Personal Beliefs and Medical Practice from the GMC is guidance for medical staff that states  doctors must not allow their personal beliefs to compromise patient care. The guidance explores how doctors should deal with a range of dilemmas including abortion, the wearing of face-veils and male circumcision.  It also looks at patients’ own beliefs and how they can affect the doctor/patient relationship.  It aims to balance a doctors’ right to practise in accordance with their views and beliefs, and the patients’ right to receive timely and appropriate medical care.

The Response to the independent inquiry into Modernising Medical Careers (see earlier posts Aspiring to Excellence: Final report, and Aspiring to Excellence to see details of the Tooke Report) is the Secretary of State for Health’s response to the recommendations of the Independent Inquiry into Modernising Medical Careers, led by Professor Sir John Tooke. Many recommendations are met with a direct response; others of the recommendations are substantial and require further work to develop them ahead of implementation. The response informs national and local planning for recruiting and training doctors in the future.

NHS Pay Modernisation: New contracts for general practice services in England (Executive Summary) from the National Audit Office notes that it has contributed to improved recruitment and retention of GPs, with numbers increasing from 26,833 to 30,931 since 2003. However, the contract has cost the Department £1.76 billion more than it originally budgeted for.

In the first two years of the contract, productivity has fallen by an average of 2.5 per cent per year. GPs are working on average seven hours less per week than in 1992, partly because of the removal of the responsibility for out of hours care. While the number of consultations with patients has increased, these are not in proportion with the increase in costs. Primary Care Trusts’ spending on GP services has however now started to level off.
The largest overspend of the contract was due to an underestimation of the amount that GPs would earn from the pay for performance scheme, the Quality Outcomes Framework (QOF). While there is evidence that the QOF has improved consistency in the quality of care, it is too early to say if overall patients’ health has improved as a result.

In 2005-06 the annual average pay of a GP partner was £113,614, an increase of 58 per cent since 2002-03. GPs report, however, that over the last year their pay has stayed the same or decreased. GP partners have taken more profit from the practice as pay while the average salary for GPs they employ increased by only three per cent in the first two years.

The report found that nurses are delivering more practice work leaving GPs to spend more time with more complex cases. The proportion of consultations undertaken by practice nurses increased from 21 per cent to 34 per cent between 1995 and 2006. GPs now spend more time with each patient, an average of around 12 minutes compared to 8 minutes in 2002-03.

The report concludes that Primary Care Trusts have not made use of all the levers in the new contract. Money for new local services has not led to improvements such as increased opening hours and some of the most deprived areas remain under-doctored. Some 40 per cent of GPs believed that aspects of the contract had not helped tackle health inequalities.

The report recommends that the Department develop a strategy for yearly negotiations on the QOF and the QOF should be based more on health outcomes. Primary Care Trusts should provide more services based on local need and review the number and skills of staff employed to commission and performance manage GP services with the aim of improving local commissioning.

Mental health and ill health in doctors looks at mental health and ill health in doctors and the factors that influence them. It outlines ways in which the NHS can provide appropriate services and encourage doctors and other health care workers to seek early advice and support for mental health problems.

The Report identifies that if doctors are to receive appropriate mental health care, they, their colleagues, their employers, commissioners of services and key national organisations must have a shared view of what is needed. This should cover:

• Access to information
• Designated care pathways and services
• Role of occupational health services
• Need for confidentiality and privacy

Delivering Quality and Value: Consultant Clinical Activity 2005-06: Activity rates of consultants in five surgical and five medical specialties is a tool to enable acute trusts to benchmark consultant clinical activity in 10 specialties. Charts have been sent to individual trusts with the data for their own consultants. The methodology used this year is the same as previously and uses the methodology outlined in York University’s report: Measuring productivity of hospital consultants using hospital episode statistics in England (Executive Summary). This exercise will be repeated using HES data for 2006-07 and 2007-08.

Violence in the workplace: the experience of doctors in Great Britain from the BMA’s Health Policy & Economic Research Unit shows that a third of doctors have been subject to physical or verbal violence in the last year.  Findings were that

• 50% doctors identify violence in the workplace as a problem
• More than half had witnessed violence against other staff, such as nurses and receptionists
• Female doctors are more likely to experience violence in the workplace (37% compared to 27% for males)
• Junior doctors are the most likely to experience violence, followed by GPs
• Nearly two thirds of psychiatrists report that violence in their workplace is a problem, compared with a fifth of surgeons
• Most doctors have not received any training in dealing with violent patients
• Only one in ten doctors has access to a secure facility in which to treat violent patients

The NHS has improved dramatically over the last few years, but still cannot guarantee that basic minimum standards are being met for patients throughout England and Wales, according to State of Heatlhcare 2007: Improvements and challenges in services in England and Wales. More than a quarter of NHS hospitals failed to provide adequate emergency services for children and 48% could not provide children with a satisfactory service in outpatient clinics, the Healthcare Commission said in its annual report on the state of the nation’s healthcare.

