NHS reform or die

Bite on my leg from a walk has become infected and I need an antibiotic cream. No chance of a GP appt without playing the 8am “you are 23rd in line, please hold” game. However I have a private GP through work l, who I book on an app, she calls me an hour later having reviewed the photo of said infection, agrees diagnosis, sends prescription and I opt to take it electronically from my local pharmacy. This is the future and I don’t care about the private/public side of the arguments. People may claim to, but what they care about is access  

Now if I could get past the 8am triage, my own practice could do the same, and have done in the past. But they can’t now as they have no capacity. In fact they were taken over and put in special measures. All the senior staff left/retired early, and I can’t blame them.

Reform will come to the state religion, not US reform, but I would start by taking the NHS governance out of the political system full stop. Run by some form of royal commission with 10% of GDP. Possible charging with reimbursement like the French system. And open three more medical schools (at least) and admit mature students on bursaries who’ve seen a bit of life. When you restrict supply side and have one purchaser, the labour market is screwed.

Because it doesn’t work. It never has and it never will. It fundamentally misunderstands the root causes of poor health, and implicitly blames people rather than looking for more effective interventions.

@Kramer

Your point around replacing GP’s with other professionals and the associated costs when they have to refer on when they reach the limits of their speciality is interesting.

IME in prehospital care since specialist centres have been introduced (PPCI, Stroke and Trauma Centres) the evidence suggest clinical outcomes have improved for those patient groups. Even though it might mean a 45min journey to the specialist centre instead of 5mins to nearest ED. I had imagined that this model would translate to primary.

With regard to the costs associated with referrals from non-GP healthcare professionals, how does this differ to a referral from a GP to a specialist service. For example – I have a musculoskeletal problem, I see a GP who prescribes some pain relief and then refers me to a physio vs I see a physio at the GP surgery who gives exercises and treatment and then refers me to a GP if they are unable to prescribe? Clinical outcome is broadly the same as a measure, perhaps better as the physio treatment has started earlier.

Maybe I’m looking at this from an over simplistic point of view, based on my observations and experience. Maybe clinicians in primary, secondary and prehospital all feel they have a better understanding of how things work. I haven’t a clue. I’d be interested in learning more to help me understand better.

I certainly agree that some roles and functions cannot be replaced with other healthcare professionals with limited scopes of practice, but I think there is a place for some, such as physio’s, in primary care.

@TiRed I don’t think it’s safe or effective to diagnose an infected bite from a photo.

Possible charging with reimbursement like the French system

How are those who don’t have the money to pay for treatment then?

Well obviously I had a video consultation (15 min) with full questioning of symptoms, medical history and alternative diagnosis (including was it a tick bite for Lyme disease). The photo was to help. The path to even talking with a GP is almost closed where I live. A pharmacist could perhaps have also prescribed, but not here. People care about access. They care less about who is paying (ideally not them as “free at the point of delivery”). When a hip is replaced, does it really matter if it cost 5% more to a private supplier but the patient was up and about a year earlier? I don’t think so.

I agree with the needing more and better management. Ideally by people who run efficient organisations. My son’s life is optimised by a department who, if they get it wrong, will cost a lot of money and if they consistently get it wrong, the company goes bankrupt. Supermarkets and Amazon are optimisation and logistic Gods. These are the skills needed. And they cost.

Access to medicine is a commodity like anything else. And whether we like it or not, economic laws will still apply, even in the hugely distorted NHS market.

Not going to solve the NHS problem no matter who is in charged.

The major root cause of the health problems in this society can easily be attributed to the followings … based on my own non-medical observation.

1 Lack of sun.

2. Dampness in house (causing dampness in the body and that is the root cause of many health problems)

3. Poor diet

Can’t control the sun but the other two can be managed and they are symbiotic.

If you don’t wish to suffer with your health then escape the winter is the least you can do.

based on my own non-medical observation.

Really?

As someone who works for the NHS a couple of observations often identified.

Too many highly paid managers managing managers, and not enough nurses nursing.

