Category Archives: Heart Disease

Family doctors working ‘beyond safe levels’, says GPs’ leader

As doctors describe dealing with up to 70 patients a day, college warns of risks to public health

Waiting room of GP practice


Patients face longer waits to see a GP, says the Patients Association. Photograph: Alamy


GPs across Britain are working above safe levels because of relentless and unmanageable workloads, leading doctors have warned.

Prof Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that family doctors were “regularly working way beyond what could be considered safe for patients”, potentially jeopardising their own health and wellbeing.

Her comments were made in response to a survey by GP magazine Pulse. It heard from 900 GPs across the UK and found that each deals with 41 patients a day. The European Union of General Practitioners (UEMO), a leading forum of European family doctors, has said that seeing around 25 patients is safe.

The Pulse poll found that one in five family doctors (20%) deal with 50 daily patient contacts, which include face-to-face and telephone consultations, home visits and e-consultations. Some GPs told Pulse they have 70 contacts a day.

Prof Stokes-Lampard said: “GPs expect to be busy, and we are making more consultations than ever before as we strive to deliver the best possible care to all our patients who need it. But the workload at the moment is relentless and it’s taking its toll.”

One doctor, who reluctantly left a career carrying out 13- to 14-hour days as a partner for a more manageable workload as a salaried GP and 31 to 40 daily contacts, told Pulse: “I felt I was at a risk of making mistakes and causing potential harm to my patients and my career.”

Another spoke of one exceptional “horrendous” Monday where he had 71 contacts. Since then the practice has since increased the number of on-call doctors on Mondays to three.

Prof Stokes-Lampard said the survey backed up what the college has been saying for years – that many GPs are regularly working way beyond what could be considered safe for patients.

It was not necessarily the number of consultations, but the content of those consultations, she added. “Our patients are increasingly presenting with more complex, chronic conditions, many of which require much longer than the standard 10-minute appointment,” she said.

“Our workload needs to be addressed – it has risen at least 16% over the last seven years,” she added. “Yet the share of the overall NHS budget general practice receives is less than it was a decade ago, and our workforce has not risen at pace with demand.”

Dr Richard Vautrey, British Medical Association general practitioners committee chair, said: “We know that an unmanageable and unsafe workload is the primary reason behind doctors leaving general practice, which is leading to serious issues including practices closing to new patients and other surgeries closing entirely. This workload pressure also means GPs are increasingly suffering from burnout and patients are being put at risk of unsafe care.”

He urged the government to work with the BMA to come up with a longterm solution “to ensure the needs of a growing population with increasingly complex conditions can be met safely on the front line”.

Patients’ groups and MPs also expressed concern at the findings. Liz McAnulty, chair of the Patients Association, said: “We have gone past the point where efficiencies can be found, and firmly into territory where GPs’ workloads are unsustainable and where patients face growing waits to access GPs and greater risks to their safety.”

Shadow health secretary Jonathan Ashworth said the Royal College’s warning should serve as an urgent wake-up call to ministers. “The truth is, since 2010 years of severe underfunding of our NHS has left general practice squeezed with tired, overworked and overstretched GPs. We have lost 1,000 GPs in the past year.”

Family doctors working ‘beyond safe levels’, says GPs’ leader

As doctors describe dealing with up to 70 patients a day, college warns of risks to public health

Waiting room of GP practice


Patients face longer waits to see a GP, says the Patients Association. Photograph: Alamy


GPs across Britain are working above safe levels because of relentless and unmanageable workloads, leading doctors have warned.

Prof Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that family doctors were “regularly working way beyond what could be considered safe for patients”, potentially jeopardising their own health and wellbeing.

Her comments were made in response to a survey by GP magazine Pulse. It heard from 900 GPs across the UK and found that each deals with 41 patients a day. The European Union of General Practitioners (UEMO), a leading forum of European family doctors, has said that seeing around 25 patients is safe.

The Pulse poll found that one in five family doctors (20%) deal with 50 daily patient contacts, which include face-to-face and telephone consultations, home visits and e-consultations. Some GPs told Pulse they have 70 contacts a day.

