and does not follow CQC processes which have been likened by some to a “witch hunt” – early signs are promising that Wales is taking a separate approach
  • Pushing for investment in premises
  •  Ensuring that sessional and salaried doctors continue to have their needs met and issues highlighted
  • Finally, but importantly, we will be watching to ensure that the Health Ministers expectation that Health Boards will move more resources into the community is kept. I will be supporting the RCPG fairer funding campaign, and conference I would commend you to actively support this both personally and through your practices / workplaces too.  

There will be the opportunity to ask us questions during negotiators question time this afternoon.

Conference, that concludes the report of the Welsh General Practitioners Committee.

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What the Welsh cancer patient experience survey means for GPs

By administrator at January 27th, 2014

Guest blog by Susan Morris, General Manager for Wales, Macmillan.

Doctors are providing a supportive and sympathetic service to cancer patients in Wales, with nearly three-quarters of patients being referred to hospital within two visits to their general practitioner, according to the first Welsh cancer patient experience survey.

The survey, published today, was produced and funded by the Welsh Government in partnership with Macmillan Cancer Support in Wales. It was completed by 7,532 people from across Wales, all of whom had received a primary diagnosis of cancer between June 2012 and March 2013.

The survey shows that more than seven in 10 (73%) respondents said they saw their GP either once (53%) or twice (21%) before they were told they needed to go to hospital. This is encouraging news as it shows that GPs are referring nearly three quarters of people with suspected cancer to secondary care within two appointments. The statistics also show that 17% saw their GP three or four times before being referred and 10% saw their GP five or more times. 21% said they did not see their GP before going to hospital.

Early diagnosis can be key to cancer survival rates. As such, Macmillan is piloting an electronic tool to support GPs to diagnose bowel, lung, oesophageal/upper gastrointestinal, ovarian and pancreatic cancer earlier in 21 Welsh GP practices. These types of cancer were chosen for the pilot as their symptoms either present a particular challenge to GPs or are cancers for which an early diagnosis has a significant impact on the patient’s outcome.

The survey also found that how quickly a patient was referred to a specialist depended on cancer type. Patients were more likely to be referred within two appointments for breast cancer (91%) and skin cancer (84%) and less likely for brain or central nervous system cancer (57.6%) and haematological cancer (59%). Unsurprisingly, these are the cancers where symptoms can be delayed in presenting themselves or can initially present as another condition.

Macmillan welcomes the fact that four in five patients (84%) said they were told the news they had cancer sensitively. However, two in five (30%) were not told they could bring a friend or relative with them for support when they were diagnosed.

For those cancer patients whose general practice was involved in their care, nine in 10 (92%) said that their GP was given enough information about their condition and treatment by the hospital, while seven in 10 (69%) said all the people involved in their treatment always worked well together to provide the best possible care, with a quarter (25%) saying they did this most of the time. However, only two-thirds (67%) of respondents said that GPs and nurses definitely did everything they could to support them while they were having cancer treatment, which shows there is some way to go in fully meeting cancer patients’ needs.

The good news is that four in 10 people now survive cancer. However, ‘surviving cancer’ is not the same as ‘being well’ and one in four of those who survive will face poor health or disability. This may include bowel or urinary incontinence, crippling fatigue, sexual difficulty, mental health problems, gastrointestinal problems, lymphoedema and an increased risk of heart or bone problems. Patients may also find themselves feeling isolated from friends and family or unable to continue working, which can cause increased financial difficulties as well as further isolation (which we know from other research).

Although nearly nine in 10 cancer patients (89%) rated their overall care as excellent or very good, Macmillan is working with doctors and other health professionals to ensure services for cancer patients in Wales continue to improve.

Macmillan is working with Local Health Boards and the Welsh Government to share best practice, fund new posts and services and support them to make improvements where needed. Patient experience is important and good patient experience will help Local Health Boards to deliver more person-centred care, which is a commitment in the Welsh Government’s Cancer Delivery Plan.

A positive patient experience is strongly connected to improved health outcomes, a person’s well-being, their ability to understand and relate to professionals and to take responsibility for their care choices. It can also save the NHS money – a positive patient experience can reduce a patient’s stay in hospital, make them more likely to adhere to their treatment plans, and decrease staff turnover.