Too many people wasting NHS time and resources chasing diagnosis such as ADHD.

I went through numerous training courses for management the posts I held, including regular refresher courses. My experience and clinical knowledge meant I fully understood the roles of staff and what they were expected to do as I had done the job. Those that were management from outside others areas didn’t always understand or took a long time to learn.

And this was partially my point.

Too many highly paid managers managing managers, and not enough nurses nursing

My second point by someone who works in the NHS, my wife concurs.

Again I suspect that the reason that GPs are/were so cost effective was that a small to medium sized GP surgery is a very efficient and agile unit of organisation, at least until we started to be micromanaged.

THis has been proven even in my world of trials within the civil service realm, many times over, only to be overidden because dave who has been here 55 years is up for retirement soon and as a senior civil says what goes, mainly because no one wants to tell him things have moved on

causing dampness in the body and that is the root cause of many health problems

Shit, I’m about 60% water, damp, I’m bloody sodden!

They both seem to have better healthcare outcomes on more or less the same overall % GPD spend. (Germany 12.7, France 11.9 UK 11.3) Not every private healthcare model = the US version.

Pound to a pinch of some ordure we’ll get the US model if it were to happen.

@poly 2 that were regularly in the public eye : Dr’s Graham Garden and Michael Mosely, less well known Dr Adam Kay.

Shit, I’m about 60% water, damp, I’m bloody sodden!

Yes, you are liquid. LOL! Doom you are.

Funny isn’t it when we are full of liquid we can consider ourselves aquaman, yet a slight dampness in our house screw our health up slowly.

Abroad, retrain in other professions, consultancy, reduction in hours, private sector etc.

So reduced hours and private sector are still GPs right? They still are part of the wider network of people sharing the patient workload.  I guess I was really wondering what other professions they retrain in…  bearing in mind your claim they were leaving for better money…  (I’m not suggesting GPs are massively overpaid – but there’s not a lot of jobs you could quickly retrain in and quickly earn more) – so I’m sceptical that people leave GP to retrain for more £.  I also know it’s often claimed they go abroad for more £ – but I’m not sure that’s the actual motivator, would they have really stayed in the U.K. just by earning the same (adjusted for cost of living)?  Money might be a factor, but is it the factor?

And why would they tell you, do you get the full CV of everyone you interact with?

You might be surprised at how normal people interact with each other – but I meet lots of people from all sorts of backgrounds, and if someone had gone to medical school and then made it far enough through a medical career to “almost be a GP” then I would be pretty surprised if it never came up.  The same is true of any other profession someone spend perhaps 8+ yrs in before their current role.  I have interviewed hundreds of job candidates, and looked at thousands of CVs,  probably a third of them have gone through a significant career change at some point.  Medicine would be relevant domain knowledge.  None have ever been healthcare professionals.

@sandwich:

Dr’s Graham Garden and Michael Mosely, less well known Dr Adam Kay.

None of them ever began training as GPs.  Garden never practiced medicine, Mosley was a psychiatrist and Kay was in Obstetrics.    Kramer’s suggestion was there were large numbers of people starting general practice but quitting before they became fully fledged GPs (MRCGP?).

One system. One record. All information.

There are many projects underway to get things linked together better. But you would not believe (you probably would actually) the number of systems that need joining up. It’s a total mess.

I’ve been involved in a local project to replace a particular system which hit major problems due to a constrictive time frame and a poor chosen product. The project should’ve started years and years ago and had a three year or so time frame, but the over arching trusts screwed the procurement and obfuscated time and again and we ended up trying to spanner it in in a year.

I’ve also worked on a similar project. Queensland is ‘supposed’ to be the first jurisdiction in the world to go to a single system hospital medical record. The process began in c2016. I’ve just looked to see how many of the hospitals are fully connected now and I can’t find the answer. It’s spectacularly complicated because of all the bits and bobs that different services use. And that’s before you get onto primary healthcare. We have systems that are supposed to help connect GPs to hospitals, but because GP-world is basically a million private businesses using a range of different systems themselves that’s even harder to connect.