Prof Stokes-Lampard said: “GPs expect to be busy, and we are making more consultations than ever before as we strive to deliver the best possible care to all our patients who need it. But the workload at the moment is relentless and it’s taking its toll.”

One doctor, who reluctantly left a career carrying out 13- to 14-hour days as a partner for a more manageable workload as a salaried GP and 31 to 40 daily contacts, told Pulse: “I felt I was at a risk of making mistakes and causing potential harm to my patients and my career.”

Another spoke of one exceptional “horrendous” Monday where he had 71 contacts. Since then the practice has since increased the number of on-call doctors on Mondays to three.

Prof Stokes-Lampard said the survey backed up what the college has been saying for years – that many GPs are regularly working way beyond what could be considered safe for patients.

It was not necessarily the number of consultations, but the content of those consultations, she added. “Our patients are increasingly presenting with more complex, chronic conditions, many of which require much longer than the standard 10-minute appointment,” she said.

“Our workload needs to be addressed – it has risen at least 16% over the last seven years,” she added. “Yet the share of the overall NHS budget general practice receives is less than it was a decade ago, and our workforce has not risen at pace with demand.”

Dr Richard Vautrey, British Medical Association general practitioners committee chair, said: “We know that an unmanageable and unsafe workload is the primary reason behind doctors leaving general practice, which is leading to serious issues including practices closing to new patients and other surgeries closing entirely. This workload pressure also means GPs are increasingly suffering from burnout and patients are being put at risk of unsafe care.”

He urged the government to work with the BMA to come up with a longterm solution “to ensure the needs of a growing population with increasingly complex conditions can be met safely on the front line”.

Patients’ groups and MPs also expressed concern at the findings. Liz McAnulty, chair of the Patients Association, said: “We have gone past the point where efficiencies can be found, and firmly into territory where GPs’ workloads are unsustainable and where patients face growing waits to access GPs and greater risks to their safety.”

Shadow health secretary Jonathan Ashworth said the Royal College’s warning should serve as an urgent wake-up call to ministers. “The truth is, since 2010 years of severe underfunding of our NHS has left general practice squeezed with tired, overworked and overstretched GPs. We have lost 1,000 GPs in the past year.”

A tall tale? Accuracy of Trump’s medical report – and new height – questioned

So-called ‘Girthers’ question why Trump’s stated height is taller than his license says, and the convenience of his being 1lb shy of obese

Trump’s driving license, issued in May 2012, stated his height as 6ft 2in.


Donald Trump’s driving license, issued in May 2012, stated his height as 6ft 2in. Photograph: Susan Walsh/AP

Donald Trump’s surprisingly glowing medical report has led to questions about the accuracy of some of the data announced by White House physician Dr Ronny Jackson on Tuesday – including how a man in his 70s has apparently grown an inch in height.

Trump’s driving license, issued in May 2012, stated his height as 6ft 2in. Yet according to the report issued by the White House physician on Tuesday, Trump is 6ft 3in.

The seeming growth spurt led to people comparing images of Trump to celebrities who are allegedly of the same height.

One image showed Trump standing next to former baseball player Alex Rodriguez, who is 6ft 3in. Rodriguez looked considerably taller.

James Gunn (@JamesGunn)

Two 6’3″ men standing next to each other. #Girther #GirtherMovement pic.twitter.com/yI14O6YpQ6

January 17, 2018

A photo of Trump next to Barack Obama, taken one year ago at Trump’s inauguration, seemed to show that the pair were of the same height. Obama is 6ft 1in.

Eyebrows were also raised at Trump’s stated weight. His mass of 239lb was just 1lb under him being classed as obese.

The intrigue over the president’s body mass was fuelled by people sharing a series of photos of athletes who are also said to weigh around 239lb. The comparisons included NFL quarterback Jay Cutler and Minnesota Vikings running back Latavius Murray, both of whom weigh around 235lb.

The athletes both looked significantly different from Trump.

Trump’s suggested weight and body circumference has given rise to the “girther” movement, and Guardians of the Galaxy director James Gunn offered to pay $ 100,000 to a charity of Trump’s choosing if the president would publicly step on a weighing scale.