For example, the plan says that by 2016 all patients will be given a full assessment of their needs and be involved in developing a written care plan. However, just one in five patients surveyed (22%) said they had been offered a written care plan while less than three in five (58%) had been offered the opportunity to discuss their needs and concerns to put together a care plan.

Macmillan believes that the needs of people with cancer should be at the heart of how care is planned. This means treating people with sensitivity and compassion and ensuring that their care goes beyond the clinical to address wider social, financial, emotional, practical, psychological and spiritual concerns. Research shows that a bad experience can impact on a person’s health and can cost the NHS money.

Every LHB has been sent a copy of Macmillan’s Providing Person-centred Cancer Care in Wales: a Toolkit for Local Health Boards, to highlight good examples of person-centred care in Wales and how Macmillan can work with LHBs to improve cancer patients’ experiences. A copy of the toolkit can be found here.

Macmillan has a number of GP advisers working across Wales who host a range of training events for GPs about ways to support patients with cancer. We also run a course for practice nurses to learn more about meeting the needs of cancer patients. To find out more, please contact Macmillan on 01656 867960.

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Doctors and Mental Health Survey

By administrator at January 27th, 2014

Guest blog from Dr Debbie Cohen OBE

You may have already read this blog post. Re-posting as a reminder to participate, as well as to inform you that the deadline for responses has been extended until March.

The Centre for Psychosocial Research, Occupational and Physician Health at Cardiff University has launched a new survey to understand doctors’ in Wales attitudes to their own mental health.

Doctors are recognised as an ‘at risk’ group for developing mental ill health and there is a growing recognition that this requires closer scrutiny if we are to support doctors effectively in the workplace.  At present we have only a rudimentary understanding of doctors’ attitudes to disclosure of their own mental health concerns and their perceived obstacles to disclose to their workplace.  Understanding these obstacles is important if services in Wales are to deliver effective and timely support.

This survey aims to address some of the gaps in our understanding and provide evidence for how such services should be developed and delivered. This anonymous survey is for all doctors, regardless of whether they have personally experienced mental ill health.  If you are a doctor working in Wales and you wish to share your views, please complete the short online anonymous survey available here:

https://www.surveys.cardiff.ac.uk/doctorsdisclosing

 

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Thousands of sick days taken by NHS staff due to stress related illnesses

By Richard Lewis at January 7th, 2014

A freedom of information request by the Western Mail has revealed the number of sickness days taken by NHS employees due to stress related illnesses over the past three years.

The escalating rise in the number of sickness days taken come as no surprise to BMA Cymru Wales given the high level of demand placed upon doctors and other health care workers on a daily basis in Wales.  Trying to do the best for patients and provide high quality safe services within diminishing resources, staff vacancies and lack of capacity is inevitably demotivating and stressful.

Life and death decisions are made by doctors daily and this enormous responsibility is accepted as a component part of a doctor’s professional role; that in itself is hard enough, but made infinitely worse when faced with relentless pressure on a daily basis simply to keep up with the pace of demand, and meet targets that do not always equate to delivering the highest quality of care and best patient outcomes.  Our members have confirmed increasing levels of stress that has worsened over the past two years and this is reflected in these health board statistics affecting all NHS staff in Wales.

Last year the BMA conducted a national survey amongst doctors which found that 4 in 5 respondents thought that the level of pressure they were experiencing in work was high or very high.  Meeting clinical demands, a lack of time and excessive bureaucracy were the top three workplace stresses cited by the respondents.

The increasing intensity of work has to be better managed to mitigate the rising levels of stress and sickness absence that these figures demonstrate, and to avoid burn out amongst doctors and other health professionals.  Doctors and health staff must be supported, valued and protected to secure the integrity of the workforce and better improve recruitment and retention rather than promote burn out and early retirement.

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Crisis looming for the NHS in Wales in 2014

By drphilipbanfield at December 31st, 2013

I am writing this blog because we must stimulate a public, professional and managerial debate on the future of the NHS and junior doctor training in Wales – the foundations on which the NHS stands are being weakened even as I write.

I apologise in advance, for what is necessarily a long blog, as I touch on the inter-related issues of service provision, medical training, geography, cost, and – above all – urgency. Please bear with me!