My experience across multiple industries is that communication is always the source of most of the problems.

The Australian health system is basically a public system supported with private health insurance. That insurance can be used to pay for care in either system (There’s a tax incentive to have a level of private healthcare insurance once your income reaches a certain level. We just got a tax bill because we’d unwittingly moved into another category.) Yet, all of the problems I hear about the NHS are the same as I hear here.

There are a million improvement projects going on all the time that are trying to chip away at the fact that our massively improved medicine and standards of living mean people are living longer and living longer with chronic diseases.

I ran a workshop yesterday where a group of staff complained about not feeling that the important work they’re doing to improve the transfer (or not) of patients between primary care and hospitals was accounting for anything, because waitlists keep growing. What they don’t seem to realise is that if they weren’t doing it the problems would be far worse.

It’s all Band Aids, but i don’t think there’s a silver bullet solution.

Anyway, back to trying to fix Hepatology referrals :-(

A pharmacist could perhaps have also prescribed, but not here.

@Tired – one of my local pharmacies would have prescribed for that.  The other maybe doesn’t do prescribing or doesn’t want that business (it’s not entirely clear they want any business!) but whilst claimed as the solution to GP availability there’s only one pharmacist and whilst she’s talking to a patient in the consultation room nobody’s meds are getting dispensed/checked!

I do have an online GP app like your employer provides.  I’ve used it once to get my daughter through a physio referral (because they won’t take self referrals for kids) but I cant recall the last time I went to the GP and it didn’t involve blood being taken / blood pressure/ stethoscope / or some physical poking and prodding how do they do that over the phone?

Now if I could get past the 8am triage, my own practice could do the same, and have done in the past. But they can’t now as they have no capacity.

They are not all like that so look at the ones that are not and use that as a model. My GP surgery is in a well populated small town 2 miles down the road. Phoned last week at 08:30 (because I thought that was when they opened and not 08:00 when they actually open as never phone them) and got a face to face appointment at 12:00. y wife uses it more and she always gets same day appointments and never joins any 08:00 queue.

My mums surgery is the opposite and a nightmare to get an appointment.

Not every private healthcare model = the US version.

This is the key message that needs to be put across because the minute we start talking about NHS reform people start screeching about the US and debate gets shut down.

it didn’t involve blood being taken / blood pressure/ stethoscope / or some physical poking and prodding how do they do that over the phone?

I get an annual healthy assessment from the company and I also get the NHS BP/lifestyle assessment from the practice. Those are planned in advance. Of course when the practice sent the email and sms to book I tried to book that too. Online as requested to avoid the 8am emergency crush. Three times. And there were no appointments available. Finally they came to me and gave me a time, where my BP was taken by a health assistant. Contracting those out rather than rewarding the practice for the number of over 50’s screened, would  have been a much better option. I vakidated my home Omron BP monitor against both visits.

As for taking blood, I don’t think I can recall the last time a  GP took my blood. If blood is requested, we must go to the hospital to have a blood draw, unless the phlebotomist is my is visiting the practice. And if they are, guess what? They’re booked up on advances, so off to the next town to have your blood taken.

Sorry, but where I live primary care is failing. And don’t start on Wexham Park hospital…

@Tired I had a similar situation to your but called 111 (I won’t name my employer but they’re the last people you’d expect to offer private health cover…).  I basically had the same outcome as you, phone call with a 111 GP, diagnosis, prescription sent to the nearest late night chemist, text message 10 minutes later to say it was ready to collect, all sorted.

I’m lucky in that I think I’ve been to the GP once or twice in 12 years. I don’t need an old school ‘family GP’, I just want to see someone with the relevant knowledge who can refer me to right place or give the right prescription or advice.   Some people will need to see the same GP every week for chronic problems so the continuity and relationship will be important. But for lots of people they just want to be seen and treated quickly, and the 8am phone game doesn’t work for that.

One system. One record. All information.

Sounds good, I suspect it may be impossible. Different requirements for different purposes. A federation of systems that can share information may be more deliverable.