The president’s diet does not immediately suggest a man whose health is “excellent”, as White House physician Dr Ronny Jackson said.

Trump’s food intake has a heavy focus on McDonald’s, KFC and Oreo cookies, while he distrusts exercise – believing the human body comes with a finite amount of energy which is depleted by cardiovascular and resistance training.

Trump is being assigned a new diet and exercise regimen and hopes to lose 10-15lb.

Jackson said Trump’s life expectancy is “the same as every other American male right now, but it’s certainly no less”. The life expectancy for a man in the US is 76.1 years (Trump is 71).

During Obama’s presidency Trump suggested Obama was not born in the US, and in 2012 offered $ 5m to a charity of Obama’s choosing if the then president released his college records and passport applications.

The Guardian contacted Trump’s representatives at the time asking for Trump’s own college records and passport applications. A Trump adviser said that request was “stupid” and accused the Guardian of “trying to be funny”. The documents were not released.

Thangam Debbonaire: ‘The moment I saw the light about alcohol and cancer’

The Labour MP and former cancer patient tells how her mission to change Britain’s drinking culture is not a moral crusade – it’s about saving lives

Thangam Debbonaire in her Bristol constituency .


Thangam Debbonaire in her Bristol constituency . Photograph: Stephen Shepherd for the Observer

After the elation of becoming an MP in May 2015, Thangam Debbonaire was still getting used to life at Westminster when she got the bad news. “I was diagnosed with breast cancer on 16 June 2015,” says the Labour MP for Bristol West, recalling the date with calm clarity. Days later she had to forsake her new home at parliament and begin undergoing the rigours of chemotherapy. She finally returned, in good health, in March 2016. “Rosie Winterton, Labour’s chief whip at the time, said: ‘Come back when you’ve finished treatment.’”


Determined to carry on as normally as possible, she set up her constituency office, hired staff and worked as much as she was able. “Casework was done, emails were answered and constituency visits were made when I was in my good weeks,” says Debbonaire. “On a chemotherapy cycle the first week’s pretty awful. But on the second and third weeks I tended to do constituency work.” One of the emails she received then turned out to be fateful and life-changing.


“A publican in my constituency complained to me that the new safe drinking guidelines, which had been published in January 2016, had obviously been over-influenced by teetotallers. I was about to email this person back saying ‘yes, that sounds terrible. I’ll investigate’. But then I thought, ‘hang on, I’m not sending that reply until I’ve read the research,’’’ she recalls. Her inquiries proved revelatory.


“After reading a lot of research about alcohol I learned what a unit was and how to calculate it, for example. And I realised that there is no such thing as a safe level of alcohol consumption and that alcohol causes at least seven forms of cancer, including breast cancer. I didn’t know that before.”


Scientific research has produced enough hard evidence in recent years for charities such as Cancer Research UK and the World Cancer Research Fund to state with certainty that alcohol is a direct cause of seven forms of cancer: of the liver, colon, rectum, larynx, oropharynx, oesophagus and breast. Worryingly, though, opinion polls show that only small numbers of people know there is a causal connection between the substance and the disease. One survey last week found that only 10% mentioned cancer when asked which diseases and illnesses were linked to alcohol.


“After my treatment, I was at a course in Bristol run by Macmillan Cancer Support to help women who’ve had breast cancer with the emotional, physical and other impacts of the disease,” says Debbonaire. “The first thing most women wanted to know was: what do I have to do to reduce my risk of getting cancer again? The health practitioners there told us that one thing was reduced alcohol consumption. I wasn’t drinking anyway, what with chemotherapy and nausea, so I thought: that’s fairly easy, I’ll just not drink,” she says, sitting in her Westminster office.


She was approaching her 50th birthday. “I wasn’t teetotal, and I’d drunk all my life, mainly wine or a cocktail, but I’d never been a big drinker. I drank quite sparingly. The last time I’d been significantly merry was the night in February 2015 I gave up my job [with Respect, which helps perpetrators of domestic violence], went out with my colleagues and had cocktails. But I just decided it was easier then to have a default setting of ‘I won’t drink’ as a way of reducing my risk,” she recalls.


