Dr John Crippen
Hospital says "No!". Is that it? Of course you can beg. Just send in a letter, and we will see if you really need your treatment.
It will surely spread to other trusts, don't you think?
"P.S. Does anyone know why Dr Janet Sooo-Chung was awarded a CBE?" - google says "services to health care" - how vague.
"Janet’s other commitments include being an Independent Board Member at the Department of Trade and Industry, Member of the Public Interest General Council of the Office for Public Management and Member of the Expert Advisory Group for the National Standard Framework for Older People."
So if that is not an acceptable solution over the next 3 -6 months, and in the absence of information on the other cost cutting measures the PCT are taking, what else can P. Hewitt's whipping boys do to get back into financial balance and keep their jobs?
This explains how Patricia is going to balance the books for April. I'm disgusted, but I half expected it. What the hell are they going to do after April when all the water they've allowed to gather behing this beurocratic dam flows again? Where's the extra money going to come from? Perhaps this is why I haven't heard any commitments to remain in balance next financial year.....
Isn't it far better to allow service as normal and just stop the ever increasing loss of cash into the black hole of hangers-on we have in the NHS today? If only Sir Lancelot Spratt was here....
Any doctor who decides to get involved with the running of the PCT exceptions panel would do well to consult their defence body first.
I suspect that the GMC will take a dim view if anything goes wrong.
Or perhaps I should say "when"...
Well at least she's not saying that it's the fault of GP's!
It's a disgrace but no better in PCTs which aren't in financial difficulties with arguments between PCTs and hospitals about who is to pay for a treatment which the PCT say it wouldn't be ethical to stop.
I am actually pretty sure that making appropriate referrals is part of the contract GPs have with the PCT.
It is quite interesting how they are passing the buck. They would prefer the GP to say that the patient is undeserving and should be denied treatment rather than it being a PCT decision. If a GP does not refer and the patient complains who exactly will be in the dock?
I'll make a guess.
"P.S. Does anyone know why Dr Janet Sooo-Chung was awarded a CBE?" You surely aren't expecting some cad to say "Because she can afford it" or "Because she's New Labour", are you?
Anyhow, to this patient it looks like an almost-frank admission that there's not much money left, and tough titty. Tell me, how do the committee members ensure that they and their families do get treated? I take it that we needn't expect the highest Presbyterian standards of rectitude on these matters?
really you should get the GPs to get the press involved, this is simply too far
i suppose on one level they are at least being honest about it, and not hiding it behind a multitude of referrals to nurses etc
re "Treatment/removal of all non malignant skin lesions" how the fuck do you know whether its skin cancer unless its been removed? ive heard the surgeon say "theres only a 1% chance its cancer but we wont know until after weve taken it off" i would refer these using the super quick cancer referral scheme and give them some targets to meet
re "Trigger Finger – injections should continue in primary care, referral into secondary care will require prior approval. " as i know in great detail in bad cases if you leave the op too long this significantly impacts long term recovery as tendons etc cannot recover as well
sent this stuff to some mps, the councillors, the press, etc etc
this should be emergency debate in parliament the next day stuff
Whats being said in the local press??
No one, the press has been involved to an extent. Have a look at:
http://www.thisisyork.co.uk/
disp...ctors_hands.php
GPs complain
http://news.bbc.co.uk/1/hi/engla...ire/
6246671.stm
The cuts
http://www.harrogatetoday.co.uk/
...ticleID=1969498
Harrogate
http://www.timesonline.co.uk/
art...2530550,00.html
http://www.yorkpress.co.uk/news/
...costcutting.php
John
yea and be honest with the patients and tell them their health is being significantly impaired for political reasons
Janet Soo-Chung's 22-year career with the NHS began after she graduated from the University of Manchester in 1983 with a degree in Psychology.
She joined North Western Regional Health Authority as a National Management Trainee and in 1985 was promoted to Assistant Support Services Manager at Trafford General Hospital.
She moved steadily from trainee and managerial positions to directorial roles and finally to chair and chief executive posts. Her extensive experience is based in the North Western, West Midlands and Northern & Yorkshire NHS Regions and has been gained at regional, district and provider level.
She was made a CBE for services to health care in the New Year's Honours List of 2002 and she sits on the Board of Governors of the University of Lincoln.
the "sits on the Board of Governors of the University of X" theme seems to be quite common with NHS senior management, seems to be their way of ensuring complaints from the university about crap nhs treatment for students is kept quiet, think this little tactic is at bursting point also
The local newspaper doesn't seem to be bothered by it - at least not here in Harrogate. I guess that's because our local GPs are under the North Yorkshire/Craven PCT, but the local hospital is part of the Harrogate and District Foundation NHS Trust which isn't under the same financial pressures.
I guess it's only a matter of time though before problems start to occur.
I might pop down to see the esteemed chairwoman since her office is only 10 minutes away and ask her what's going on.
is Ian Donnachie Chief Executive of Bradford Health Authority married to Janet Soo-Chung ?
I have no idea who is wed to who is Yorkshire PCT, but nothing would surprise me after this:
http://burningourmoney.blogspot....-of-ex-
con.html
John
Isn't one of the reasons for carrying out a diagnostic D & C in order to check for endometrial cancer?
Frightening beyond words. In September, my GP referred me for an urgent (2 week) appointment at the pigmented lesion clinic. After seeing the consultant, we agreed that the best course of action was surgery and that happened 6 weeks later.
Particularly bad considering skin cancer's mortality rates and comparative ease of treatment if caught early enough.
There is an existing way to delay treatment... its called the waiting list. But of course that would breach a target so the aim of this policy is both to deny treatment and hide the scale of the problem by simply refusing to even consider people for treatment. Meanwhile, the vast majority of hospital costs (salaries, PFI Interest...) continue to be incurred anyway so efficiency falls further.
Truly awful.
Doc - a question.
Given that there is a finite amount of money available for the NHS, what do you think is the best way to ration healthcare?
The York Press has ran a few articles on this, but they are mainly backed up with "Aren't we doing well.." press releases from the PCT.
What is more worrying is that Hugh Bayley, MP for York, has been exceptionally quiet on the issue. Normally, he can't wait to get his picture in the paper, but on this he's been like a door mouse. Although it doesn't surprise me - he's a Labour MP, and an extremely loyal one at that. He toes the party line, hook, line and sinker.
I've found out more about my local PCT from reading this blog entry than I ever would have in the York Press (but then again, there's a rumour in York that it is run and written by half-trained monkeys).
York is no place to get ill between December and April. We must make sure that we stay healthy until April, when we are 'allowed' to use the hospital again.
Legally, could a patient complain/appeal if the GP refused to apply for exceptional circumstance, OR if the 'prior approvals' committee rejected their case?
What would concern me most is that this wouldn't be as temporary as they claim, but 3 months turns into 6, turns into 12 and so on...
Deeply scary stuff though. There's one thing asking doctors to delay referrals, but setting up some committee which realistically isn't going to be able to meet its target of letting people know etc etc. *shudder*.
That is fucking ridiculous! When something goes wrong and a patients dies because of this, and it will happen! GPs will get the blame for it, not the PCT!
I expect this trend will spread like wildfire among trusts with huge black holes in their budgets.
noone said:
is Ian Donnachie Chief Executive of Bradford Health Authority married to Janet Soo-Chung ?
I don't know whether they are married or not, but they are partners. And they make a lovely couple:
Janet Soo-Chung, chief executive of South West Yorkshire PCT, and Ian Donnachie - no longer chief exec of Bradford Health Authority, now Senior Vice President of Nations Healthcare, a private firm which runs treatment centres in Bradford, Nottingham and Burton on Trent.
I've often wondered about relationships between NHS executives - do they occur because it is hard to meet people outside of work, or because they appoint each other?
Sheffield is about halfway between Bradford and Nottingham - do you think he'll give her a discount if she asks nicely one evening?
I sent my Mum for a removal of an itchy mole. Bear in mind that when I say "I sent her", I mean that I asked her strongly(++++) to go and see her GP. Thank piss she had private health insurance or she would have been dead by now. She was a Breslow thickness away from near certain mets.
She still had to wait and now it seems, in Yorkshire, her peer group of melanomas with no insurance are doomed. I wonder what the savings are when one compares a relatively (yes, I understand that it is not really that simple) simple operation and a pathology to chemo, radio and grief.
Short term gain, long term loss. Idiots.
Dr Sniper
The York Press has ran a few articles on this, but they are mainly backed up with "Aren't we doing well.." press releases from the PCT.
What is more worrying is that Hugh Bayley, MP for York, has been exceptionally quiet on the issue. Normally, he can't wait to get his picture in the paper, but on this he's been like a door mouse. Although it doesn't surprise me - he's a Labour MP, and an extremely loyal one at that. He toes the party line, hook, line and sinker.