The problem is that NHS Wales’ current dependence on junior doctors (primarily here for training, but used as the foundation for service delivery) is unsustainable. This is about recruitment, retention and variation in the standards of training in Wales.  A previous report into training (Calman) envisaged patients being seen less often by trainees and more often by specialists and consultants, but this has not materialised in many Health Board areas, particularly in the acute and emergency specialties.

I worry that so few people have an over-arching appreciation of just how many different factors need to be aligned to dig the NHS in Wales out of its current predicament or how soon this needs to be done.

It is clear to me that the NHS in Wales must take immediate action to decouple the NHS from training in some hospitals. Failing that, both emergency and acute services in the NHS face imminent collapse from August 2014, because of an apparent failure of the service to plan far enough ahead for anticipated reductions in trainee numbers in key specialties.

The time is upon us for action – neither delay nor prevarication can be the response.  There seems to have been a lack of prospective action by Health Boards over the last 3 years, despite being warned several times of the reductions in trainees.

It is possible that the newly published Greenaway Report (on the future shape of medical training) will help with training in Emergency Medicine, Paediatrics and Psychiatry in the medium and longer term, but this will take time to implement.  The time for that to translate into outcomes just does not exist for the NHS in Wales.

The challenges in north Wales demonstrate the dilemma faced by rurality on the one hand whilst having cross border services geographically near by for those in the East, but three acute hospital sites on Welsh soil.  Here, the challenge will be to have junior doctors on sites that can deliver training specific to their identified training needs, with a faculty of qualified trainers – most likely on two of the three acute sites.  Different levels of trainees could be found on one tier of a rota at one hospital and others at another.  This is not an all or nothing solution – services can (and must) be maintained on 3 sites with consultant and SAS Doctors, some of whom may wish to work towards Certificates of Eligibility for Specialist Registration. The value of this work needs to be clearly recognised.  Yet the main topic of conversation seems to be of who will and will not be able to keep their bit of service open.  This is unhelpful because it does not put the needs of patients first.

We cannot allow the changes in training and services to widen health inequalities, yet the needs of our patients do not seem to be at the forefront of many of the current discussions and future decisions being tabled. We seem to be moulding the patients to fit the NHS rather than building an NHS based on the needs of the population of Wales. Put bluntly, it is completely unnecessary, in my view, to make large numbers of patients have to travel 60-80 miles for relatively straightforward conditions or services (such as having a baby, for example).

There are new opportunities for academics and researchers to bring a different focus on each site and within different departments. North Wales has strong links with several universities, but the ‘U’ (University) in UHB remains unexploited for the benefit of the people of north Wales.

The timescale for the Deanery reconfiguration plans are ahead of those in the service and relocating or concentrating services on alternative sites takes both time and resources (financial and staff) to set up.  Current gaps are often bridged by expensive locum staff, for example, so there will be a need to train non-medical practitioners, but we would suggest valuing and building on the excellent service given by Staff and Associate Specialist doctors throughout Wales.

The recent sums of money announced by Welsh Government to support transition are welcome, but seem designed only to prop up an existing service creaking at the seams, rather than address the needs of the massive reconfiguration phase staring us in the face.  Now more than ever, the public needs to debate with politicians, both locally and nationally, to obtain clarity about what the future holds.

We cannot ignore the need for high quality postgraduate medical training in the solution. BMA Cymru Wales understands and supports the need to enhance and protect postgraduate training in Wales. The Wales Deanery has seen its funding cut and many training posts go un-filled in less popular services such as Emergency Medicine and Psychiatry, especially outside Cardiff and Swansea.  This exposes rural parts of Wales to the prospect of the collapse of several services unless something is done urgently to join up the strategy across both healthcare and higher education sectors – for the benefit of the whole of the Welsh nation.

The matching of trainees to qualified trainers is more appropriate than broad-brush 1:11 training rotas that cannot possible provide enough clinical cases in the average hospital; which form the backbone of the NHS in Wales.  It is perfectly possible, given the will, for the NHS to protect a smaller number of trainees such that rotas can be 1:8 in line with those in other UK Deaneries. The problem arises when trainees are used to fill gaps in service rotas, such that their training suffers – hence building the oft-touted 1:11 rotas becomes one challenge too far.  An alternative would be for each Health Board to make the commitment for non-training doctors to bridge such gaps.

