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#GPnews: Patients in favour of an end to GP box-ticking

16:30 Patients have backed the BMA’s call for more GPs, longer appointments and an end to ‘box ticking’ to allow GPs to spend more time with them.

More than 70% of patients who responded to the survey have indicated their support for the measures, the BMA said. Just under half (46%) also agreed that GP premises needed investment.

These respondents are the first to return their ‘urgent prescription’ cards to the BMA for analysis.

15:30 The New NHS Alliance has reacted to Pulse’s story on one in eight practice nurse positions being vacant, by criticising universities and trusts for pushing nurses towards a career in hospitals rather than primary care.

Heather Henry, co-chair, New NHS Alliance, says: ’Twenty five years ago nurse leaders warned about the demographic time bomb in practice nursing. These messages were not heeded and the problem is now fully impacting on general practice at a time of unprecedented demand.

’We… need to challenge universities and trusts who point newly registered nurses towards secondary care in order to gain necessary experience before a career in primary care. We want to reverse this logic. The community is where people live their lives. The more nurses understand this, the better nurses they will become. We aim to challenge a wholly medical model because general practice is about family and community. These are the things that keep people well.’

12:30 Simon Stevens has said the NHS has to put in a ‘huge effort’ in the next 18 months to address the problems in primary care which have not been given the attention that other sectors receive.

The NHS England chief told delegates at the NHS Confederation 2016 conference in Manchester today that in the next few months ‘we’ve got a huge effort to help respond to the very genuine pressures that have been building in general practice, receiving far less attention than the pressure in other parts of the system.’

Adding that ‘on workforce, workload, on work redesign, if we don’t get these right in the next 18 months then – as a headline in the BMJ put it recently – if general practice fails then the whole of the NHS fails.’

He also said GPs would be central to soon to be announced developments in urgent care, with five key priorities from the urgent and emergency care review to be announce in coming weeks.

Mr Stevens said this would see more trained clinicians in NHS 111 saying they would be ‘souping up 111 and GP out-of-hours’ front-end, more clinical intensity and engagement there, as well as internal process issues and a big focus on delayed transfers of care and the interaction with social care.’

11:50 We’ll have more on Simon Stevens’ speech to NHS Confederation conference shortly. Meanwhile, here is the confederation’s take on it:

9:50 NHS England’s chief executive will announce today that more patients will be able to manage their conditions through their phones and tablets due to a funding injection.

The Telegraph says that millions of patients will get access to life-saving gadgets that can diagnose conditions in less than a minute, with innovations including a simple metal strip, which can be attached to a smart phone, in order to take a heart reading in just 30 seconds.

Simon Stevens will tell the NHS Confederation conference in Manchester today: ’The NHS has a proud track record of world firsts in medical innovation - think hip replacements, IVF, vaccinations and organ transplants to name just a few. But then getting wide uptake has often been slow and frustrating. Now - at a time when the NHS is under pressure - rather than just running harder to stand still, it’s time to grab with both hands these practical new treatments and technologies.

’In the rest of our lives we’re seeing the difference that innovative tech makes, and now the NHS will have a streamlined way of getting ground-breaking and practical new technologies into the hands of patients and our frontline nurses, doctors and other staff. By doing that, we can transform people’s lives.’

Got a story? Let us know by tweeting the hashtag #GPnews or emailing newsdesk@pulsetoday.co.uk

Readers' comments (4)

  • Yup, gadgets and google will save the day. Who needs docs, hey ?! More unnecessary workload coming our way folks.

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  • OH! Mr Stevens - our CEO - well paid over many years - we have seen just talk and no action. Thank you Sir- under your watch over many years - we in General Practice- are today in a dire state. In other industry you would be sacked by shareholders. Time to Go man.

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  • 'Huge effort' means he is not going to put in what is needed - 'huge wad of cash'.
    TBH £20-30/ patient would be enough for many practices for a few more years.