I've found out more about my local PCT from reading this blog entry than I ever would have in the York Press (but then again, there's a rumour in York that it is run and written by half-trained monkeys).
York is no place to get ill between December and April. We must make sure that we stay healthy until April, when we are 'allowed' to use the hospital again.
BL |
+++++
Very worrying. I went to school in York, and have stong attachments to it. Scary stuff.
John
This is happening everywhere, PCTs quietly remove treatments from the SLAs, or don't allow newer, possibly better treatments, to be included and label them as "extra contractual". Then GPs have to persuade a committee that their patient is "exceptional". For example where I am you pretty much can't get varicose veins surgically treated unless there is evidence of skin changes, ulceration, bleeding......and PAIN doesn't seem to count!!!!!
write off all debts and start again!
The think tank Doctors for Reform says.
a good idea- start again with tight fiscal control from there on in. Heavily indebted PCTs have no hope of getting to financial balance. Cancelling ops this year just delays the inevitable
Doc - a question.
Given that there is a finite amount of money available for the NHS, what do you think is the best way to ration healthcare?
Sam |
+++++++++
Sam,
That is a fair, rational and appropriate question. And I could write a book on it and still not answer.
From where to we start? We start from a basis of HONESTY. As Wat Tyler has shown, on present trends by 2100 health care could consume the whole world's GDP.
There is a pretense in the UK that the NHS can provide everything for everyone. It cannot. So we have stealth rationing; arbitrary rationing; the post code lottery - you don't want to live in York at the moment.
I think that NICE is the right approach, but as currently organised it too much under the thumb of the politicians and is guided by them and their focus groups. So "trendy" fashionable diseases like breast cancer get shed loads of money, and mental illness gets bugger all.
NICE has just decided that some very expensive drugs for colon cancer should not be available on the NHS for the time being, apart from in trials. These drugs have been in use in the USA for three years.
I think the NICE decision was correct. And provided that it applies to the whole of the UK, that is fine. But I suspect it will not. The private sector will provide it.
Rationing has to be planned. York PCT is having an end of financial year panic, and the pressure will be off in April. You cannot do it like that. You need to take a long term view and politicians never do that. They do not think beyond the next election.
But it is vulgar and inappropriate to deny treatment to men with tight foreskins, and old ladies with bunions to save a few bob at the end of the year. It is also short termism, because on the long term, this policy actually increases expenditure. You have to pay for the bureaucratic controls to delay the health care; the GPs and A/E departments have to work harder to support these people, and you still have to do the surgery a few months later.
Crazy.
John
3 month waiting for wisdom teeth extraction?
In Germany I had to wait for one week (and I did not have any pain).
I think it’s the hypocrisy that angers me the most. If the health service has run out of cash, if rationing of care is needed then at least say so. Be honest. The government should stop spouting this “best year ever” propaganda and tell the electorate the true situation in the health service. If the state cannot provide the service then help people to pay privately. Allow them to buy health insurance or private treatment from pre tax earnings or let them pay a lower NI rate, anything, but stop pretending.
I can see where Reform is coming from, but I disagree. Unless there's fundamental change in the system, the problem will recur. We need doctors, nurses and other necessary HCP in hospitals and the government just have to bite the bullet, take a hit on their unemployment figures that they are so keen to protect (but which are going hopelessly wrong for them) and sack much of management. I worked at York for a while and enjoyed it - just at the cusp of managerial exponential growth. It is notable that once, at a nearby hospital, so frustrated was I at being heckled by clipboard-carrying, non-medically qualified folk telling me to discharge patients, that I demonstrated my point by picking up the phone and asking switch to put me through to the head of paperclips.....I got through to someone....
There is a pretense in the UK that the NHS can provide everything for everyone. It cannot.
Absolutely. At least part of the problem is that there is no clear consensus on what the NHS is actually for. What, for example, is the rationale for the "everybody is entitled to one round of IVF" diktat? It makes no sense, and is rooted in no fundamental logic. It's just a reasonable-seeming band-aid slapped on top of a broken philosophy.
I think that NICE is the right approach,
Agreed, assuming it came with a philosophical core that described what the purpose of the NHS actually is. I'll agree with your "trendy" complaint, too.
NICE has just decided that some very expensive drugs [..] should not be available on the NHS [..]
I think the NICE decision was correct. And provided that it applies to the whole of the UK, that is fine. But I suspect it will not. The private sector will provide it.
This will always be the case. Rich people will always be able to afford more expensive medical care than the NHS.
Rationing has to be planned. York PCT is having an end of financial year panic, and the pressure will be off in April.
Agreed, again. One wonders why the PCT allowed itself to overspend in the first half of the year. The words "PCT managers", "arse" and "both hands" are springing to mind here.
the only solution if for the nhs to become a state backed insurance company, guaranteed minimum payouts - but paid equitably to everyone regardless of political clout, providers all become free market competing for the cheque from the insurance company via the patient, this gives patient opportunity to top up for newer/better treatment, cleaner surroundings, more convinient appointment times etc
then the patients can honestly see there is no money, and that is the problem, if there is no insurance payment they see immiediately its a money problem, rather than being lied to that they are on a list or in front of a committee to see if they can get on a list
incentivises innovation and better care amongst providers, and more efficient (less managers) treatment
etc etc
What a load of shite,
so for the next 3 months the local hand surgeon will twiddle his thumbs on full pay (or will his waiting list just fall within targets...)
lumbar spine xrays necc for exclusion of occult malignancy or discitis, all surgey mentioned could be worded to have an impact on working activities so this is just telling OAP's that we dont give a shit if your legs ache from viens or your toes are sore or your carpal tunnel makes you drop the kettle.
Bastards
NICE = National Institute for Cost Effectiveness.
I think the NICE guidelines are quite sensible. But they should apply to all NHS spending.
For instance, the NHS IT programme will cost at least £12bn. The NICE guidelines state £30K per "extra year of quality life". Therefore, the NHS IT programme should give 400,000 people an extra year of quality life. Simple. And each of those management consultants they employ for £200K, apply the same formula.
Seriously though, these faux-market style reforms need looking at carefully. The US is an example of a completely market based system and they spend nearly twice as much per-head as we in the UK do. And a quarter of that money goes on administration of "claim validation" - i.e. can we possibly get out of paying for this treatment. Can anyone else see parallels between this and what the PCTs are doing to try and come in within their "budget"?
I understand Dr C's pain. Do the PCTs really think that experienced doctors refer people to hospital for a laugh?
I think all the GPs in that area should formally declare to the GMC that they are being obstructed from doing their job. From 'Good Medical Practice', first and foremost:
"Make the care of the patient your first concern" - as opposed to the draconian financial problems of Ms SooChung & Ms Hewitt
ALSO
"Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk"
Well, I don't know if Ms SooChung could be counted as a 'colleague' but her actions are certainly risky. Virtually all of the proposed restrictions impact on medical treatment which is invariably necessary. If they were not necessary, why does she think GPs refer for them? If she is circuitously accusing them of being incompetent in making such referals, perhaps she would like to produce evidence first? If not, she should accept it is ethically wrong to restrict these referals, and have the cojones (ok so she is a lady) to tell Ms Hewitt where to stuff her financial crackdown.
Why are the GPs in North Yorkshire not up in arms about this?
I think in this context, CBE is short for "completely brainless entity"
With regard to:
"is Ian Donnachie Chief Executive of Bradford Health Authority married to Janet Soo-Chung ?"
"I don't know whether they are married or not, but they are partners. And they make a lovely couple"
This highlights the total lack of ethics in todays public services - about twenty five years ago a friend of mine, an executive officer in the civil service, based on the twelfth floor of a tower block in Scotland married a typist on the third floor...because it was received government policy that some conflict of interest must arise out of this (it was only the Inland Revenue for gods sake) he was involuntarily transferred to Brighton, presumably to keep them apart... Totally OTT nonsense of course, but contrast the situations....
Cor! I'm no doctor. I did however work in a GP's surgery putting medical records onto the computer for quite some time. As such even I can recognise that this is going to have a huge impact on the poor people of Yorkshire. Thank god I don't live there! Surely they can't get away with this? And of course don't forget Tony Blair tells us the NHS is working better than ever!
lBoody hell. Looking down that list, even I can see obvious problems with letting things like sterilisation of women and trigger finger sit for another three months.
Given that there is a finite amount of money available for the NHS, what do you think is the best way to ration healthcare?
Sam | 25.01.07 - 7:55 pm | #
Give the money back to individuals instead of taxing it away from them, and let them make their own value decisions about the healthcare they want.
Unbelievable.
We have problems with disingenuous rationing here, but crikey! Outright refusal of treatment for carpal tunnel, trigger finger, all lumbar radiography...wtf?
If a 75 yo patient presents with back pain and weight loss, are they still refused an x-ray ?