Key findings are:

The health of the population is improving with significant increases in life expectancy, but there are major disparities around the country, particularly in poorer areas where there are often fewer GPs.

• Men are living over four years longer than they were 20 years ago, while women are living three years longer.
• Men from more deprived areas live for a decade less than those in wealthier areas. Looking at local authority areas, for example, Kensington and Chelsea has the highest life expectancy for both men and women, at 82.2 years and 86.2 years respectively. The lowest life expectancy for men is in Manchester at 72.5 years, and for women in Liverpool at 78.1 years.
• In poorer areas, where people tend to experience worse health, there are 18% fewer GPs than in the least deprived areas (54 per 100,000 people compared to 66).

Patients are positive about hospital services overall but some organisations perform poorly. Beneath the headline figures there are concerns about aspects of care such as dignity and privacy.

• National analysis of the Commission’s survey of 80,000 inpatients at acute hospital trusts shows that 89.2% (149) were ranked “satisfactory” on patient experience, 7.8% (13) were “below average” and 3% (5) were “poor”. Eleven of those in the latter two groups were rated as “below average” or “poor” for the second year running. The survey also shows concern about specific issues such as help with eating - one in five patients who wanted help eating did not get it.
• Almost a third of the complaints about hospitals referred to the Commission for independent review relate to dignity and respect, nutrition and other aspects of basic personal care. They included: patients left in soiled bedding and clothing; no regular baths or showers or oral hygiene; inappropriate or inadequate clothing.

There have been dramatic improvements in waiting times but there are hidden waits for some services, which are not measured and therefore difficult to address.

• Government standards say no patient should wait longer than 26 weeks for a hospital appointment. In 2006/07, 83% of trusts met this, leaving some 350 patients with longer to wait than 26 weeks. This is a vast improvement on figures for 2000 when 264,000 patients waited this long.
• Waiting time targets do not apply fully to some services, making it difficult for problems to be addressed and patients needs to be met. Evidence suggests that a two-year wait for those referred for psychological therapies is not uncommon. People in some areas are still waiting between 12 and 24 months to have hearing aids fitted.

NHS trusts are performing better overall on quality of services, but the performance of primary care trusts (PCTs) has declined, with many not getting to grips with the needs of their communities so as to provide services to match.

• Overall, the quality of NHS services is improving with 46% of trusts rated ‘excellent’ or ‘good’ in 2006/07, compared to 40% in 2005/6. But for PCTS, only 26% were ‘excellent’ or ‘good’ in 2006/7 compared to 33% in 2005/6. Many PCTs went through a reorganisation over the period but this does not provide a complete explanation for the underperformance.
• The Commission says PCTs form the bedrock of healthcare. They control more than three-quarters of the budget, purchasing services from other providers, including hospitals. They are directly responsible for providing services handling more than 80% of NHS contact with patients, including those carried out by GPs and dentists.
• The report says that many PCTs do not fully understand the health needs of their local people, making it difficult for them to buy targeted services. For instance, last year 2.3 million people did not have their BMI index recorded as planned, with GPs not recording the data, which provides vital statistics on levels of obesity. The number of people diagnosed with heart failure is also considerably less (140,000) than expected, indicating that GPs may not be picking up on signs of serious illness. There is also a poor understanding of the sexual health of local populations at a time when sexually transmitted infections are rising rapidly.
• Where there is a known need, PCTs are not always providing the services required. Some 60,000 people with serious long-term conditions did not get the care from community matrons that was originally planned. Forty-one per cent of PCTs failed to purchase sufficient crisis services for people who are seriously mentally ill, resulting in 5,000 fewer people receiving the service than planned. Some 85% of PCTs did not have arrangements for providing education programmes for patients with diabetes in their area. And 2,000 GP practices did not fulfil their PCT’s plans to establish registers for those people at risk of coronary heart disease, designed to help prevent these patients from becoming seriously ill.

There is progress towards a stronger culture of safety and grounds for cautious optimism in reducing healthcare-associated infection. But trust boards need to show stronger leadership.