She wrote back to the publican, thanking him for raising the issue of alcohol. “I said: ‘I know your pub – I’ve drunk in your pub and I will do so again, though I’ll probably have an orange juice. I’m pretty sure that these new guidelines, from the chief medical officers of the four home nations, aren’t going to stop people going to your pub and you might want to think about offering a wider range of non-alcoholic drinks and snacks.’ He wrote me back a really nice email. He was really sweet and he didn’t argue, which I was really impressed by – he sort of took it on the chin.”


Their exchange of views, and her journey of discovery about alcohol, prompted other lifestyle changes too. She now runs three times a week, five kilometres on two weekdays in the various royal parks near Westminster and 10km every weekend in Bristol. She also eats far more fruit and vegetables.


“The last thing I do every night is chop up four portions’ worth of vegetables – red, yellow or green peppers, carrots and courgettes – put them in bags and during the day reach for them, rather than biscuits.” Angela Merkel did something similar a few years ago to help her lose weight.


But her new-found knowledge about alcohol’s potential toxicity has also unleashed an almost missionary zeal to raise awareness about its role as a cause of cancer, using her platform at Westminster. She is seeking a parliamentary debate and planning a campaign of oral and written questions to ministers on the subject. She is also working with alcohol and cancer charities and is keen to see graphic warnings put on cans and bottles of wine, beer and spirits, warning drinkers that alcohol and cancer are linked, modelled on those seen on cigarette packets.


“The two most dangerous drugs – alcohol and tobacco – are both entirely legal,” says Debbonaire, an ex-smoker, with a mixture of disgust and wonderment. She reels off a list of alcohol-related harms, including broken marriages, rotted livers and injuries caused or sustained. She is keen to tackle what she describes as “widespread ignorance” that leads to disease and death.


For example: “Of the many MPs across all parties I’ve spoken to about alcohol and cancer, the only ones who knew about the link with breast cancer were those who had had the disease themselves.”


Did her moderate drinking cause her cancer? “I don’t know if my particular cancer was causally related to alcohol, [but the] chances are reasonable that there was a causal link. My dad died of bowel cancer, which is one of those linked to alcohol. Two of my aunts had breast cancer. I had an alcoholic grandfather in India and other relatives in India who died of alcohol-related diseases. So alcohol has caused my family, and me as part of that, great harm.”


She is appalled at parliament’s intimate relationship with alcohol. “Yes, I worry about the drinking culture at Westminster. There are – what? – eight or 10 bars? There’s free alcohol at receptions. I’m concerned that alcohol is built into the parliamentary way of working. With late-night votes you’re certainly aware that some people have been drinking. This is not a moral judgment; I worry about colleagues’ health because of the lifestyle in this place. Alcohol is worryingly prevalent.


“In my third or fourth week as an MP, just before I was diagnosed with cancer, but when I knew it was a possibility because I’d already found the lump, Charlie Kennedy died in his early fifties. He comes here to Westminster as a young man for the first time [after being elected in 1983 at the age of 23], finds this [drinking] culture with, you know, ten million bars or whatever there were in those days, late nights, overnight sittings. What’s he going to do?

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People said that the smoking ban was nanny state nonsense. I said it too… but it has helped people to quit


“Mr Speaker has encouraged the provision of mental health support [for MPs], which is very good,” she adds. “I’m quite idealistic about parliament. I think it ought to be a place where high standards are set – not just on expenses and sexual harassment, but on health and wellbeing, too. I would be delighted if there were more gyms and fewer bars.”


Debbonaire knows fellow MPs may think her a puritanical bore. “I’m not trying to kill anyone’s joy. I think alcohol can be a lovely thing. I had a glass of champagne at my niece’s wedding in September – though only one. But I’ve seen my own dad deteriorate from bowel cancer and visited a liver ward in Bristol where people in their 20s or 30s look 30 or 40 years older from drinking.”