Classic carpal tunnel syndrome is highly disabling, fairly common, and fairly easily treatable...if one is allowed to treat it !?
Unbelievably dangerous. I wouldn't believe it unless I'd seen the letters.
Dork
The most extreme appropriate correction for paraphimosis is not circumcision, but preputial plasty - a slit or slits on the upper side of the foreskin which allow it to easily slip past the glans corona. This removes no sensual tissue, unlike circumcision which removes about 15 square inches of an adult's sensitive mucosa and over half of a male's sensual nerve endings.
'Janet Soo-Chung's 22-year career with the NHS began after she graduated from the University of Manchester in 1983 with a degree in Psychology'
aand the doctorate is presumably in media studies( or media manipulation)
when are they going to ask Gerry Robinson to give his opinion as to how to blame all this on the consultants? One assumes that will be in April when the money starts flowing again.
Janet Soo-Chung uses the title "Dr". Evidently not the "Dr" title taken by those with bachelor's degrees in medicine since hers was in psychology. Must be a PhD, but is it? - how does anyone do the 3, 5 or more years of work for a PhD while climbing the NHS greasy pole? Maybe it's an honorary PhD? This kind of pretence is becoming quite fashionable. The Chief Nursing Officer at the DoH styles herself "Professor" Christine Beasley. Still, getting honorary titles is a lot cheaper than buying them off the shelf from an American "degree mill" and a lot easier than actually signing on for a PdD programme and doing the work.
Would one idea be to allow NHS trusts to charge what they like for a particular operation rather than having to follow a fixed price tariff. If a given hospital can do knee ops for 10% less than the national average then they presumably could do a “special offer” on knee ops and bring in extra business (and cash) from other PCT’s, the resulting competition between Trusts could then result in savings and/ or more opertions across the board.
All those conditions sound and look deeply painful. Is it right to let someone suffer high pain levels which can impact their work and relationships? Surely that just contributes to the divorce rates, impacts the labour market and just means more incapacity benefit being claimed?
I may try to malinger as a man with trigger finger; it wouldn't be too hard. Why would the owners of the other afflictions consent to be photographed?
it is utter madness
i wonder what will happen to all these poor people with carpal tunnel, bunions etc. the powers that be see them only as minor ops, but the impact upon someones function can be significant.
as an OT i have made splints and given advice to patients with such conditions and i know how much their ability to carryout everyday activities can be limited.....what will happen is they will become less independent and then need more and more social care......but
many social services depts are now operating panels for all decisions about care, social workers are having to leap through the same type of loops as GPs will in yorkshire in order to obtain the care they know a person needs.
makes you wonder why they bother asking any of us for professional opinion on anything?????
Rant coming up:
(1) Waiting lists by any other name would smell as sweet...
Actually this is worse: at least the old, evil, waiting lists were arbitrated and internally priorotised by doctors. Now this modern 'don't-call-it-a-waiting-list' is managed by a... CBE.
-- Improvement means deterioration.
(2) Since demand for health services is infinite and supply is limited, rationing is inevitable.
There are only two fundamental ways to do this: by queuing and by price. If a nation has been foolish enough to place their health services in the hands of a monopolistic socialist entity like the NHS that is 'free at the point of use', queuing is unavoidable.
Added funding for an entity like the NHS may provide short-term relief for this dilemma, but in the end will only make the problem worse, as newer and better facilities and services become available due to the extra money: these very improvements will increase demand. And since it is impossible to increase funding at the level needed to meet demand for ever (or even for very long) the certain result in bigger and better queues than before.
-- Improvement means deterioration.
What we are actually witnessing is the bankruptcy of state socialism of the Stalinist/Hewitt model: all queuing is bad, but queuing in a monopolistic system is iniquitous because there is no alternative. It is not quite the worst of all possible worlds, but it's heading that way.
We have just have it proved beyond reasonable doubt before our very eyes that the system is bound to fail, not just in health but in education (for example) too. Throwing money at problems like these solve nothing in the end if the system itself is holed below the water line.
This does not mean we should consider returning to a red-in-tooth-and-claw rampantly capitalist sort of health system that is (by its detractors, exaggeratedly) supposed to exist in the United States. The experiences of France, Germany, etc., show that there is a middle way. I would characterise this as a sort of universal compulsory BUPA or PPP, to greatly oversimplify.:
(a) Everyone is insured by one of a number of medical insurance companies. Their premiums and payouts are policed by an agency set up for that purpose. Premiums are determined by income; applicant's existing health problems cannot be taken into account, the insurance is uncancellable (by the insurance company) and carries unlimited liability. Those who cannot afford the premiums for whatever reason are either financed by the state or join a state insurance fund set up for this purpose.
(b) Medical practitioners, both GPs and specialists, are independent professionals, funded in the most part by fees charged to the medical insurance companies.
(c) Hospitals and other facilities (such as labs, etc.) are owned and operated by a mixture of charity, private and (local) state entities. There are groups or chains of them as well as stand-alone ones (like hotels) as well as stand-alone hospitals
(d) Hospitals, etc. are also funded by fees charged to the insurers.
Result?
If one surgery, or hospital, or insurance company imposed the sorts of restrictions we see in the Yorkshire NHS today, patients or their doctors could go elsewhere--without having to leave Yorkshire; the post code lottery would be no more. Ironically, by removing the NHS's obsession with equality of health care across the land, the result would be more equal health care across the land.
This does not constitute a perfect solution. Far from it. But it must surely be better than people being faced with a one-size-fits all, take-it-or-leave it bureaucratic monopoly that is clearly too vast to be managed properly in any case.
(I've never understood why any sane politician would want to try to run such a monstrosity in any case; their ultimate failure and denigration is inevitable and the sooner the government divests itself of trying to perfom this impossible task the better. But then, why would any sane person want to be a politician in the first place?)
John
Janet Soo Chung was awarded an honorary doctorate by the "University"of Lincoln, which is I think a former teacher training college. I may be a snob but if this is the title she is using, it is really bad form.
JEM- it was long but it was worth it my friend. Change the world buddy. Slight amendments to my previous post: for 'hard', read 'difficult'; for 'be photographed', read 'a photo'. Hi ho, hi ho, it's off to work I go.
http://news.bbc.co.uk/1/hi/scotl...ast/
6300071.stm
they could shut down the stupid nhs call centres and give the money to some patients to go see a real doctor ?
Absolutely shocking. If I fell into this category, I would take the matter to Court.
I read in the press that the Hospital Trust covering the area where I live are using the BMI standard to determine if someone should receive surgery. One mature man who was 28 lbs overweight, a non smoker was refused a knee operation. I found this interesting as many clinics (Mayo for eg) are critical of the BMI standard and do not feel it should be used as a test for surgery. What about sportspeople, rugby players, rowers etc? Their BMI would be high but this would not accurately reflect their fitness or surgery outcome?
I agree with closing NHS call centres. Friends who have phoned believe it is a total waste of money with often abrupt staff. In addition, many have had a call back some four hours later - hardly an emergency helpline.
I wonder how long the appeals process takes. More than three months?
Anonymous 10:28--
The cancellation or suspension of all NHS computer projects could release £billions for actual health care.
It is probably the right short-term solution, but ultimately suffers from two fatal flaws:
(1) It is palliative only. These extra funds will in the relatively short-term end do more good that G Brown's extra NHS funding in general (see my previous posting)
(2) It involves senior members of the government, not least T Bliar and Nanny Svetlana Hewitt, standing up and stating in public, "We screwed up on an epic, royal scale." For this to happen... well, don't hold your breath.
The stupidity of this blinkered approach is that it doesn't actually save any money. Much of a hospital's costs are fixed in capital and staffing costs, whether the patients are treated or not. Instead of saving money, you end up with hugely expensive hospital assets and professional resources sitting around kicking their heels and the shortfall simply moved across from the PCT to the hospital trust..... not to mention the risk and pain suffered by the patients.
In philosophical principle, I agree with the "no one" approach of an insurance scheme that gives patients the buying power. I'm a great believer in markets. My worry is that the cheques would go to the crystal healers and astrologically inclined aura aligners. Then when the patient was even sicker the insurance scheme would have to provide even larger cheques for the reputable medical profession to do its stuff later in the day.
Markets work best when the customer is well informed. If the insurance company passed money to the GP for him/her to redirect to hospital / specialist / hospice / etc. then I think we'd be much better off both socially and financially. We could call it "fund holding" or something like that.