As a profession, we cannot continue to ignore what is going on .The alternative is to see the slash and burn of many elective, and some emergency, services and even more prolonged waiting lists, while the service catches up with the junior doctor staffing crisis that it has had warning of for several years.  As now, the solution to this may end up being patchy, reactive, and ad hoc. Creating hugely expensive waiting list initiatives or transferring patients either to England or the private sector isn’t the answer. Each can be equally wasteful of Welsh NHS money.  That is not to say, of course, that some specialised services couldn’t be provided with closer links with partners across our border, where this has clear benefits for Welsh residents.

There is absolutely no reason why the NHS in Wales should be re-shaped by a “collapse by default”, so 2014 will be a pivotal year – we will either be lamenting the removal of substantial portions of the NHS for many patients, or we will be celebrating a unique NHS for our nation that could be the envy of the world.

Let’s be clear – it doesn’t have to be like this. Only by collaboration and co-operation will the NHS in Wales plan and train it’s way out of this impending disaster.

Yes, there are commentators who believe that the devolved nations can avoid copying the fundamental dismantling of the NHS in England. Our solution to a population living longer and having more complex medical and social needs should have “Made in Wales” written through it.

BMA Cymru Wales remains committed to professional and intellectual engagement during the transition from our current unsustainable position to the new NHS in Wales.

I’m reminded of one of my favourite film lines, where Lord Scrumptious said to Caractacus Potts in the children’s film Chitty Chitty Bang Bang “Had your chance, muffed it”.

As we enter 2014, let us hope that the same cannot be said to those creating the future of the NHS in Wales.

Philip Banfield

 

 

 

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Chairman’s Christmas message 2013

By drphilipbanfield at December 24th, 2013

Dear Member,

Doctors in Wales have spent a great deal of the year examining the state our NHS in Wales is in and where it is going.  Before Francis, Welsh Council had already started to debate the culture that exists within the NHS in Wales and how it needs to change. Fear breeds secrecy, but openness fosters blame if those responsible at the top do not take time to understand how the system as a whole has failed those caring directly for our patients. There is much to learn, yet NHS Wales fails to do so with regular monotony; the ‘system’ remains largely a poor listener.  Whereas it could and should welcome and act on continuous feedback of our service, it seem to have become over-complicated and stifled individuals’ ability to make things better, in favour of a bureaucracy for complaints, concerns and whistle-blowing.  What should be a matter for a continual desire to improve, remains an adversarial-based cumbersome machine, with no prompt mechanism for sorting out what went wrong, for learning why it did, nor for putting it right in a timely fashion. That is what makes a difference to patients and front-line staff.

Any new way of working means understanding how groups and teams best work; how to make broken teams better and how to build cohesion out of a system that seems to be encouraging fragmentation of the continuity of care that was the hallmark of yesteryear. I suggest that part of the answer lies in the professional role of doctors being re-visited and valued – and this is our challenge for the year ahead.  Many of us seem to have become resigned to an acceptance that the future is not in our hands.  I disagree and I know that many of you do too.

Key to me making this statement is that doctors are central to providing clinical leadership in NHS Wales.  This goes way beyond the traditional consultant firm, into the new territory that is the multidisciplinary environment we find ourselves in.  But it is vital to understand what a leader is – “someone who is able to influence those who will follow”, and it becomes necessary to then link it to followership – “the ability to influence those who lead”.  The NHS spends millions on the former and pays scant attention to the latter, then wonders why leaders can’t lead and the front-line staff feel disempowered and under-valued.

At a recent leadership event, organised by the DCMO in Cardiff, the dropped penny was finally revealed. Our ability to lead is not just based on a set of skills and learned accomplishments, but on behaviours and feelings – valuing the people we are asking to do extraordinary work, often in challenging circumstances, every day.  If you don’t care about the carers you cannot expect them to provide the sort of quality and compassion you would wish for. Check out

http://www.leadershipacademy.nhs.uk/discover/leadershipmodel/ not necessarily for the complete answer, but for an interesting take on a new direction that shows great promise, I think.