As an example from the banking world, “One customer” was once a thing. A single system that holds all the info about a customer in their many possible roles e.g. personal account, named person on a business account, insurance policy, MD of a plc that the bank has loaned money to. All require some of the same data but all have vastly different and changing needs for data depending on the persona. Having one system that has to implement the changes for all the different areas at the time they need it becomes really hard, to the extent that e.g. if a law comes in saying that you need to hold extra info for say MDs of a plc and the central system can’t add it in time, you need to add it outside of the central system. Do that a few times and the central system falls apart.

A federated system works much better, the common data can be mastered in one place and the area specific data can be local to the area that needs it. Indeed the local may keep a copy of the central data so that it can work independently as necessary.

This is precisely the kind of application to point AI at isnt it? An interface that can talk to all the disparate systems and draw out the info required? Rather than the admin in each area manually sifting? IANAComputerist.

This is the key message that needs to be put across because the minute we start talking about NHS reform people start screeching about the US and debate gets shut down.

I am aware of more functional state provision/insurance hybrids in Europe and elsewhere.  It would be better perhaps than the current situation if that’s where we ended up. I just don’t have confidence that a UK government (of any hue) could deliver that without a bodge or ending up in the pockets of massive private health companies. You’ve only got to look at any major government project involving the private sector for just about forever, to see the costly and dysfunctional balls-up we’d likely end up with.  I just don’t believe any UK government has the skill, patience and maturity to deliver it without endless delays, mission creep, fights between stakeholders etc. And all the time rapacious corporations circling like vultures to pick over the bones.

This is precisely the kind of application to point AI at isnt it? An interface that can talk to all the disparate systems and draw out the info required? Rather than the admin in each area manually sifting? IANAComputerist.

hell no!

1. You know chat GPT doesn’t know how many r’s in strawberry and doesn’t “learn” when corrected.

2. You know that for “AI” to learn it requires huge access to vast amounts of data – your data, your medical data.

3. the interconnectivity issue isn’t hard because “on this system they store the patient as John Smith and that one it’s SMITH, John and here we call it ug/L and on this one it nM.” Those are all simple issues for well informed human developers.   The problem is these systems are all in different physical infrastructure, with different security regimes, owned by different organisations, some well documented and designed and some only understood by the guy who built it quietly to solve a problem.

4. Ai needs huge amount of processing power and energy – it’s obviously hidden in a data centre but for datasets the size of NHS they really should be asking questions about the environment!

ai has a lot to offer, but it’s not the solution to everything and it’s use in medical applications where a small error has big implications must be tightly regulated.

Yeah but tell me what you REALLY think

Bite on my leg from a walk has become infected and I need an antibiotic cream

Got an infected bite on holiday in Wales in the summer. Google told me to ring Welshpool MIU, I was in and out an hour later with a weeks worth of antibiotics.

That is why the NHS has to be protected for those who don’t have access to private care.

ai has a lot to offer, but it’s not the solution to everything

No, but what you need is directed AI. I don’t think anyone would want the undirected alternative. We have the perfect being the enemy of the good, when we don’t even have “adequate” at the moment.

You know that for “AI” to learn it requires huge access to vast amounts of data – your data, your medical data.

I would hope so! And hence we have projects like the UK Biobank to direct that learning by linking genome data to healthcare records. YOUR healthcare records (if you are one of the 500,000 who signed up). That’s a big enough sample set for any inference.

Google told me to ring Welshpool MIU,

Lucky you weren’t in Slough. Our MIU is now closed. it used to be excellent. As I said patients care about access much more than provider.

There is some interesting stuff here :

https://www.kingsfund.org.uk/insight-and-analysis/blogs/comparing-nhs-to-health-care-systems-other-countries

And not least the conclusion that :

There is little evidence that one individual country or model of health care system performs better than another across the board. 

The interesting thing is that the so called “beurocratic waste” in the NHS is lower, but the outcomes not as good. So that really indicates that the NHS is actually quite efficient by comparison to other nations. So why are NHS outcomes worse if the system is actually quite efficient?  Well the suggestion is that is total spend is the problem, the figures for mri scanners is very revealing.

