I love the NHS but is it broken?

One thing I’d add, practice nurses, nurse practitioners, paramedics, mental health practitioners, first contact physios are all nice to have, but they do not replace GPs who are essential for primary care.

sure – but they must take some of thew workload for the stuff that does not need a doctor?  Again my practice the nurses do all the asthma clinics for example.

sure – but they must take some of thew workload for the stuff that does not need a doctor?

It’s not as clear as you would think. I think they actually induce demand, much in the same way that building bypasses doesn’t reduce traffic in the long term.

My experience has been that when they first start, they have lots of appointments, but they fairly rapidly become full, and then we’re back where we started, but without the flexibility of having an extra doctor on the staff. They definitely (generally) increase patient satisfaction, but there’s not a great deal of data to say that they’re particularly cost effective.

Hmmmm.  food for thought.  ta 

I have to say I saw the mental health nurse once and he was useless and gave me bad advice 🙂

In General Practice, most patients benefit from a holistic approach. There are very few (if any) other professions other than a GP who can offer this.

Anecdotally, I think it’s a problem in hospitals too. More and more they’re moving to nurse led clinics, who are great at dealing with stuff that falls within their remit and training, but not so good (IMHO) at dealing with the stuff that is outside of it.

Thats interesting.  My experience is nurse are much better at the holistic approach than GPs / doctors – but I would say that wouldn’t I 🙂

MY GPs are better than other doctors I have seen – very much “patient led”

 very much “patient led”

I’m really not a fan of the “patient led” healthcare philosophy. I’m more into the “coaching for health” approach.

Hmmm – perhaps I am using the wrong terms?

I mean its stuff like my GPs will ask routinely ” what do you want here / what outcome are you looking for” or “these are the options, which would you prefer?”  They also do the thing of if its marginal if you need a med say antibiotics they will give you a script and say – fill it if needed and give yo some parameters as to what you should do – ie “if its not cleared in 2 days get the script filled” ( apparently this actually reduces antibiotic usage?)  Possible that they modify their approach to me knowing I have some knowledge but as I always say – ” a little knowledge is a dangerous thing” 🙂

Please expand @kramer – I trust it’s not as paternalistic as it sounds.

GPs aren’t all the same of course, but I’ve experienced occasions when I’ve felt I’ve needed to coach my GPs (in the UK and Australia).

@tjagain – it’s called Shared Decision Making

Ta reeksy.  Whatever it works for me. 

Ive been patronised badly by doctors in the past and this lot do not do it

Chatting to the nurses one of them described the current state of the hospital and the NHS service as ‘third world

Whilst the description may be emotive, perhaps even helpfully so.  I’d suggest that this nurse had probably never been in a hospital in the developing world.

There is a perception that what makes the patient happy is a good service, and that is not always the case, antibiotic prescribing for example.

Kramer – I almost 100% agree with you there, although if the patient is unhappy that they didn’t get a prescription for something that doesn’t merit a prescription the doctor is failing if they don’t communicate that to the patient in terms the patient understands.  Some doctors are pretty shit at adapting their communication style to different patients and I think many are even worse at understanding WHY patients go to the doctor.  Our GPs have obviously been on a course that told them they should ask the patient what they were hoping would happen today – its a stupid question, which at least for a patient who is not a regular and has no relationship with the doctor is probably not going to really tell you what the patient hoped for even if the patient knows that.

But I don’t really agree with this:

One thing I’d add, practice nurses, nurse practitioners, paramedics, mental health practitioners, first contact physios are all nice to have, but they do not replace GPs who are essential for primary care.

I think they are misused, perhaps even under respected, poorly deployed or undertrained but I don’t buy the argument that carefully thought through and managed that they can’t reduce workload on GPs and improve patient satisfaction.  I actually wonder if your statement that GPs are essential for primary care is actually true.  Its the model we have, but actually why do we have it? Is it still relevant in the 21st century?

I find the variability in GP services odd.  Would we have more consistency / control with them being brought into the NHS?

It probably would improve consistency, but it might be consistently bad!  I can’t think of anything else the government has standardised which has brought everything up to the standard of the best can you?

Most of the “poorer” ones tend to be relatively underfunded.

Or could they just be mismanaged?  The criteria for being a good doctor and running a good practice are rather different and medical school doesn’t teach you about managing people, finances, or workloads.

The 08:30/09:00 ‘rush’ is a function of over-demand and patient expectation, and needs solving with more GPs that are not killed by workload, demand management and patient education.

I can’t think of any other workplace that manages its appointments quite the way GPs do.  The idea that if you are sick enough to need to see a GP at 08:30 you couldn’t book that at 16:30 the day before is bizarre.  The idea that if you are not actually needing to see a GP today, but later this week would be a good idea, in many practices the only way to do that is to join the 08:00 scrum.  The idea that actually everyone is sitting at 0800 hitting redial and the receptionist essentially give out the calls on a first come first served basis to people who meet the basic criteria, and anyone who isn’t lucky enough to get through is obviously not sick enough today and can try the lottery again tomorrow.

