BMA Welsh Council elections and you!

By drphilipbanfield at May 16th, 2014

The BMA exists for the benefit of its members.  For many, it might not always feel like that, but the relatively small size of the BMA presence in Wales gives greater opportunity for cohesion. As ‘health’ is a devolved power, the BMA in Wales has more direct access to Government, politicians and senior civil servants.  The healthcare environment in Wales is different, though no less challenging than in England; a collaborative, rather than ‘market based’ approach.  Ours is a ‘national’ health service, while England is (not so subtlety) being gradually privatised.

Individual BMA members can meet locally through a ‘Divisional structure’.  Although Divisions’ traditional role may have largely been superceded by social media, they still offer a way to feed into the ‘Annual Representatives Meeting’ (ARM), which makes overall BMA policy.  It is through this structure, and the challenges to service changes in north Wales made by my local Division, that I became involved in medical politics, and I haven’t looked back! Now I’d like to invite you to participate in our work.

The trade-union role – including Terms and Conditions of service – is largely dealt with at specific Branch of Practice committees such as GPs, Consultants, Academics, SAS Drs, Junior Doctors, Public Health, Armed Forces and Retired members. Welsh Council sits over many of these committees in Wales, with representatives from each, but it is expected to produce a cross-Branch of Practice perspective where required to do so.

Welsh Council has a simple vision:

“…to improve the health of the people of Wales by representing the doctors who care for them”.

In recognising that Welsh Council needs to reflect members more transparently, part of its membership is achieved by direct elections from the whole membership in Wales. In the last 2 years we have begun to push further to develop Welsh Council as the professional voice of doctors in Wales. As service and training reconfigurations have threatened profound change, we have, for example, been clear that the health needs of patients must come first and exposed the detail – sadly often lacking – that is required for the public and clinical staff to make informed decisions.

In the wake of the Francis Report, Welsh Council is engaged proactively in work on leadership, transparency and openness – for these remain common issues brought to our attention by members  – and our work on whistle-blowing and professionalism will continue in the next term.

There is an expectation that a member of Welsh Council is there to contribute.  The BMA Office staff in Cardiff are simply superb, but cannot replace the voice of members of the medical profession being heard directly.

Although we have a common aim and a team approach, we respect, value and appreciate the diverse views of our membership, and therefore those on Welsh Council.  In considering and working through differences, we arrive at a consensus position.  We have a personal and ethical code of conduct and behaviour that reflects our professional duties as doctors in Good Medical Practice.  This is the only place where medical students, junior or SAS doctors have an equal voice with their seniors. It demonstrates the strength of the BMA in shaping the future of NHS Wales, for it is only by breaking down barriers and silo mentalities that the necessary collaboration will take place – and this is good for doctors and even better for patients.  I follow immediately that we are ‘senior’ only (and most often) in age!

There is an expectation that the directly elected members will feedback to their respective Divisions, completing the circle to the members we serve.  In the age of social media, we are working on innovative ways to meet the modern expectations of members.

This is a pivotal time for NHS Wales.  We can and must re-establish the medical and other professions as leaders and change makers in the NHS in Wales.

The BMA is your organisation and Welsh Council is neither a club, nor exclusive, so we would encourage you to stand at the forth-coming election.  Welsh Council is a friendly place to be in a world that seems very contradictory and hostile to what many of us felt we came into medicine for – to care for patients, their families and our communities.

2014-2017 will see a new NHS in Wales.  We believe that BMA Welsh Council has a vital role in this – and we invite you to be part of that, too.

 

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Coming soon … Welsh Council Elections

By administrator at May 2nd, 2014

Keen to influence and debate the key issues facing the medical profession in Wales today? Then why not think about standing for election to Welsh Council? Elections for the next session 2014-2017 of the Welsh Council of the BMA will begin in mid May.

Welsh Council is the cross-branch of practice committee in Wales which deals with matters of concern to the whole medical profession in Wales. There are 15 directly elected members on Welsh Council.

Members are elected to Welsh Council for a 3-year term, with 4 meetings a year. Travel and associated costs are reimbursed in line with BMA expenses policy.