What do you make of this? - (it is in the Daily Mail)
"NHS staff asked to ease budget problems by working for free"
http://www.dailymail.co.uk/
pages...in_page_id=1770
Janet Soo-Chung uses the title "Dr". Evidently not the "Dr" title taken by those with bachelor's degrees in medicine since hers was in psychology. Must be a PhD, but is it? - how does anyone do the 3, 5 or more years of work for a PhD while climbing the NHS greasy pole? Maybe it's an honorary PhD? This kind of pretence is becoming quite fashionable. The Chief Nursing Officer at the DoH styles herself "Professor" Christine Beasley. Still, getting honorary titles is a lot cheaper than buying them off the shelf from an American "degree mill" and a lot easier than actually signing on for a PdD programme and doing the work.
Jonathan | 26.01.07 - 8:50 am | #
Some honorary degrees are awarded simply for celebrity service I know, but others (such as, as I understand it, Chris Beasley's) are awarded for a genuine contribution to the field (which you can't deny that Prof. Beasley has made to nursing).
Some honorary degrees are awarded simply for celebrity service I know, but others (such as, as I understand it, Chris Beasley's) are awarded for a genuine contribution to the field (which you can't deny that Prof. Beasley has made to nursing).
Nurse
++++
Yes, indeed, a major contribution. One that is contributing to the destruction of the proper nursing profession.
JOhn
Just on the A&E point - are you sure that triage is always carried out by SHO and registrar grade doctors in the NHS? At a reasonably wide spread of times of day and night (so I don't think my experience has been distorted by shifts or staffing patterns), University College Hospital in London has always had a nurse (or at least, a woman in a nurse-type uniform) as the first point of contact after you've walked up to the desk.
I am not 100% about this - I've always gone in there with fairly serious things (and I admit I've never gone to A&E in the hope of doing an end run round the appointment system, though I can see how that might be the right thing to do sometimes) - because I've always ended up seeing a doctor pretty soon after, but I strongly got the impression that the nurse/practitioner/whatever was occupying a gatekeeper role.
A google search for "triage nurse" seems to suggest that this is pretty ubiquitous practice in the USA too.
Remember, don't come to York on holiday. As nice a city as it is, if you fall over and injure yourself, you might as well be in the middle of the Gobi desert.
Tourists beware! :p
This is awful. I will be spending this weekend to take out private health insurance for myself and my family. We will reduce our mortgage payments and take out health insurance instead.
Is this accurate at all?
"Doctors and nurses have been told they each must save £2.50 a day by measures such as prescribing cheaper medicines, reducing the number of sterile packs used, cutting hospital tests and asking patients to bring drugs in from home."
http://www.dailymail.co.uk/pages...ge_id=1770&
ct=5
If you have queuing by a NHS scheme, those who place a higher value on health care.....and have the financial resources......will go private. Fewer will be able to do it, one would imagine, as the financial resources have been taxed away.
The bottom line is.....healthcare is STILL rationed by economics, even in the NHS. The rich get better healthcare.
It is silly to try to pretend that ANY healthcare financing scheme will "equalize" healthcare access. It will never happen. There is two-tier healthcare everywhere on Earth. Acknowledge reality, and make the lower tier acceptable.
re "In philosophical principle, I agree with the "no one" approach of an insurance scheme that gives patients the buying power. I'm a great believer in markets. My worry is that the cheques would go to the crystal healers and astrologically inclined aura aligners. Then when the patient was even sicker the insurance scheme would have to provide even larger cheques for the reputable medical profession to do its stuff later in the day.
Markets work best when the customer is well informed. If the insurance company passed money to the GP for him/her to redirect to hospital / specialist / hospice / etc. then I think we'd be much better off both socially and financially. We could call it "fund holding" or something like that."
easily solved by only making the chqeues cashable by qualified medics
the problem with your (and the conservative party) solution is that we have massive wastelands served by crap GPs, and GP services need to be subjected to market forces as much as hospital services do
if the patient has no buying power we end up in the situation we have now where
i) they cannot select a GP of their choice, rather being restricted to a few very local to them (catchment area provision) which forces people to move house to see a decent GP, made much worse recently by new distance rules introduced by PCTs as part of GP contract etc
ii) GP surgerys only open restricted hours, dont even pretent to take appointment phonecalls or allow prescription collection over lunch
iii) no access to GP at weekend or evening
iv) sub standard out of hours cover
I strongly recommend the PATIENTS are given the buying power, as again real PATIENTS move around and in these days of flexible working half the time they are not even in the right part of the country to see their own GP whoes job it would be to decide providers, rather they need to be able to spend wherever they want or happen to be
and this includes taking the cheque to bupa, nuffield or foreign hospitals
are you sure that triage is always carried out by SHO and registrar grade doctors in the NHS?
++++
It isn't now. It's increasingly done by all sorts of amatuers. But in the old days, ALL patients were seen by a doctor; there was no triage.
Triage is a battlefield word. And the crazy crazy thing about it is that so called "triage" in A/E departments is now done by the most inexpereinced people in the department, whereas, if it is going to work, it should be done by the most experienced - i.e. the consultant or what used to be called the SR - because they are the ones with the experience and medical knowledge to make a swift assessment as to what is serious and what is not.
But no, it is cheaper to get the monkey to do it.
John
Is this accurate at all?
"Doctors and nurses have been told they each must save £2.50 a day by measures such as prescribing cheaper medicines, reducing the number of sterile packs used, cutting hospital tests and asking patients to bring drugs in from home."
------------------------------------
I'd say so. I've seen this sort of penny pinching first hand. The PCT where I live let the district nurses use sterile dressing packs, yet when I stayed at my parents the PCT there didn't. I was not impressed.
no triarge by nurses in milan A & E, just walk in and get seen by a doc, not queue, no waiting room seen, just easy simple, polite, and clean, i guess the queues are kept down by the ready availability of GP services 24x7
if the italians can do it i really dont see how the uk can be so fucking crap at running its medical industry, oh yea i remember its run along communist lines which dont work
we really are the laughing stock of the whole world
Dear God, whatever happened to doctors seeing patients and deciding what they needing doing to them. No doubt the PCT has protocols for arse wiping stuck on every loo door.
Where's the A+E Charge nurse when you need him??
Seriously, A+E should not be the Dept Of Triviatrics, for people who can't be arsed to wait for a GP appointment, or want a flu immunisation (this was at Cheltenham A+E)
PCTs have to pay the Acute trust for every patient booked in at A+E. (something like £60) Why shouldn't they try to divert people who don't need an Accident and Emergency doc to see them? The patients who, when they can't get an immediate appointment with the GP when they turn up at the surgery, say "right then, I'm off to the Accident Unit"
I totally agree that true'Triage' needs to be done by someone competent, in my view this means a medic, but those that aren't real A+E material can go to a PCT Minor Injuries unit or whatever. Lets keep A+E for the real stuff.
A similar system operates during Out Of Hours locally, A+E is through a swing door. Our A+E staff get swamped by patients, they are only too glad to be able to divert appropriately.
"I'd say so. I've seen this sort of penny pinching first hand. The PCT where I live let the district nurses use sterile dressing packs, yet when I stayed at my parents the PCT there didn't. I was not impressed."
A sterile dressing pack is not always appropriate. Often only a small part of their contents is used. Personally I am not impressed at the careless use of taxpayers money.
Neil, not an A&E charge nurse, but I am a consultant nurse in A&E and have previously held a charge nurse position - will that do you?
There needs to be somebody on the front line who can establish with what level of urgency a patient needs to be seen - we have a finite number of staff and bedspace, and cannot possibly see every patient the second they come through the door (although perhaps as others suggest, if we had a more comprehensive primary care/walk in centre service then perhaps we might be able to). Hence patients have to wait.
In the old days, before us big bad nurses started triaging, patients would be seen in the order in which they arrived, unless there was a very obvious reason to push someone up the queue (e.g. throwing up blood all over the receptionist). This meant that the football player with the sprained ankle would get seen ahead of the acute abdomen etc. etc. Obviously this situation is dangerous.
So, by the mid-nineties, it had become accepted practice throughout the UK (and indeed the world) to have a senior nurse on every shift whose specific job was to perform a baseline assessment on all the patients who came through the door and decide the priority with which they needed to be seen. They are not there to diagnose or treat patients, merely to establish how critical the patient is. Nurses have been shown to be good at this, and the manchester triage scale inparticular has helped to standardise levels of care.
Triage is absolutely necessary in modern A&E departments, infact that's been recognised for a good 20 years now. Who does it is trivial as long as they're able to. It is invariably the nurses who get stuck with it, but if any doctor would like to learn how it's done and have a go then they can feel free to come down to my department and do it any time - I have a million and one other jobs to do and they'd be quite welcome to take it off my plate.