In General Practice, most patients benefit from a holistic approach. There are very few (if any) other professions other than a GP who can offer this.

I’m not 100% sure what a “holistic approach” means. I know what the words mean but in practice what does it mean to say that a GP provides a holistic approach? My experience (my/wife/children) is that they treat the condition sitting in front of them.  Now there may well be complex patients who genuinely do get a bigger picture view, but I don’t recall ever exploring anything other than the symptoms presented.

Anecdotally, I think it’s a problem in hospitals too. More and more they’re moving to nurse led clinics, who are great at dealing with stuff that falls within their remit and training, but not so good (IMHO) at dealing with the stuff that is outside of it.

My hospital medical experience is naturally quite narrow, but I don’t think thats a symptom of nurse led clinics – its a symptom of specialisms.  Once things start to cross over into another discipline nobody wants to (or has time to) step outside their lane.  If your diabetes control is affected by your lack of exercise which is caused by physical injury nobody is tying those together and saying we really should fix the injury quicker!

Had a big bike crash in Spain so went to Spanish A & E on a Saturday with my Health Card. Got seen by a doctor, a consultant then had a scan then seen by doctor again all in about 5 hours.

I now need a follow up scan in UK after seeing local Doctor and it’s a 4/6 week wait.

May not been totally broken but wheels definitely coming off.

I have had the misfortune to need a fair bit of NHS care over the last few years.  My experiences

Urgent / emergency treatment – very good indeed

Urgent diagnostics – very good indeed ( cancer scare)

Mental health – poor – went private

Non urgent diagnostics ( finding out what caused the cancer scare)  Poor – 18 month wait.  Went private

I think this is a typical picture

Broken, no, but it’s getting very close. 

It’s ‘funny’ but I read a few days ago that the UK Austerity Policy is fundamentally flawed, at least in part, because of an Excel error.  

There are a few reasons for it, and yes Tory rule is usually very bad for the NHS and it’s users, as was of course the pandemic, an ageing population and more and more conditions the NHS is being asked to treat and lots of new and expensive treatments for them. 

I could rant away for pages on the NHS and it’s problems, but I also don’t really want to give away my connection to it, but fundamentally most people in the NHS the cleaners, porters, catering staff, HCAs, Nurses, Doctors, Surgeons etc etc etc do it to help others, they really do. You wouldn’t do it otherwise. I do have some issues with GP surgeries (not GPs per-se) as they are businesses that the NHS sub contracts too and some I know are more commercially minded than I think they should be. Personally, I’d nationalise GP Surgeries. 

The NHS though, it’s under ‘attack’ from all sides, the Government (of all types), use it as a political pawn, users abuse it, contractors and suppliers are trying to squeeze every penny from it. It doesn’t help itself either, staff hate management for being inept, but after decades of awarding the best Nurses and Doctors with management rolls, they actually started to employ non-medical managers to manage, they only hated that more. 

I think 2024 will be rock bottom for the NHS. The pandemic is (mostly) over, the Tories are leaving and the economy (and therefore tax revenue) should start to recover soon. I suspect that Labour will find that magic money tree and things will start to improve. 

The excel error thing is a funny story but the truth is that austerity was tory ideology since the year dot, they’d have grabbed onto any and all opportunities to justify it, and it’s a huge stretch to believe that if that single bad paper hadn’t existed, they would have just said “oh better change all our core beliefs then”.

I actually wonder if your statement that GPs are essential for primary care is actually true.  Its the model we have, but actually why do we have it? Is it still relevant in the 21st century?

My understanding is that when it’s been looked at, GP centred healthcare comes out as the most cost effective system.

It’s ‘funny’ but I read a few days ago that the UK Austerity Policy is fundamentally flawed, at least in part, because of an Excel error.  

Do you have a link?

My understanding is that when it’s been looked at, GP centred healthcare comes out as the most cost effective system.

I’m genuinely intrigued how you measure that, and if cost effective equates to best patient outcome? after all in pure financial terms the most cost effective solution is for us all to die young before we become expensive! in economic terms it would be to keep the workforce working as much as possible, but in healthcare terms it might be about spend not output?  And is “GP centred” the same all over the world?

Here’s one random link to the Reinhardt-Rogoff excel error thing. You can look for Hannah Fry on xitter for another view (no I’m not joking, sadly).

https://stanfordreview.org/clarifying-the-implications-of-the-reinhart-rogoff-excel-error/

Doesn’t look broken (if you work in Barts Trust management)…in fact, looks great!

https://twitter.com/TomStocks1982/status/1769318109159022623