The problem with “AI” is that the amount of data that’s needed to go from prototype to working model is so large that it’s not possible. Hence no self driving cars, and Babylon Health giving up, and the likely upcoming AI bubble.

Not talking about AI robodoctors, just the admin.

Yeah, I’ll believe it when I see it, especially for a safety critical industry.

 So why are NHS outcomes worse if the system is actually quite efficient?

Efficiency is a measure of admin/management, we score lower on those becasue 1. It’s arguable that the NHS utilises it’s clinical workforce to do these functions rather than directly employed managers, it’s not necessarily a good thing but it is ‘efficient’ and 2. A huge amount of time in countries like the USA and Europe that charge patients at the point of care is taken up with dealing with all the aspects of money transactions that by and large we just don’t have to in GP or Trust settings.

I have a local GP and have also paid to see a GP via an app to cut waiting time, it cost me around £50, I felt listened to (cos I was a paying customer) and id use it again in certain circumstances. I’m not rich. My GP just resonated stress last time I saw her and told me I had X amount of minutes with her (I used double the time) I didn’t feel listened to and she did not have the capacity, empathy or time to help me. I’ve also had a private chiropractor refer me for a private MRI as dealing with the rigmarole to going through my GP is just too much.

Another (controversial) thing to consider is introducing more “risk” into the NHS…

Eg:
In order to discharge patients some ward doctors set their expectations at a level which is beyond the realities of the capacity of the system leading to, on occasion, patients begrudgingly remaining in hospital months longer than clinically necessary and vastly increasing their risk of hospital acquired illness.
I’ve had the pleasure of sitting in numerous meetings with around eight band 6/7/8 staff who are trying to safely discharge a patient back into their own home but are unable because of the considerable complexities of having the patients fridge cleaned and emptied of old food before they will discharge. This went on for months. It would have been far, far quicker to have one person jump in a private taxi, pop round, empty and clean the fridge, have a quick hoover and then leave the patient at home (where they wanted to be, not in hospital).
Another option was to discharge them back into their own home with rotten food in the fridge and see what happens (had capacity)….

The ward doctors sometimes adhere to a gold standard in order to discharge patients, but the hospital is a war zone, and sometimes these doctors have no insight of the front door pressures that their introduction of a little risk could ease.

Obviously, they would need to be supported in their decision making and being protected.

Band 6 paramedics autonomously work with more risk in the community, particularly when leaving someone at home, and perhaps some of this threshold needs introducing into hospitals.

and it’s use in medical applications where a small error has big implications must be tightly regulated.

We have two patients (mum and daughter) who share the exact same name (including a middle name) and live at the same address. We almost sent the pat record of the daughter to the mum the other day, and only caught the error becasue one the reception team just happened to know the patient personally and doubled checked. I’d hate to rely on AI in those scenarios.

I’d hate to rely on AI in those scenarios.

Surely AI would rely on DOB and unique NHS number too? It is extremely unusual that two people share identical names and DOB. It has happened. I’d rather rely on proper systems than human checking. Humans make mistakes too. BTW “AI” seems to be a recent catch-all for data science and analytics.

My wife has the same name as her mother. It’s an endless source of annoyance. Don’t do it folks ;-)

As for taking blood, I don’t think I can recall the last time a  GP took my blood. If blood is requested, we must go to the hospital to have a blood draw

Strange. At my GP a nurse does the bloods. As for appointments I find the easiest way is to pop in and speak to a receptionist. Oddly they are quite pleasant and don’t each have two heads or anything.

As for appointments I find the easiest way is to pop in

Do you work full time?

the interconnectivity issue isn’t hard because “on this system they store the patient as John Smith and that one it’s SMITH, John and here we call it ug/L and on this one it nM.” Those are all simple issues for well informed human developers.

I wouldn’t call those simple issues. Name matching is a nightmare. Tying it all together to a single identity, including of course the possibility to correct that identity in all those different systems… Simple it isn’t.