So in 2013, BMA Cymru Wales has helped move forwards the debate on reconfiguration and service reviews, with the publication of specific guidance on both. Our lobbying strengthened both the Human Transplantation (Wales) and Active Travel (Wales) Acts and we influenced the Public Accounts Committee report on the consultant contract when we highlighted the need for training in job planning. Numerous BMA members have also been supported through their individual problems in the work place.

Our task for 2014 will involve effective union action on consultant and junior doctor contracts, but also the professional contribution we can all make as doctors to take the NHS in Wales forwards, not backwards.  I’m frequently asked “what makes doctors different?” It is intangible and defies easy definition, but I know of no doctor who does not feel that the transition from student to doctor and beyond has not affected them fundamentally. It is this difference that cannot be consumed by apathy or resignation to an NHS that does not work for our patients.  This is why we must not give up on the NHS in Wales, for it needs us more than ever – precisely because doctors are different. And that matters.

I wish you and your families a happy and peaceful Christmas.

Dr Phil Banfield

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Officials stay vigilant for flu over Christmas and New Year

By administrator at December 20th, 2013

By Public Health Wales

In the run up to Christmas and the New Year, health officials in Wales have urged all those in ‘at risk’ groups to protect themselves against flu and stay protected throughout the winter too. This includes all those aged 65 or over, pregnant women, and those with long term health conditions. The usual rounds of coughs and cold are circulating this winter, but health officials are wary that flu could start circulating at any time. For those meeting in large groups of people, or travelling a lot over this festive period, the message of hygiene and ‘Catch It. Bin It. Kill It.’ is especially important.

Dr Richard Roberts, Head of the Vaccine Preventable Diseases Programme at Public Health Wales, has commented: “For most healthy people, influenza (or ‘flu’) is usually an unpleasant, but uncomplicated illness, which usually means a few miserable days at home. However, for those in ‘at risk’ groups flu can sometimes result in serious complications, and can even be life threatening. Because we haven’t seen a serious outbreak of flu for a number of years, people can forget how serious flu can be. These ‘at risk’ groups should be especially careful this winter to avoid catching flu, whilst others should be vigilant not to spread it to others if they have it. By following the ‘Catch It. Bin It. Kill It.’ motto, you can help protect yourself and others from catching flu. Every time you sneeze or cough, catch it in a clean tissue and then immediately throw it in the bin, and clean your hands with soap and water or hand sanitizer. Once flu is spreading widely, apart from vaccination, hygiene is the only method that can help prevent spread.”

The annual flu vaccination programme aims to ensure that the people who need it most get free protection each year against the flu. This includes everyone aged 65 and over and people with certain long term health conditions, as well as pregnant women. This year for the first time a flu nasal spray vaccine was offered to children who were two or three years old on 1 September and school year 7 pupils. The younger children had the spray in their GP practice while Year 7 children received their nasal spray vaccine in school.

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Doctors and Mental Health Survey

By administrator at December 5th, 2013

Guest blog from Dr Debbie Cohen OBE

 

The Centre for Psychosocial Research, Occupational and Physician Health at Cardiff University has launched a new survey to understand doctors’ in Wales attitudes to their own mental health.

 

Doctors are recognised as an ‘at risk’ group for developing mental ill health and there is a growing recognition that this requires closer scrutiny if we are to support doctors effectively in the workplace.  At present we have only a rudimentary understanding of doctors’ attitudes to disclosure of their own mental health concerns and their perceived obstacles to disclose to their workplace.  Understanding these obstacles is important if services in Wales are to deliver effective and timely support.

 

This survey aims to address some of the gaps in our understanding and provide evidence for how such services should be developed and delivered. This anonymous survey is for all doctors, regardless of whether they have personally experienced mental ill health.  If you are a doctor working in Wales and you wish to share your views, please complete the short online anonymous survey available here: 

https://www.surveys.cardiff.ac.uk/doctorsdisclosing 

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Bywyd Doctor FP1: Amser I FEDDWL

By administrator at December 2nd, 2013

Dr Holly Kirk

“A yw’r swydd mor wael a mae’r rhaglen deledu Junior Doctors yn ei bortreadu?”