    Why not just let patients pay top up fees? an extra £50 / year for unlimited access is still incredibly cheap.

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  • The Worldwide Health Crisis


    Paying for health and social care delivery is becoming a problem for this country and others. There are three factors demanding extra resources;

    1. INCREASING ELDERLY POPULATION
    An increasing number of elderly people who often have multiple chronic conditions
    2. ACCESS
    Patient demand for greater access and higher quality of care
    3. NEW SURGICAL PROCEDURES AND NEW MEDICATION
    An ever increasing number of often very expensive treatments that are becoming available.
    Put this against the fact that Governments are reluctant to increase the resources going into health and social care. The difficulty now is that the western world has reached a peak of percentage spend of GDP. Although it is only 8 or 9% in the UK and up to 18% in the US, it is unlikely Governments will allow the spending to increase.

    This results in an equation that doesn't add up.

    THE PROBLEMS WITH RATIONING HEALTHCARE
    Rationing health and social care is not necessarily the answer. Patients or their families will still pay the extra for private health and social care delivery. This of course results in less financial resources for the population to spend on other areas resulting in further depression in the economies of the world. This will only get worse given the increasing number of elderly people.

    So what are the solutions?

    ACCESS
    The issue of access to health care is a contentious area. The important thing to realise is that most illness is self-limiting. This is why ‘did not attend’ rates are higher when patients have to wait longer for an appointment. By the time they get to be seen their symptoms / illness / concern about ‘something’ has resolved.

    Having worked and experienced health care delivery in different countries, access to health care is varied. Where resources are less, as in Africa, most minor conditions are not seen by Doctors. Patients manage these problems through local pharmacies where they exist, their families, bare foot health care delivery and what ever local herbs and practice is locally prevalent.

    In the western world where standards of health care are higher and better resourced patients are able to access care more quickly. Longer waiting time for primary health care is not a problem unique to the United Kingdom in the western world. Waiting time is frequently over two weeks in Canada and USA, where patients have to contribute at least part payment up front.

    The real issue is that patients everywhere are demanding more access. So how can we improve access to health care within a tight financial envelope? There has been an increasing trend towards delivering telephone rather than face-to-face traditional consultations. When delivered by a clinician that is experienced in this form of health care delivery productivity can be very much higher. There has been a slow growth in private on-line health delivery services e.g. Babylon. GPs and hospital Doctors are available 8-8 to consult patients over the phone, by email or video for a fee. However just like adding another lane to a motorway demand for this Health Care rises as people grow to trust the new form of Healthcare delivery. This is a fashion that is growing. The market place will regulate its growth on a private basis, but It is becoming increasingly untenable through the NHS unless money is saved elsewhere that can be diverted to pay for this service. Some GP practices that were previously carrying out routine telephone consultations have either limited the access or stopped completely because the demand for consultations has grown too high. One must also realise that clinicians are not routinely trained in delivering virtual consultations. At the same time there is growing litigation and naturally clinicians are more concerned if they are not able to see and examine patients. Even when clinicians are prepared to carry out telephone consultations there is a huge variation in how many telephone consults are turned into a face-to-face consult at a later date. This is exactly the same as the huge variation in referrals to secondary care by GPs and other clinicians. Unfortunately the rise in litigation is not helping. Video consultations can satisfy the often ‘perceived need’ to see patients. However the general public is not used to receiving video communication. It is likely that this will be more frequently used in the future if mobile video communication becomes the normal way to communicate. This, in itself, is debateable as there are many advantages in just communicating using audio. There is another major problem of logistics. Because video communication is not routinely used on mobile phones and reception is variable, clinicians have to agree specific appointment times with patients for video consultations. On the other hand mobile phones have the advantage that everybody has one. Once a request for a telephone consultation has been made, clinicians phone back patients directly. These patients do not need to come to the surgery and are frequently at work. No specific appointment times need to be made.