• On safety more generally, there has been an encouraging increase in reporting of incidents. Reported figures show more than 229,000 known incidents causing low or moderate harm and more than 9,400 incidents causing severe harm or death.
• Only 58% of NHS trusts complied with all the government’s nine core standards on safety, with infection control, decontamination of medical devices and medicines management the biggest areas of concern.
• Infection control is arguably of greatest public concern; latest figures suggest grounds for cautious optimism. Cases of MRSA fell from 7,096 in 2005/2006 to 6,381 in 2006/2007. There are early signs that increases in cases of Clostridium difficile are slowing. Between 2005 and 2006 the number of cases increased 7% to 55,620, compared to a 16% rise from 2004 to 2005.
• By the end of October 2007 the Commission had visited 87 trusts to check their performance in meeting the requirements of the hygiene code. Only one trust needed to be issued with an improvement notice, suggesting that organisations are taking the issue seriously. But there was a need for stronger leadership from trusts’ boards to improve monitoring, isolation facilities, training, and compliance with policies and procedures.

New figures show that more independent healthcare providers meet core standards, mirroring a similar trend among NHS trusts. But there are concerns about compliance among independent providers of mental healthcare.

• The proportion of independent healthcare establishments that met the government’s national minimum standards - including those that were not inspected as they were considered not to be at risk - was 63% in 2006/07 compared to 50% the year before. Five per cent of independent establishments failed five or more of the standards.
• Although NHS trusts must meet a different set of standards, the broad picture is similar. The number of trusts that were “fully met” on government core standards rose from 49% in 2005/06 to 55% in 2006/07. Six per cent of trusts were judged “not met” on core standards overall.
• In the independent sector, non-compliance was greatest on national minimum standards covering: monitoring of quality of treatment (C4); ensuring patients get care from appropriately recruited, trained and qualified staff (C9); and taking account of patients’ views (C6).
• Independent mental health providers, which mostly look after NHS patients, performed worse than others in the sector. Non-compliance was greatest in relation to national minimum standards for: ensuring patients receive care from appropriately recruited, trained and qualified staff (C9); providing treatment in safe and appropriate premises (C17); and ensuring patients are resuscitated appropriately (C27).
  Independent providers of mental health services need to focus on ensuring patients are appropriately and safely restrained. In 2006/7, 17% of establishments failed a standard in this area compared with under 9% in 2005/2006.

The NHS often fails to meet the needs of children and young people and there are concerns about other groups requiring specialist care, such as people with mental health problems and with learning difficulties.

• Paediatric hospital services are generally good at looking after children, but other more general services are not. Some 70% of specialist inpatient services were rated “good” or “excellent” by the Commission, but 28% of emergency and day case services were “weak”. Transition from children to adult services is not managed well in services for people with mental health problems, diabetes and disabilities, and those requiring palliative care services. Vulnerable children such as those with disabilities, those in care and young offenders face particular problems in getting appropriate care. One in 20 NHS trusts are not yet compliant with child protection standards.
• On specialist wards for people with mental health problems and people with learning difficulties, more than half of the inpatients were found to be in mixed-sex accommodation.
  Levels of violence in mental health services remain high, although there are signs of it being dealt with better. The report includes new data from an audit into violence in the sector, which found that almost one in 20 patients reported being assaulted. Forty-six per cent of nurses reported being physically assaulted, and 72% said they had been threatened or made to feel unsafe. On older people’s mental health wards, almost two-thirds of nurses reported physical assault by patients.

There have been dramatic improvements in responding to the big killers - cancer, circulatory and respiratory disease - but five-year survival rates for cancer, and mortality rates for respiratory disease, are worse than in other comparable countries.

• The mortality rate for people under 75 diagnosed with cancer fell by almost 17% between 1996 and 2005, which suggests that some 60,000 fewer people died prematurely.
• Despite this improvement, the UK survival rates do not compare favourably with most of Europe. For instance, the survival rate for lung cancer in Holland and Spain is around double that in England, which stands at 6.5% for men and 7.6% of women.

MPs have said that big pay rises given to hospital consultants in England have not translated into a better service for patients. The Committee of Public Accounts report ‘Pay Modernisation: A new contract for NHS consultants in England ‘ states that consultant pay rose by 27% in two years to an average of £110,000, after a new contract was introduced in 2003. But working hours decreased, and figures suggest productivity fell by 0.5% in the first year of the contract.