Nurse you are talking bollocks to the wrong people
You see some of us have actually lived in many other parts of the world
What's a "consultant nurse" by the way? In the UK context it sounds like a jumped up job title to me, my best mate is one of the most qualified and experienced nurses in the country and he doesn't use such a pretentious title
So
Re "The patients who, when they can't get an immediate appointment with the GP when they turn up at the surgery, say "right then, I'm off to the Accident Unit"" I think you are massively underestimating the problems real people in the real world have getting registered with a GP or making an appointment with a competent GP in some part of the UK, we have all sorts of bollocks from "you must come in person at 9.00 am on a Monday to register" which isn't exactly helpful for a worker with a precious 20 days paid holiday a year, to no appointments allowed to be booked more than 2 days in advance, to "no appointments unless you are an emergency today or tomorrow", which often leaves no fucking choice at all other than turn up for an appointment exactly 2 days hence, and by the way that only includes if you can get registered - there are some areas with waiting lists to get on an NHS GP list, so its hardly surprising people turn up in A & E, the rest of the world has "minors clinics" where you can go if you are in agony with ear ache 3 in the morning, or with minor cuts etc, and leave A & E for major trauma - we would do well to establish similar AND SET THEM UP SMALL AND LEAN AND COMPETING WITH EACH OTHER as competition is the only way to keep them customer focussed, i.e. clean, and short queues etc
Re "and cannot possibly see every patient the second they come through the door" so how comes the rest of the Western World pretty much manages this then?
Re "accepted practice throughout the UK" yes "(and indeed the world)" very big NO NO NO
Triage was invented by the US Military for battlefield use, faced with masses of casualties and limited resources it can make sense, and in a disaster here it would also, for use as routine for the normal flow of patients into A & E it is frankly complete bollocks
"I believe the NICE decision was right"
Sorry John, I disagree. I think the principle behind NICE is of course one we can all sign up to, but aside from your quite correct point about trendy diseases, there are many other faults with the NICE system. Without labouring the point, on a very basic level the number of QALYs you have to gain may be very different if you are 40 years old compared to 85. Therefore a treatment which is not cost-effective for an older patient may well be so for a younger one. Similarly a parent who wants to see their first grandchild born may get a great deal more quality out of an extra 9 months of life than someone with dementia in a care home. Of course we are not allowed to be ageist, and indeed there is good evidence that many cancer treatments provide the same relative benefits for the old as the young, but there is no way of really quantifying the potential cost-effectiveness for an individual. Therefore making NICE absolutely binding is a typical 'dumbing down' and removing the ability of the doctor to make reasonable decisions about what is the most cost-effective treatment.
Furthermore refusing to fund a drug on the NHS result in patients having to pay a huge mark-up if they wish to receive it in the private sector, as they are not allowed to 'mix and match' their treatment and buy extra treatment from the NHS, so the people who can least afford these treatments (the wealthy usually have private insurance) are the ones who have to pay most. Is that fair and equitable?
No one.
Firstly, regarding your question about my role. I believe I've explained it in detail here before, but it goes something like this: My speciality is critical/emergency care. I spend roughly 1-2 days a week in university teaching nursing students as well as qualified nurses studying for further qualifications. I'm also involved in research in emergency/critical care nursing (I won't say on what topics otherwise I'd easily be identified, but I would imagine that I'm on a par with your "best mate" in terms of seniority and contribution to my speciality in nursing). At least 2 days a week are spent on the shop floor, either in A&E or the Intensive Care Unit (and very occasionally I do shifts in pre-hospital care, attending major incidents and serious entrapments/RTCs with ambulance paramedics and doctors). When in A&E, I usually act as the senior nurse either in triage or resus, although I have been known to work in minor injuries. In the ICU I'm usually supervising junior/student nurses or working with the outreach team (responding to emergencies on the wards). As for the title - I don't like it very much. I don't think it's pretentious, but it does rub doctors backs up for no real reason, as well as add to confusion for patients.
I think you'll find that patients are not infact seen immediately in anywhere but the quietest hospitals. If you want to moan, compare us with the USA, where waits of 12-14 hours are standard. I have some links with Australian departments, and they all also use a triage system to manage the waiting.
The form of triage in everyday use in A&E departments is not the same as that used in major incidents such as the millitary system you talk about (although we do use such a system in the event of large scale disasters, for obvious reasons). In a UK A&E department, everybody gets seen within an appropriate length of time, and at that time has the full battery of resources available to them. In a majax, patients physically cannot be seen within an appropriate time and resources are stretched - this is not the same scenario.
Re the dressing packs - it has been shown that wounds being dressed in the community do not require an aseptic technique (not that you can realistically achieve it anyway in the patients' home). It is only in hospital/clinic settings (where a large volume of patients bring a large variety of bugs in) that a strict aseptic technique is required. If you're being visited by the district nurse in a home setting, a clean technique is all that's required. Dressing packs, as Neil points out, are a waste of money at the best of times, but in a patients own home they are almost always unjustified.
re "seen immediately in anywhere but the quietest hospitals" but youre wrong you see, you actually believe this dont you, youre so out of touch with how far behind the rest of the developed world the uk has become
Glad to see that with 17 years of training and experience I'm just an 'Ambulance Driver' again.
For the record, I think Drs are best in these roles, but constantly insulting those who work with you through what I suspect is your ignorance of what they are capable of doesn't do you any favours John.
I'm sure you could spend all day illustrating which ENP did what wrong, but lets not ignore the fact that many nurses and paramedics could equally point out as many failings in our medical colleagues.
One of you buggers nearly killed me with a completely incompetent diagnosis back in the 90's, but you won't find the details on my blog.
SD
I don't profess to know what goes on in every emergency department in the world, but I do have, as I said, links with prominent departments in the US and Australia, and I have attended and presented at a number of international conferences on emergency nursing; so I'd like to think that I have a fairly good idea of what goes on. Triage, in one form or another, and whether or not that's what it's called, is in use in most developed countries which experience high flow to their emergency departments.
So where is this flowchart? All I see is a guesschart with no decision conditions by the arrows.
I'm in the US and though on our recent visit to A/E (husband's chest pain) we were seen quite quickly everyone we know expected us to have a 5 hour wait - A/E depts are clogged with patients who don't have medical insurance.
"no triarge by nurses in milan A & E,
no one | 26.01.07 - 6:59 pm | # "
That's odd because there's research published into triage in A&E in Milan, so you may not think they use triage, but the people doing it think they do.
Ann Ital Chir. 2004 Sep-Oct;75(5):515-22.
[Trauma registry at the Niguarda Ca' Granda Hospital of Milano: epidemiology and quality assessment]
well ive walked straight into A & E in Milan and been greeted by a doc and treated immediately, and I was not the biggest emergency on the planet (although i did need to be there), didnt see a waiting room, didnt have to queue for 30 minutes to talk to some teenager eating her sandwiches behind a security grilled reception as i have in uk
My husband used to work in computer analysis and programming... He has a very nice ruler with the draw through templates for flowcharts (sorry, bit braindead this evening and don't know how to explain it better) that I would be more than happy to send you so you can make your (much better) flow charts for all this carp.
These people need a decent systems analyst - as does the rest of NHS 
Best wishes, as ever, from Liverpool
need a basic understanding of queuing and scheduling theory too
Hi Neil, thanks for thinking of me - just got in from work.
A&E as you know has been rebranded a few times - casualty, A&E and more recently ED, or emergency department.
Despite the emphasis on EMERGENCY I'm sure most departments are frequently overwhelmed by the numbers of attenders with relatively non-urgent problems.
Our department, for example has seen a 30% increase in the last 10 years - and I wouldn't be suprised if there are others with much larger increases over the same period.
In theory, the principle of providing patients with a range of services may actually benefit them PROVIDING choices are real and appropriately resourced, although I do not know about the situation in Yorkshire.
Nurse [above] has already commented on triage. Our department has used the Manchester triage scale for many years and Dr Crippen should know that this model was devised by senior A&E authorities [MacWay-Jones, 1997].
We are little more than monkeys or amateurs in his eyes even though A&E nurses safely triage thousands of patients every year.
Ecparamedic [above] is clearly irritated by this condescending attitude and I am too.
Yes, of course it would be nice if A&E consultants triaged thousands of patients each day, but first of all few departments provide 24 hour consultant cover, and more to the point they wouldn't want to even if they did.
OK, what about the SpRs, perhaps they could triage, 'why' any experienced Reg would ask, the nurses have been doing the job for years, if something aint broke, why try to fix it ?
"well ive walked straight into A & E in Milan and been greeted by a doc and treated immediately"
Oddly enough no one, in my n=1 study of personal casualty visits, I've walked into A&E in a certain Scottish city and been seen immidiately. Probably would've been different if it were 2200 on a Friday or Saturday night not 1000 on a Tuesday morning... Imagine it would be the same in Milano too. I'm sure you have more stories, but remember, as medical students have been told since time immemorial: "The plural of anecdote is anecdotes, not data".
Out of interest, how would you make sure everyone who walked into A&E was seen immidiately by a doctor? Unless you're prepared to have 30 docs sitting around at the taxpayer's expense - because, let's face it, in your 'preferred' private scheme, a private hospital ain't going to be paying 30 docs to sit round on the offchance the're all needed. So like it or lump it, triage is neccessary.