    Because patients want more health care access Politicians demand that health care providers deliver this. What the public and Politicians do not understand is that patient demand for health care is unlimited if more access is always available. Patients frequently consult several times in the course of one period of minor illness such as an upper respiratory tract infection (URTI), back pain, flare up of eczema etc. Could online software alleviate this demand? Unfortunately I think the answer is probably no because of the uncertainty around cause of symptoms. Even when patients are seen for a face-to-face consultation doctors are frequently not absolutely certain of the diagnosis. As an example, what appears to be a simple URTI may develop into a serious case of pneumonia or even meningitis after a couple of days. There is no didactic investigation or test that can easily distinguish between a minor viral infection and the possibility of this becoming an overwhelming viral or bacterial one. The decision as to how to manage conditions is largely based on the experience of the clinician involved. Here in lies the dichotomy that we face. The only thing that we know is the vast majority of symptoms are benign and self-limiting. However the period of illness can sometimes be several months. As an example low back pain frequently goes on for six weeks. Even an URTI can go on for many weeks. Nowadays this results in patients demanding further access for health care on numerous occasions during the course of this long episode of minor illness.

    So could self management plans be substituted for direct health care contact, whether face-to-face or virtual?

    Clinicians are only now starting to deliver virtual consultations. Much of industry has moved on to automated on-line delivery of services and products. The problem is that health care delivery is labour intense. Patients are reluctant to move towards virtual health care delivery, let alone on-line self management plans. Because illness as previously stated is a nebulous one, software has been designed to be risk adverse. This, as in the case of the 111 service, has not helped to reduce patient demand for consultations.

    Can we make better use of automated healthcare delivery through the use of mobile applications with sensors without intervention from clinicians?
    In the past few years there has been a growth in the development of mobile sensors that can measure vital signs and many other parameters. This has led to the growth in Telehealth. It was perceived that if clinicians are made aware of worsening vital signs such as O2 sats, rising or falling blood pressure, arrhythmias etc, it would then be possible to stop a deteriorating new or acute exacerbation of illness. This would then negate the requirement for a hospital admission and save money. Unfortunately the recent Nuffield Trust trial was not particularly supportive. There was a slight drop in admissions, but ‘Telehealth did not appear to be a cost effective addition to standard support and treatment.’

    There has been a growth in the provision of on-line Pharmacy-led software allowing patients to privately order a number of medications on-line based on patients satisfactorily answering proforma questions. Examples of this are Dr Thom (www.drthom.com), Lloyds online doctor, Superdrug and Boots. The real problem with this is it is only applicable for a very narrow range of medications e.g. vaginal thrush, erectile dysfunction, repeat prescription for asthma inhalers, sexually transmitted diseases etc. Patients worry about various symptoms and are becoming increasingly concerned when they check their symptoms online. Unfortunately software such as the NHS symptom checker will often bring up more serious conditions. This frequently results in more patients contacting primary care services. Various software has been used by NHS direct and more recently the 111 service. This software tends to be risk adverse, which results in more patients being directed to primary care and A+E.

    Automated history taking

    What is more interesting is the slow growth in the development of software that can take a very detailed history of patients' symptoms. ‘Instant Medical History’ is a very sophisticated on-line software package that was designed over several years in the USA. It is designed for patients to answer the questions themselves without the requirement of any clinician or receptionist. The software adapts to patients’ responses to questions. So if, for example, a patient complains of being tired all of the time (a very common time consuming symptom for GPs), the software goes into overdrive asking numerous clinical questions. Practically all diagnoses are based on having a full medical history. The routine use of this could decrease consultation time, but not the demand for health care access. It has to be stressed that the software history still has to be assessed by a clinician. Then one must not forget that the act of a clinician taking a detailed medical history is very therapeutic in itself and has been proven to be the real reason why homoeopathy is liked by some patients. It is also the reason why patients like being referred to hospital. Hospital Doctors are given more time to deal with just one problem e.g. commonly 20 minutes compared to a GP who has 10 minutes to deal with multiple problems. The other interesting fact is that GPs who are very experienced with most issues refer patients to be seen by a junior doctor who has less experience, but just more time.