A formal notice will follow in the BMJ. In the meantime, for more information, please contact Sarah Ellmes on 029 2047 4604 or email: sellmes@bma.org.uk

 

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General Practice is stretched to breaking point

By administrator at April 22nd, 2014

by Dr Charlotte Jones, Chair, GPC Wales

Looking around me at the enormous challenges facing GPs across the UK with respect to the workforce, rising demand and ever lowering morale, it has made me reflect on some correspondence we have had from GP practices across Wales. As we all know, practices across Wales are experiencing significant recruitment / retention problems, and are seriously having to consider the range of services they offer to patients due to ever dwindling resources and feeling the pressures of ever increasing demand. What has been interesting is that some have reported that their Health Boards are supportive but waiting for Welsh Government, the Deanery and GPC Wales to solve the problem……interesting……..but this has highlighted to me that there is a lack of understanding about the role of GPC Wales.

GPC Wales is the elected body of GP representatives who have a statutory role in negotiating contractual matters with Welsh Government and others. In addition, GPC Wales has a professional advisory role raising wider issues affecting GPs, giving opinions and offering solutions / assistance where appropriate (eg our workforce paper, work on rural DES) or informing WG what will be the consequences (eg practice closures). GPC Wales does not have the gift or resource to put in place the solutions – this is for HB and WG, so it is disingenuous for HBs to imply they hear practices pain but are powerless to help. I think practices MUST go back and ask Health Boards “thank you for sharing our pain, now what are you going to do to help”? I believe LMCs need to push HBs to start addressing the issues that are impacting adversely on General Practice – GPC Wales cannot do it alone.

There is too little visible progress being made on General Practice matters – this is most definitely not down to inertia on the part of GPC Wales and the negotiating team who continue to use all avenues / opportunities to push the need to address issues to ensure the future of General Practice but it is simply not in our gift to solve these problems.

I believe that General Practice is stretched to breaking point – it feels like a “perfect storm” and a very real crisis on the ground across large parts of Wales and indeed across the UK. Without urgent intervention, this will lead to practices closing and patients having difficulty accessing General Practitioners. This is not what ANY of us want. WG and HBs cannot afford for this to happen.

Whilst I wanted to give a cheery message to those of you who will have a well deserved break over Easter – for those of you working OOH I will be sharing some pain – chocolate has been shown to improve a sense of wellbeing and happiness……I don’t think any amount of chocolate Easter eggs will solve the problems of Welsh General Practice no matter how much I eat on your behalf – time for practices and LMCs to push HBs to “act now”.

@MadameGPWales

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Macmillan Wales offers new free course to practice nurses

By administrator at April 16th, 2014

Guest blog by Dawn Casey, Senior Learning and Development Manager for Macmillan Cancer Support in Wales

Macmillan Wales is offering a free new course to practice nurses to support them to learn more about cancer patients’ needs and how to meet them.

We ran our first practice nurse education course last year in Brecon and 22 nurses from GP surgeries across Wales completed it.

After completing the course, every nurse said they rated their understanding of cancer as either strong or excellent.

Each participant also said they had either carried out or were going to carry out cancer care reviews to assess the needs of patients who had finished cancer treatment within the last three months.

This review includes assessing their emotional, financial and psychological needs in addition to their medical ones.

Feedback from nurses who completed the course included: “Previously I was not at all comfortable talking to cancer survivors or patients undergoing cancer treatment, mainly due to lack of knowledge.

“However, since starting the course and acquiring vast amounts of information, I will now initiate a conversation with patients. I will quite happily and confidently discuss matters that they wish to talk about.”

Another nurse said: “I have found this course so helpful, I hadn’t realised just how many of our patients with chronic conditions were cancer survivors.”

Macmillan hosted a celebration event for everyone who completed the course at The Barn, Brynich, on Wednesday 26 March to celebrate their successes.

We are now offering more dates for the course, which is made up of five one-day sessions covering topics such as cancer awareness, conducting a cancer care review and health policy in Wales.

We are running the course as more than 120,000 people in Wales are living with or beyond cancer and will need ongoing treatment and support at their GP practice either during or after their cancer treatment.

Results of the first Wales Cancer Patient Experience Survey, which the Welsh Government carried out in partnership with Macmillan, showed that only two thirds of cancer patients (67%) felt that GPs and nurses did everything they could to support them during their cancer treatment.