And if you can't register with a GP, have you tried contacting the health board or PCT? Although, I imagine you will be winging about how crap they've been to "my best mate" too...
What I forgot to say in my earlier comment about systems analysis was that it needs someone who understands the "system" and in this case is also medically trained. I'm not doing too well today, so I apologise for not getting my thoughts together properly before posting.
Best wishes to all who contribute to these discussion, and THANKYOU to Dr C for giving us all this space where we can voice our disquiet.
As it happens a family member had to attend A&E at Addenbrooks in Cambridge just last weekend. The problem could not wait until the Monday's GP surgery, but was not life or death.
Arriving at about 6 pm on Saturday evening, the patient was seen by a very competent doctor literally within minutes. He diagnosed and gave initial treatment, but sent for the surgical registrar on duty, primarily in order to confirm or extend the diagnosise or treatment already given.
The registrar turned up within half an hour, conducted his own examination, and confirmed what had been done was correct. The patient was told she could go home as soon as the nurse had dressed the wound.
There followed a two hour wait for the nurse, who did what she was told with bad grace, and the patient left. Halfway home, the nurse's handiwork fell off the patient, who returned to the hospital. Eventually, the same nurse as before appeared and, accusing the patient of "interfering with the dressing", re-dressed it.
This time the dressing did not fall off until the patient was back inside her home, and the family gathered round and patched the dressing up well enough to see the situation through until a visit to the GP's practice nurse on Monday morning.
Like the curate's egg, A&E was good in parts. There was no triage, and the patient was immdeiately seen by a doctor.
What a bloody farce. I didn't think that this dumbing down of the NHS would extend to A&E departments of all places. Looks like nowhere is safe under Patricia's reign...
Just found this petition on the PM's site... Sack Patsy
"We the undersigned petition the Prime Minister to Remove Patricia Hewitt from the office of Health Secretary: Common consensus among frontline healthcare staff suggests Patricia Hewitt is the worst health minister in living memory. She has lost the confidence of NHS staff on the shop floor and seems to have no idea about what is going on (2006 being "the best year ever" for the NHS)! Her reforms have been draconian and NHS morale is at rock bottom because of them"
I'm sorry.....not too good for the patients!
I've recommended you on my site!
theanonymousmedicalstudent.blogspot.com
If you saw some of the discussion fora on which emergency department consultants communicate, you would realise how frustrated many of them are by not having the resources to have the most experienced doctors doing the triage.
A consultant or experienced registrar in the triage room speeds things up enormously; however most departments don't have enough senior staff for managing the resus cases and supervising the juniors and ENPs, let alone the rest of the work.
We've all hauled 'triage disasters' out of the waiting room at one time or another. No system is perfect, and some staff are better at triage than others.
Taxpayers would prefer doctors but can't afford them. Doctors back in the day weren't paid for all they did but for what they were paid for, they were overpaid (think). New York doctors are about to have their gravy train derailed by Governor Spitzer. The same must eventually happen here; the survival of the NHS demands it.
From across the Atlantic. Sound Familiar?
Spitzer cited the 2002 health care package negotiated between then Gov. George Pataki, legislative leaders and the politically powerful leader of the state's biggest health care worker union. In part, the multibillion agreement rushed through the Legislature paid for pay raises for the union's workers.
"The time was ripe for a debate on how best to invest money," Spitzer said. "But instead of a public debate, the state committed billions of dollars in new spending to underwrite a portion of the increased costs of the hospitals' pending labor agreement."
My medical friends have told me that the reason you don't get many doctors specialising in Casualty work is that there is no private market for it.
Anyone care to comment?
Agreed tielserrath,
But over the last 15 years or so there have been two main approaches in A&E in the UK ;
[1] no system of prioritisation [book in with reception stafff then simply wait your turn].
[2] Patients triaged by nurses.
If the amateurs are so crap, why haven't the 1'%s done something about it - yes, A&E consultants are very busy people but do you think they'd let bodies pile up in the waiting room because of monkey-nurse ?
I've never heard so much rubbish in all my life.
tielserrath - maybe I'm being naive, but in my experience A&E consultants are happy (infact eager) to dump more and more on the nurses, often more than we can or want to take on.
As you say, though, there is a problem with having a doctor doing it - you'd need a senior doctor (so an experienced SpR or a consultant - SHOs haven't generally been around long enough to make that kind of decision), who was prepared to sit in a room for 12 hours deciding only how ill a patient was - not diagnosing them, not treating them, simply placing them on a scale of priorities and sending them on their way. What doctor do you know who'd be prepared to do that? And with the recent MMC changes decreasing speciality training time, what doctor do you know who has time to do that as well as getting their hours in doing their actual job?
Yes, we have all flagged up a serious error in triage (and in other areas of care) from time to time. Yesterday I stopped one of our registrars from discharging a back pain which was obviously (to me, at least) an MI - 30 minutes later, we had the patient bundled up and on the way to the cath lab. But as someone said above - anecdotes like this do not make for sound data, and we have to accept that all of the proper, validated research which has been done points to triage working most of the time and most patients turning out to have exactly what the doctor diagnosed them with - wouldn't you agree?
I like my "n=1 study" not because its a single anecdote, but because I've been in contact with the medical profession around the world, and in many 10s probably 100s of examples I'm struggling to think of anything I would be critical about of the many foreign interactions, yet every single time I personally or friends/family come into contact with the nhs it is substandard in some way, this is not mere anecdotal evidence - this is experience built up by a large collective of friends and family over a lot of experiences
Re "Out of interest, how would you make sure everyone who walked into A&E was seen immediately by a doctor?" As I tried to explain, but probably did a bad job, was I think you need in a typical large town/city
i) A good well equipped A & E, serious trauma/sickness only
ii) Several "minors clinics" operating 24x7, charge a modest fee to force people to think about why they are there, handles the mass of stuff which is important to the person concerned, but is unlikely to require surgical intervention
iii) Decent out of hours GP service 24x7
ii) and iii) radically reduce input into i), allowing A & E to tighten up its act
ii) in particular is a great innovation which with a little less crap and interference from the nhs could probably be done privately for modest fee to patient
You see the nhs model of expecting people to wait in outrageous pain in an A & E waiting room for 4 hours just because the condition isn't triaged as the most serious thing in the building is subhuman, and for fuck sake it wouldn't happen to a pet taken to a vet hospital, this for me demonstrates how fucking unreal all you wankers supporting the nhs have become
Re "Unless you're prepared to have 30 docs sitting around..." I don't pretend to be an expert, I do know many cities in the world where the patient experience is a whole lot better than most parts of the UK, my suggestion would be you get off your bums and go and look at how it works in some of the best cities in the world, let me list Auckland, Milan, Brussels to name just 3 that I have seen with my own eyes repeatedly provide care a lot better than the rubbish the nhs doles out
Re "at the taxpayer's expense" what's this supposed to mean, I want efficient spend of the publics health money, I really really don't think anyone could make a case for current health spend being done efficiently
Re "And if you can't register with a GP, have you tried contacting the health board or PCT?" complaint in progress, really don't have time for it, and I will probably end up moving address since my partner is diabetic and the current shit provision is life threatening.
Come of people, wake up and smell the coffee, I know there are lots of good genuine folk doing their best to do a good job in the UK health system, but as a collective, and as an organisation you're just not delivering, your processes, your governance structures, your fundamental ingrained approaches are just not delivering the goods, you really need to go look at best practise elsewhere and face some harsh truths
If you saw some of the discussion fora on which emergency department consultants communicate, you would realise how frustrated many of them are by not having the resources to have the most experienced doctors doing the triage.
A consultant or experienced registrar in the triage room speeds things up enormously; however most departments don't have enough senior staff for managing the resus cases and supervising the juniors and ENPs, let alone the rest of the work.
We've all hauled 'triage disasters' out of the waiting room at one time or another. No system is perfect, and some staff are better at triage than others.
tielserrath
++++
Please may I have details of the fora
John
Ladies and Gentlemen..
I give you the real reason numpties like Patsy walk all over the NHS.
The Doctors are fighting with the nurses and ECPs over 'whose the monkey'. The nurses are fighting with other nurses over regrading from years ago.
Paramedics are fighting with ECPs over falls, leave at homes etc etc etc.
Everyone seems to think paramedics, techs and ECPs are 'just ambulance drivers' and everyone hates their managers.
There you go folks, you got Patsy because your too bloody busy knocking each other down to notice you are all being bent over a barrel and right royally shafted, and when you do notice, you've already pissed off those who might stand with you.
SD
No-one, you've shot yourself in the foot a bit there: I've actually been in Auckland City Hospital's emergency department as a visiting senior nurse, and I know full well they use a triage system.