    CAN WE HUMANISE AUTOMATED HEALTH CARE DELIVERY BOTH ON-LINE AND THROUGH THE USE OF ROBOTS AND AVATARS?

    This seems at first a crazy impossible task. This will not happen in the short term. However much research is taking place in Japan enabling software to show human traits like compassion and empathy. Avatars have been developed that can express human emotion through facial and body movements. This could be a solution for some health and social care provision in the future – see

    http://topdocumentaryfilms.com/into-future-communications/

    INCREASING ELDERLY POPULATION

    There are an increasing number of elderly people with multiple chronic conditions that add to the workload. As doctors we need to realise that our profession is a service industry. Similar to other industries people demand higher standards and faster access. Other industries can provide this by decreasing their costs through mechanisation, reducing the need for labour, or contentiously out sourcing labour to areas of the world where it is cheaper. The medical profession's problem is that it is very labour intensive. Perhaps employing pharmacists, physician’s assistants and nurses to be the first port of call for patients could help. In essence a new routine cheaper health care worker trained to a lower level could become the standard entry portal for health care delivery. So patients would have no right to consult GPs directly. Would this save money? This is difficult to say and definitely not if a significant number of patients are referred on to GPs. However if GPs had more time to spend with a fewer number of patients it could significantly reduce the number of referrals to hospital out-patient depts.

    So how can we improve efficiency? With the advent of amazing telecommunications is it possible to outsource healthcare delivery to areas of the world where this can be provided at a cheaper cost? Of course all of us would not wish that for obvious reasons. Nevertheless, this is a concept that should not be negated. Even if this does happen the unit cost for delivering this health care will eventually rise, as in the case of large PLCs that outsourced factories to South Korea, Taiwan and China etc. The PLCs are increasingly moving their factories back to the western world because of rising labour costs in third world countries that when combined with shipping costs make it non-financially viable. One of the main problems is that people are not used to virtual health care delivery. This is less of an issue once patients experience a well delivered virtual health consultation. However most people like to develop a close relationship with one healthcare practitioner. This is also why surveys have shown that patients prefer their health care delivered by a single-handed GP practice. It is interesting to compare this with the up and down trends of supermarkets. People liked corner shops. However large supermarkets offered people the advantages of one-stop shopping, and frequently cheaper prices. Despite this the trend is changing and people are now choosing to shop more locally resulting in declining profits for the larger supermarket stores. So perhaps healthcare delivery can learn from this. At a local level it appears that patients do prefer to have a closer relationship with a named healthcare individual. The problem is that they just want more and more of it. With the advent of Federated GP practices and large out of hours networks are we perhaps making the same mistake that was made with the development of large supermarkets?

    NHS Direct and the 111 Service

    Although NHS Direct was unpopular when first commenced it was delivered by nurses and did have some proven success in reducing demand on other health care services. However the advent of the new 111 service went too far. This service was designed really to be a signpost to direct patients to appropriate care. There was never supposed to be any telephone healthcare delivery as was the case with NHS Direct. More recently healthcare delivery is now starting to be given to patients directly through the 111 service.

    Some patients are happy to accept any health care provider, whether that is a Doctor, Nurse or Health Care Assistant. However there are others at the other extreme that want to be referred to a Consultant for everything and to have every investigation going. This is a difficult area and it will be impossible to keep all happy.
    Perhaps the answer is for the NHS to define exactly what it will deliver and anything outside these parameters would have to be paid directly or through private insurance. If this resulted in less personal finance for patients to spend on other items (cars, houses, clothes etc) then that is the price that we have to pay for living longer and demanding ever more access to everything.

    Essentially perhaps we should let the market place decide beyond a detailed agreed NHS service provision.

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