Macmillan wants to help GPs and practice nurses to feel more confident when supporting people living with or beyond cancer.

Courses will start at The Oriel Country Hotel, St Asaph, on Wednesday 21 May and at The Barn, Brynich, on Thursday 5 June with four further dates held every month.

Practice nurses wishing to attend the course will need to register in advance.

To find out more, or to register, call Macmillan Wales on 01656 867960 or email me via dcasey@macmillan.org.uk.

 

 

 

 

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Getting it wrong

By drphilipbanfield at April 15th, 2014

We must make more effort to define and address the unintended consequences of decisions on our health services.

A recent tweet about trying to ban mobile phone roaming charges in Europe, reminded me of one of my (many) times I ‘got it wrong again’. Quite a few years ago, I lectured in Moscow as part of work I was doing with the WHO European Office in Copenhagen, finding myself put up in a local hotel, with a matriarch guarding each floor and only one international phone in the lobby. It was character building, to say the least.

Determined to be more accessible next time, I took my mobile phone with me the following year. It worked much better in Moscow than it did in north Wales. Four days away from home; I limited my calls to brief hellos to the kids and quick updates on the trip. The Russians couldn’t get their research fellow to the next WHO meeting – I rang Denmark, feeling proud of negotiating $200 for their doctor’s airfare. Job done.

Back at Manchester Airport, I took to my ‘phone to confirm my arrival.

“Calls from this mobile are barred”, announced the automatic message.

I rang customer services from a pay-phone. After all, I had never defaulted on my £17/month plan.

Did I have a credit card on me? They would re-connect me if I paid £300. I asked – purely out of interest – what the actual bill was. £678!

I wanted the ground to swallow me up. I asked them to explain at what point they had noticed I was spending more than my monthly average and why they hadn’t phoned me to query the usage, but to no avail.

Mrs B took it in her stride, but then she’s a calm GP and like that. We found a way to pay off the bill over several months – and changed ‘phone company. In my zeal to be helpful to a Russian colleague, I had generated the unintended consequence of finding myself more out of pocket than if I had just paid for the ticket myself.

I mention this because this is what is happening to our NHS in Wales – a series of relatively isolated decisions with scant scientific or economic evaluation and practically no attempt to consider the unintended consequences, arising from reconfiguration of both hospital services and postgraduate medical training. Decisions made seemingly without consideration, understanding or appreciation of the impact they have on patients and their families.

Sadly, we are getting reports that those who highlight deficiencies or question motives, outcomes and practicalities are still encountering veiled threats of a disciplinary process! Instead of stopping to consider whether this minority may have a valid point, the tendency to steam-roller on through the security of ‘group-think’ seems to be prevailing under the umbrella that something must be done urgently to address short-comings in our creaking under-funded service, but this risks alienating clinicians dedicated to caring for their patients. Have we learned nothing from Mid Staffs?

We still seem to have NHS organisations that close their ears to criticism and which do not have the where-with-all or resources invested in actively listening – to patients or staff. And nearly a year on from the National Staff Survey many frontline clinical staff still report feeling unsupported while doing their job, even just a little bit better. In fairness, austerity measures really don’t help with this, but don’t get me on to HR policies, the locum bill and wasted resources again.

Perhaps it is my obstetric background that focuses my attention so firmly on individual patients; the decisions we make – and get wrong – affect a generation and whole families. Obstetricians spend a great deal of time reflecting on past mistakes and desperately trying to avoid making them again in the future. We live in the communities we serve, because we have to be immediately on hand in an emergency, constantly reminded of our fallibilities. It is no wonder that we care passionately about our patients. And I am sure that many other hospital specialties – and general practice – are the same.

It is much easier to take ‘tough decisions’ that affect others when we do not see and live with (and in) the consequences directly ourselves, either immediately or in the longer term. It’s similar to an earthquake; while those at a distance may experience it momentarily, it is those at the epicentre who have survive where havoc has been caused.

It is much tougher to admit that the evidence points to more challenging options – those that involve crossing boundaries, collaboration, forward planning and vision – for these involve a commitment to find new ideology and to breakdown the silo working. It is this failure of foresight which risks paralysing a country that otherwise should be able to find its way forwards unencumbered by the calamity of NHS commercialisation taking place in England.