As for your other points - the redirecting people to primary care facilities on site is actually what they're proposing to do in York, which all of you are decrying. And I already said above, that by reducing the number of patients presenting to A&E, you reduce the necessity of triage, particularly during the quiet times.
I had wondered what the expanded A&E Dept at York was going to have in it. At least this new Yorkshire primary care clinic will make it easier to meet the 4 hour wait target......
And what will happen to the York Dupytrens Surgery Nurse Practitioner during the 3 months? (yes there is one, she's very nice actually)
nurse
re "No-one, you've shot yourself in the foot a bit there: I've actually been in Auckland City Hospital's emergency department as a visiting senior nurse, and I know full well they use a triage system." well i needed medical treatment out of hours a few times in auckland but never needed to go to A & E, I went to one of the out of hours minors clinics they have, and got treated within 5 minutes in a clean friendly environment, if you worked in the city you should know this is how the vast majority of people get handles
now compare and contrast with the dirt and wait in the average UK A & E
Oh I like the innovation by one of our new PFI hospitals, just have a thin access road to the hospital (crap nhs planning), put the hospital miles away from the centre of town, thin the roads down on the route from the centre of the population to the hospital (anti car measures by the council), insufficient space in the car park
And whether you go by ambulance, car, taxi, bus to this particular hospital there will be a long drive out there (its not all that far just so many misguided traffic calming measures on the way make it long in time), and a circa 2 hour queue to get from the main road up the hospital drive (this is no exaggeration)
Makes the laughable 4 hour wait target once you get there a bit ridiculous
Proves managing the nhs by targets doesn't work, and that the patients should be given the buying decision and multiple places to take their health spend to generate a bit of competition
Got no problem with nurses doing triage as long as adequatley trained and have full back up. Not like the usul NP horror story of someone alone in an office with a ludicrous protocol. If casualty ain't teram working I don't know what is.
No one, once again I repeat my offer. Give me money. Lots of it. Then I'll treat yout.
But you couldn't afford my private rates, I'm afraid. Especially if you had something chronic like heart failure or COPD. Your insurance would run out, your savings would go and regretfully I would withdraw my services, leaving you to the tender mercies of the social services whcih would no longer exist as there would not be any funding. No money in it, you see.
On to Yorkshire. All my patients would be sent to the consultants on a named patient basis, using a hand written envelope marked 'private and confidential' if necessary.
Explain to patients that the PCT is refusing to pay for thier treatment, so it is not your fault.
Encourage patients to write/complain to MP (get a nice big pile of correspondence etc.), you can do this as a GP as you can criticise a policy, just so long as you do not criticise the political party involved.
re "No one, once again I repeat my offer. Give me money. Lots of it. Then I'll treat yout."
well since I paid for my last ops, and recent treatment, including recent GP consults, your invite doesnt faze me
re "But you couldn't afford my private rates, I'm afraid." thats whats good about free market I went to people I could afford, if you price yourself out of the market thats up to you
re "Especially if you had something chronic like heart failure or COPD." would be left to die by the nhs anyways so whats the difference
re "Your insurance would run out" happily you know nothing of my financial or insurance position
re "your savings would go and regretfully I would withdraw my services" i can see what youre saying, but as ever i advocate a change to a system where the nhs is a state backed insurance company, and all medical providers are not state owned and are subject to market forces at the patients take their insurance payout cheque where they want
well i needed medical treatment out of hours a few times in auckland but never needed to go to A & E, I went to one of the out of hours minors clinics they have, and got treated within 5 minutes in a clean friendly environment, if you worked in the city you should know this is how the vast majority of people get handles
Well absolutely. And (as I said above) that's what they're trying to do in York, yet you're all decrying it.
"re "But you couldn't afford my private rates, I'm afraid." thats whats good about free market I went to people I could afford, if you price yourself out of the market thats up to you"
How is that working in the US, do you think?
Oops, that was me (Anonymous at 2:01)
I am a doctor in the USA and you might be surprised to find out that there are emergency departments in the USA that offer wait time guarantees (see link) http://transcripts.cnn.com/TRANS.../09/
ltm.01.html
'"Your insurance would run out" happily you know nothing of my financial or insurance position'
Well, you have no idea how much I would charge.
And as one of the leading experts in my field, it could be pretty much what I liked. Because if you paid less, you would not get such good treatment.
And that, ol' bean, is the free market.
i tell u what crippo i like the free market a lot better than current arrangements
Regarding A&E in the 2 Yorkshire hospitals under threat from a PCT based triage. They don't just want the primary care, they want the lot (unless it is ill and expensive). They want diagnostics and XR's and only when they are really sure they can't do it will they kindly let local patients, who came to their local A&E department to see A&E nurses and doctors into the A&E. How is that for patient choice??
One of the small benefits of a Foundation Trust is that you can tell people with stupid ideas just to go away... which is what I suggest they do.... knowing the PCT they'll try not to commision any services from A&E next year
re: The Abolition of Health Care in Yorkshire (2)
Im guessing this is what to a member of my family at Sunderland General last year. She was 'assessed' by a nurse at the A&E doors and turned away, only to end up there by order of doctor a few hours later!
Does anyone know what the funding model is in Auckland, Brussels or Milan?
Primary care is relatively cheap. Specialty care is expensive.
Heart failure was mentioned. I offer discounts for payment at the time of service. What that means is, a mid-level office visit is about fifty dollars US.
Heart failure was brought up. Assume relatively stable CHF. I am looking at a list of medicines available at Wal-Mart pharmacies for four dollars a month. Four pages of medicines.
Metoprolol and most beta-blockers, digitalis, lisinopril and most ACE-inhibitors, warfarin, HCTZ/spironolactone/furosemide and most diuretics, most nitroglycerin preparations, and lovastatin, are available at Wal-Mart for four dollars a month. I've heard they just did the same with Simvastatin, but haven't seen it in writing yet.
My list is a couple months old, so probably more medicines available now. Most USA pharmacies will price-match Wal-Mart's prices. They have no choice.......
The same Wal-Mart that everybody likes to criticize, while our former Senator and probable Presidential candidate John Edwards sends his aide to get a toy for his kid right after delivering a stemwinder of a speech criticizing the store.
Wal-Mart has done more to improve access to healthcare in the USA than Hillary will ever do.
So take your pick of those medicines. About fifty dollars a year, each. My office visit, say four visits a year.
That can be the cash price for management of stable heart failure in the USA.
A lot of those "can't pay" stories in the ER's are really "won't pay".
If over 65, you're on USA Medicare, so automatically insured. If under 65, heart failure will get you disabled and on Medicare. If impoverished, Medicaid.
It's hardly Nirvana here, I'll be the first to say that. But it's simplistic to say that the chronic disease will leave you out on the street in the USA, just as it's simplistic to say it WILL be treated in the UK. I've seen to many reports of the "free" care simply not done because of waiting times.
Front lines, solo "hang out a shingle" primary care in a rural part of America, very pretty, but hard to make a living.
I'll say that the worst problem I have is with Medicaid, our "insurance" for the impoverished. Our "free" care for the poor pays far less than my discounted prices, when they choose to pay at all. Plus the "entitlement" mentality that goes along with it.
To be honest, I prefer the Mexican immigrants. I can, and do, manage their CHF and diabetes and other chronic diseases, cash.
The ones who really know the score, and their status is "legal" so they can cross the border easier....let's say I don't want to know. They go south from time to time, and pay cash, again, to get certain medicines and testing done in Mexico. They're going there anyway, to visit family. Of course, as you can imagine, the cost is far cheaper there.
I'm getting pretty good at reading consultant reports in Spanish.
Source: http://cache.zoominfo.com/cached...tName=Soo-
Chung
8th September 2005
HONORARY DOCTORATES FOR UNIVERSITY PAIR
The University of Lincoln is set to honour two people from very different walks of life at an undergraduate awards ceremony at Lincoln Cathedral next week.
Nevile Camamile, the university’s first Pro Chancellor, and university governor Janet Soo-Chung CBE will both receive an honorary doctorate at the university’s undergraduate awards ceremony on Tuesday (13th September).
Nevile Camamile is a son of the city who followed his father into the profession of accountancy at Streets in 1950. He did though, unusually for the time, combine his articles with a degree in industrial economics, completing his studies in six years.
After completing his national service he went on to become Chairman of Streets.
Mr Camamile was made the first Pro Chancellor of the University of Lincoln, an honour which involves him in the institution’s ceremonial life as the Chancellor’s representative and which acknowledges the important role he has played in establishing the university.
Janet Soo-Chung’s 22-year career with the NHS began after she graduated from the University of Manchester in 1983 with a degree in Psychology.
She joined North Western Regional Health Authority as a National Management Trainee and in 1985 was promoted to Assistant Support Services Manager at Trafford General Hospital.