The new contract aimed to make NHS work more attractive to senior doctors, increasing the time they spent with patients, reducing their private work, and make the service flexible and responsive to patient need. The report claims that implementation of the contract was rushed after protracted negotiation, managers were unclear about its aims, and the intended benefits have yet to be realised.

Mass media coverage from 18th/19th November and 22nd November can be found at Fade the Blog.

More than half of all patients arriving in hospital with severe injuries receive poor care, according to Trauma: Who cares? an investigation from National Confidential Enquiry into Patient Outcome and Death (NCEPOD) which also expresses concern about the care of patients before they even reach hospital. Trauma, or serious physical injury, is a leading cause of death of young people, who may end up in hospital after a road accident or fight. It found medical staff often did not appreciate how severely ill patients were and showed little urgency over care. They also made erroneous clinical decisions. Often the problem lay with inexperienced junior staff left to manage trauma patients admitted at night. A third of patients arriving in A&E did not see a consultant there.

A Self assessment checklist for trusts allows Trusts to check their progress in adopting NCEPOD’s recommendations following the 2007 report ‘Trauma: Who cares?’. This toolkit is for Trust use.

You can check out what the papers said on 21st November 2007 about the report on Fade the Blog.

The DH has published written evidence for the Pay Review Body and the Doctors’ and Dentists’ Review Body reviews for this year. The independent health pay review bodies make recommendations to Government on pay awards for doctors, dentists, nurses, health professionals and other NHS staff

…. and just in case you thought this was enough on the topic of pay… the GP earnings and expenses enquiry 2005/06 - initial report presents the initial results for the 2005/6 GP earnings and expenses enquiry. 17,581 contract GPs who report one or more sources of self-employment income with accounting year ending in the final quarter (1st January 2006 to 5th April 2006) were included and a sample of 2,743 salaried GPs identified as being salaried (i.e. submitted a self-assessment tax return for the year 2005/6 and were found to have more income from employment than self-employment). This is the second enquiry to be impacted by the new General Medical Services contract.

Key findings for contracted GPs were:

Average net profit:

• £106,312 for GMS GPs (an increase of 10.4 per cent since 2004/05)
  • £102,648 for non-dispensing GPs (an increase of 11.4 per cent since 2004/05)
  • £124,891 for dispensing GPs (an increase of 6.7 per cent since 2004/05)
• £120,272 for PMS GPs (an increase of 9.2 per cent since 2004/05)
  • £118,109 for non-dispensing GPs (an increase of 9.9 per cent since 2004/05)
  • £134,268 for dispensing GPs (an increase of 5.2 per cent since 2004/05)
• £110,004 for GPMS GPs (an increase of 9.8 per cent since 2004/05)
  • £106,681 for non-dispensing GPs (an increase of 10.4 per cent since 2004/05)
  • £127,061 for dispensing GPs (an increase of 6.3 per cent since 2004/05)

Income for Salaried GPs was

• In 2005/06 average pre-tax earnings from all sources of income (both from employment and self-employment) reported was £46,905.

Average gross turnover  and expenses for contracted GPs was

• Average turnover £245,020 (an increase of 6.5 per cent since 2004/5).
• Average expenses were £135,016 (an increase of 3.9 per cent since 2004/5).

This is really a post aimed at library staff but may be of relevance to HR people too.  Every now and again we get asked to supply the copy of a job advert from the BMJ that is older than the 6 months of careers supplements we hold in the library (we’ve been caught out before not having kept them).  The solution is the BMJ Jobs Archive  which reaches back as far as 2002.

The GPC surveyed all UK GPs in June 2007 on their morale, career intentions and opinions in the National Survey of GP Opinion 2007. Key findings are that:

• Over 50% of GPs describe their current level of morale as a GP as fairly low or very low and over 50% of GPs said that their level of morale had declined over the last five years. 16% of GPs said they are contemplating a career change outside general practice.

• 89% of GPs said that the intensity of their in-hours workload had increased since the introduction of the new contract and 89% said that the complexity of their consultations had increased in this time.

• Almost half of GPs said they would consider extending their opening hours if sufficient additional resources were made available but only 16% considered extending opening hours to be a good use of NHS resources.

• 63% of GP respondents disagreed that changes to the NHS in the past 10 years have made it easier for doctors to practise good medicine.

• 66% of GPs believe private organisations should be allowed to provide NHS care where there is an identified need or gap but 78% of GPs believe that the introduction of private sector providers to primary care will not improve the quality of service that patients receive.

• 62% of GPs believe that the option of Alternative Provider Medical Services (APMS) contracts poses a major threat to the quality of general practice and to the quality of patient care.