The aim, after all, is surely to learn from others’ mistakes and not to dive headlong into a chaos that we have a duty to try to prevent. ‘Prudent healthcare’ signals an attempt to change the basic ideology of the medicine we practice, and we are committed to implementing itto the full, but the organisational cultures of some NHS and Social Services Organisations may be even more challenging to detoxify. Everything, it seems, has unintended consequences. In a country the size of Wales, shifting a problem around in circles helps no-one and just depletes the dwindling pot of cash more rapidly.

None of this can be, nor should be, considered in isolation and we want to hear from doctors at the grass roots – your experiences of what works, examples of what you see as good practice – and what is clearly failing. Call us – but be wary of your mobile charges. Perhaps it is best to tweet or e-mail. After all, my Internet works better abroad than in north Wales, too.

 

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Asking about clots to save more lives

By drphilipbanfield at April 3rd, 2014

You would expect me, as an obstetrician, to be obsessed with the risk of venous thromboembolism in pregnancy – relatively rare but obviously potentially very dangerous.

I am very proud of the 1000 Lives Improvement maternity work clinical teams in Wales have done over the last three years, because this has supported a ‘bottom up’ approach to solving the patient needs identified by front-line clinicians.

For example, the team on the Obstetric Day Unit at Glan Clwyd found that their thrombo-embolism risk assessments became persistently 100% only after the healthcare support workers were empowered to actively remind the doctors and midwives to do the assessments! But then, they have a ‘let’s do it together’ approach that makes this not seem out of place.

A new initiative from 1000 Lives Improvement is the Ask about Clots campaign.

There are more deaths annually in Wales associated with a hospital stay, than deaths from breast cancer.  Surprised?  It will come as no surprise that a large percentage of thrombosis-related deaths are potentially preventable. I have written previously, as Chair of Welsh Council, about the use of RAMI, mortality ratios higher than one might expect and avoidable deaths and therefore this is a priority for us in the NHS in Wales.

We cannot ignore (and usually don’t) that thrombosis poses a significant risk to many patients in our hospitals and in the three months after they are discharged.  We have probably all had patients present with symptoms who deteriorate rapidly and die from a massive embolism – it’s not common, but it is not as rare as you might wish for.

Ask about Clots is encouraging patients and members of the public to ask healthcare professionals about their risk of developing a thrombosis.  The campaign is particularly important as a recent survey reveals that 62 per cent of people in Wales believe that they are more likely to develop a thrombosis on an aeroplane than in hospital. This lack of awareness means patients may not be asking their doctors and nurses for an assessment when they should be having one routinely on admission and periodically during their stay.

Shifting the question to the public may be considered a form of the co-production approach to healthcare, so it will be interesting to see what happens next.  When people are informed and participating in their healthcare, the outcomes may be better; doctors and patients working in partnership to identify and negate health risks. As part of this we will need to check that our expectations of improvement are borne out in practice, by a proper outcome review for all our patients – a challenge up from the much more easily done audits of process.  Getting better clinical data on outcomes is a recurring theme for NHS Wales at the moment!

So what can we do to support this campaign? Being aware of the need to be responsive when people ask to have their risk of developing thrombosis assessed is a first step.  And we need to be ready to give the right type and level of thromboprophylaxis. Having thromboembolism on our differential diagnosis for symptomatic high risk patients keeps it in our mind’s eye.  If we are alert to the dangers, and working with people to address their concerns, we have the potential to save many extra lives.

Further details can be found on the Ask about Clots website.

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New Welsh Government arrangements for identifying and responding to serious concerns

By Richard Lewis at March 20th, 2014

BMA Cymru Wales welcomes the new arrangements for identifying and responding quickly to serious concerns about NHS organisations in Wales.

It is important that patients and health professionals are assured that when the health service shows signs of serious concerns, that these concerns are dealt with robustly and quickly to reassure staff who work in the NHS daily.

But the NHS needs to develop a culture that avoids serious concerns developing in the first place. This requires a change in attitude and values in senior management and those with leadership responsibilities, such that raising concerns by staff should be welcomed and positively reinforced so that it becomes routine and everybody’s business to identify and put right
early concerns wherever they occur to avoid the new arrangements announced today ever being required.

 

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“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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