Daeth y cwestiwn ar amser perffaith i fyfyrio tra’n teithio ar y tren ar brynhawn dydd Sadwrn heb straen gwaith a chloch y beep yn tarfu ar yr isymwybod.

I fod yn hollol onest, mae’n anodd i fi ateb y cwestiwn yn gywir gan ‘dwi byth ‘di gwylio’r rhaglen! 

Roedd fy nychymyg yn byrlymu o hunllefau o beth oedd yn fy ngwynebu ar Awst y cyntaf – y diwrnod cyntaf fel meddyg go iawn.  Doedd dim angen unrhyw gefnogaeth gan y cyfryngau  - diolch yn fawr iawn. 

Y gair Saesneg amdano yw ‘hindsight.’

A dyna’n union fydde wedi bod yn berffaith ar y diwrnod cyntaf  hwnnw – deufis yn ol – ynghyd a’r stethoscope a’r bathodyn GIG. 

Dim dagre, dim bod ar ddihun trwy’r nos, dim chwysu wrth bendroni am y ‘diwnod cyntaf’ bondigrybwyll.

Un o’r gwersi mwyaf anodd i’w ddysgu yn y misoedd cyntaf, yw bod y bod y cleifion yn y gwely ar y ward yn bobl go iawn.  

‘Dyw salwch ddim wastad yn codi’n syth o lyfr meddygol:  mae pobl go iawn yn marw er gwaetha’r gofal gore ac er gwaetha pob ymdrech i’w trin.

Mae’r addysgu yn ôl pob sôn yn para trwy gydol gyrfa a ‘dwi wedi dysgu llawer am fy nghryfderau a gwendidau dros y misoedd diwethaf.

Mae fy ngolwg ar fywyd wedi dechrau newid a bydde fe’n anodd –  bron amhosib i rwystro rhag ‘neud ‘ny i fod yn deg.

Mae’n anrhydedd cael rhannu a chymryd rhan fechan ym mywydau pobl ond hefyd atgoffa ein hunain a herio ambell i ffordd o fyw.

‘Dwi heb weld unrhywbeth sy’n haeddu stori mewn rhyw ffilm arswydus eto, sy’n gwestiwn sy’n codi’n aml. 

Mae pwyslais arbennig ar y gair ‘eto’mewn meddygaeth,

“’Dwi heb gweld un o rheini eto…”
“’Dwi heb wneud y job ‘na eto…”

Mae addewid y dieithr yn bodoli a mae rhaid dod i barchu hynny a’i gyfarch fel sialens.   

‘Dwi eisoes wedi cael nifer o brofiadau emosiynol.  Dyma eto sgil anodd i’w fabwysiadu: y sgil o ddangos emosiwn a theimlad ar orchymyn ac nid trwy reddf.  ‘Dwi’n aml yn egluro i bobl fod gen i ddau ben: un meddygol ac un personol ac mae hyn yn rhoi rhyw fath o gysur i fi ac i’r claf fel arfer. 

Er gwaethaf fy ymdrechion gorau wrth adael yr ysbyty gyda’r nos, mae’n amhosib troi ‘nhefn ar yr atgofion, y teimladau a’r  amheuon, a mae hynny’n aml yn llawer mwy poenus a blinedig na’r gwaith ei hun.

Er gwaetha hyn oll, fydden i byth yn newid fy swydd. 

Mae’r  profiadau yn wobrwyol ac yn ostyngedig, gyda’r  pwer i ysbrydoli rhywun.  Mae gwers newydd i’w ddysgu o sut i ddelio â phob un claf.  Wrth gwrs ‘dwi’n mwynhau fy niwrnodau rhydd, ond ‘dwi hefyd yn mwynhau fy niwrnodau ar y ward.

Felly, i geisio ateb y cwestiwn; a yw’r swydd mor wael a’r rhaglen?  Heb os mae diwrnodau gwael ym mhob swydd a ‘dyw bod yn feddyg  ddim yn wahanol   Ond wedi dweud hynny mae’r diwrnodau da fel lluwch aur ac o’m cadair esmwyth gartre, mae adlewyrchiad y lluwch yn cuddio’r atgofion cas.

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