She moved steadily from trainee and managerial positions to directorial roles and finally to chair and chief executive posts. Her extensive experience is based in the North Western, West Midlands and Northern & Yorkshire NHS Regions and has been gained at regional, district and provider level.
She was made a CBE for services to health care in the New Year’s Honours List of 2002 and she sits on the Board of Governors of the University of Lincoln.
During the ceremony at Lincoln Cathedral starting at 11.30am on Tuesday 13th September Mr Camamile and Ms Soo-Chung will both be presented with an honorary Doctorate of Business Administration by the university.
For more information contact:
Jez Ashberry, Press and Media Relations Manager
01522 886042 jashberry@lincoln.ac.uk
Well, you have no idea how much I would charge.
And as one of the leading experts in my field, it could be pretty much what I liked. Because if you paid less, you would not get such good treatment.
And that, ol' bean, is the free market.
Crippo:
Yes.
And the other part of the free market, ol' bean, is that if you really think you can charge vastly higher fees than the competition (even if you think you are a bit better than them) you will have no 'customers' and get very hungry.
re "Well absolutely. And (as I said above) that's what they're trying to do in York, yet you're all decrying it." no in auckland you walk in and see a doc in a minute or two, get serious consideration, good treatment, friendly clean environment
york are simply trying to recude costs and their version of the service will in the nhs tradition have long waits in dirt and endless chats to nurses before you have a chance of seeing a doc
I read about this in the local press. York hospital was making it known that the spare capacity left by the local PCT sending many less patients to it was of course now ready and waiting for referrals from other PCTs outside the area. marvelous isn't it
Read this for suggestions that hip and eye operations should not be free on the NHS. Who's going to pay for all the extra care that's needed for mobility-impaired people? The taxpayer. Why pay via social services long term when we can pay via NHS short term.
http://news.bbc.co.uk/1/hi/healt...lth/
6303443.stm
no one writes:
"(I) didn’t have to queue for 30 minutes to talk to some teenager eating her sandwiches behind a security grilled reception as i have in Uk"
you are talking bollocks no one, this is not a representative picture of A&E depts. in the Uk, and when was the last time anyone saw an SpR much less a Consultant sat on the triage desk? Not since Florence was a girl I bet and even if this was possible I can't help thinking that it would hardly be an effective us of their time and expertise.
As for the effectiveness and or safety of Nurse practitioners could I remind every one of Potentilla’s analysis of the following articles:
http://www.update-software.com/A...ts/ AB001271.htm - A Cochrane systematic review on NP provision of primary care compared to GPs. Overall, this review suggests no obvious differences in clinical outcome
http://www.ncbi.nlm.nih.gov/entr...7&
dopt=Abstract - The study looked at 381 gen medical patients in the USA admitted randomly under NP or house staff care, concluding the outcomes were much the same in the case of costs, morbidity and mortality.
http://www.ncchta.org/execsumm/s...umm/ summ627.htm - An randomised crossover trial of NP v medical outpatient follow up of 80 stable, diagnosed bronchiectasis patients. Concludes that NP-lead care is as safe and effective as medical care.
Potentilla’s analysis at the time was:-
(1) The scientific evidence in relation to either the cost difference or the safety difference between NP and doctor treatment is patchy and limited (not surprising given the relatively short time that NPs have been around and the enormous complexity of the subject)
(2) We have not found any study so far that concludes, even for some limited area, than NPs are in any way dangerous to patients
(3) but neither have we found any study which concludes that NPs are actually cheaper than doctors, when everything is taken into account
(4) we have a hypothesis that junior doctors are being denied adequate training opportunities by the advent of NPs. As far as I know (but I haven't yet looked), this has not yet even been written up in a detailed way, let alone addressed scientifically
[Triage was invented by the US Military for battlefield use]
rather strange that, having invented it, the US Army decided to give is a French name? In fact, Wikipedia splits the honours between Dominque Jean Larrey in the Napoleonic French Army, and Nikolai Pirokov in the Crimean War.
Also it seems quite obvious that battlefield triage has very little to do with the kind of prioritisation exercise carried out in a normal hospital.
dsquared,
As you correctly point out triage probably began on the Napoleonic battle field rather than with the US miltary, I must admit to being less familiar with the Crimean war reference.
In its purest form triage is a system of prioritising mass casualties in order to provide preferential medical treatment to those with the best of chance recovery.
From a purely pragmatic point of view it was the best way of ensuring as many soldiers as possible recovered to face the next battle.
Perhaps the closest we come to it in a civilian context is a major incident, such as the tube bombings - I was called in on 7/7 and we received 60 or so patients in a very short space of time [this was in addition to patients already receiving/awaiting treatment].
As I mentioned above triage in A&E is almost always done by a nurse.
It provides an opportunity to expedite more serious conditions, and these day it has become more interventional- a competent triage nurse can usually make radiology requests [elbow and down, knee and down], offer analgesia [under a PGD], initiate an ECG, bloods, nebuliser, or chase up specialty teams, etc, etc.
In my view this sort of approach is beneficial to patients, although I am aware that others might be more inclined to label it as little more than baggage handling.
re ""(I) didn’t have to queue for 30 minutes to talk to some teenager eating her sandwiches behind a security grilled reception as i have in Uk"
you are talking bollocks no one, this is not a representative picture of A&E depts. in the Uk, and when was the last time anyone saw an SpR much less a Consultant sat on the triage desk? Not since Florence was a girl I bet and even if this was possible I can't help thinking that it would hardly be an effective us of their time and expertise."
you may not consider it representative, i do, i was at A & E with cut leg/possible broken bone a few months ago, i did have to queue behind about 12 other people to get to the front which was indeed staffed by a receptionist who would accurately be described as a teenager eating sandwiches, i could also point out all the toilets in A & E were broken, and the walls in some of the cubicles literally had large smears of shit on them, now this is my reality of the nhs because this is typical of what i see when i come into contact with it, you may see different bloody good for you if you do
as mentioned above i have been met a greeted by doc at foreign A & E's, it seems to be fairly regular
Come on dont be silly uk A & E really is crap, just watch how the treat injured animals arriving at an animal hospital and wonder how comes humans get treated so much worse than animals in this country
no one, the picture you paint doesn't describe in any way the A&E dept where I work or any of the other A&E depts in my area. I'm not saying things are perfect but they are no way as bad as you suggest and I suspect what you describe is not representaive of the NHS as a whole.
As for Doctors meeting and greeting patients in A&E I suspect even they would argue they have better things to do. The fact is nurses have been triaging patients on arrival in A&E for DECADES and doing it l with the support of their medical colleagues perfectly well.
Perhaps this could be an answer to the shortage of jobs for junior doctors? If big productivity gains could be made by putting a load of human capital into the triage function - which appears to be Dr Crippen's view, and it seems at least arguable to me as triage is obviously a point where bottlenecks could potentially arise - then we should go for it, and the money might be well spent on creating a load of specialist consultant posts for this reason. I am not sure that the junior doctors would be too keen on the idea of spending their entire career doing triage at A&E though, and would not be too keen on spending a lot of money bribing them into it.
In my experience, triage is not a bottleneck - that occurs at the waiting time between triage and being seen by a doctor/ENP.
A&E Nurses as good as doctors ?
http://news.bbc.co.uk/1/hi/healt...alth/
475236.stm -
No E, in some ways BETTER.
Fewer mistakes, better history taking and fewer uplanned return visits - and published in the Lancet no less.
Of course we will hear the usual 'straw man' argument but after a while it starts to wear a bit thin, especialy since ENPs have been quietly getting on with it for years and the Lancet findings seem to tie in with several other studies.
Is this Sakr et al's study? I've quoted that a few times on here, unsurprisingly whilst others are slammed nobody's ever argued with me on that one, they just ignore it!
IIRC, the reason they discovered nurses were taking longer is because they were providing nursing & medical interventions simultaneously - they tried to measure it more precisely but found it rather difficult.
Of course the study is now nearly 10 years old, and we've come a long way in terms of what ENPs do (in particular, they may now prescribe if they have the relevant qualifications), the range of patients they treat, and their training & experience (the ENP role was still somewhat in its infancy back in the late 90s when this was done).
It's also worth considering with this (and other) studies that it was only carried out in one department, and as those of us who've been around a bit know, what goes on in one department may be very different to what goes on in another. Take Ezra et al's study in the EMJ last year (or was it 2005?), which proved categorically that their ENPs were better (by a long way) at dealing with opthalmic emergencies than junior doctors. It transpired in the analysis that the ENPs had received extensive training in these injuries, and had spent considerable time in the ophthalmic clinic, whereas the doctors had had very little training; and they recognised that this would not be the case nationally.
There's never a Doctor around when you want one, too busy polishing one of their many degrees I expect.
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