She acknowledges that some will portray her as a nanny state ideologue. “People probably said seatbelts and the drink-drive limits were nanny state nonsense. They definitely said it about the smoking ban; I said it about the smoking ban. But seatbelts and not drinking and driving have saved countless lives, and the smoking ban has helped people to quit.
“Apart from the link with cancer, alcohol causes a massive drain on the NHS, costs lots to the police and the courts and affects the economy by causing lost days at work.
“Why wouldn’t we want to shift that behaviour? Nanny state? Well, I’m a Labour politician. I’m a social reformer, not a libertarian rightwinger. Interfering, for the common good, is what we do,” she says firmly.

As a GP, having my heart surgery cancelled gave me a new perspective on NHS underfunding

I am a GP partner in Oxford. I have worked in the NHS in Oxford for 20 years, barring two years in a post in rural Canada. In July 2017, we returned to the UK and a friend of mine, who’s a cardiothoracic anaesthetist, commented on my bounding neck pulses as we were chatting over a beer. A little later that day, I had a listen to my heart and even I, a GP, could hear a loud murmur. I asked one of my colleagues to have a listen, just to check I wasn’t being paranoid. I think he was trying to make me feel better and reassured me: “It’s probably just a flow murmur.”

Nevertheless, I saw my GP that day. With detached, mildly mounting alarm I registered the abnormal findings she discovered. High blood pressure, wide pulse pressure, mild tachycardia and, of course, The Murmur. Her worried expression made me more alarmed than the findings, and I found myself trying to reassure her that everything would be OK.


It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night.

I saw the cardiologist in October and as soon as he mentioned he wanted to get the medical student, I knew I was in for some bad news. He told me I had severe aortic regurgitation, where blood flows in the reverse direction from where it’s supposed to as the heart pumps. He said he’d see me in six months and by that time I would have a new aortic valve. My reaction was silence, followed by expletive-laden surprise, not least as I had had no symptoms at all. Also, doctors never get sick.

It’s funny how that kind of news affects you – for a week or so, I was mentally crossing things off the list of things I could do with the rest of my life, and confronting the possibility that I might not see my daughter grow up.

In December, I was very relieved to get a date for my operation in January 2018 but my urgent surgery was cancelled when I called in at 10am on the day of admission. It’s difficult to describe the sense of loss that I felt. It came as a surprise, even for someone who works in the NHS every day. I really did not know what to do with myself.

As doctors in the NHS, we are trained from an early stage to soak up punishment, not to complain and to always carry on. But with my patient’s brain, I idly wondered how other people might be coping with similarly disorientating news all over the UK. About how they might be thinking how unfair this was, and what would they do now. Lives put on hold, terrible feelings of uncertainty, resignation and finally acceptance. After such news they must love, fear and hate the health service all at the same time. Nevertheless, the NHS is so beloved that it would never cross their minds that the government would have deliberately underfunded it for the last seven years. Some people might think it’s pretty decent of ministers to apologise for all the disruption, and that the government, to its credit, is forward-planning for a winter crisis.

The fact is, of course, that it is not, and that the crisis was entirely avoidable and is down to consistent underfunding. Doctors and the Kings Fund predicted it, even the head of NHS England predicted it. It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night. I’m not sure how much more short-notice my surgery cancellation could have been, and yet here was my ultimate boss telling me that this was being done to avoid just such upheaval.

Q&A

Why is the NHS winter crisis so bad in 2017-18?

A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of England’s 153 acute hospital trusts was 98% or more, with the fullest – Walsall healthcare trust – 99.9% occupied.

NHS England admits that the service “has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es”.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. “We are seeing conditions that people have not experienced in their working lives,” says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take – including cancelling tens of thousands of operations and outpatient appointments until at least the end of January – underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.

Read a full Q&A on the NHS winter crisis

I was back to work the next day and I have my game face firmly back on, but I can’t deny it has been disruptive and upsetting. I’m determined not to let any of these developments compromise my patient care and commitment to the NHS. I am sanguine, but waiting hopefully for another appointment. I understand that this situation may well occur again. In that circumstance, I look forward to a time when the apology from my health secretary and prime minister will be replaced by sustained hard investment in the NHS. Platitudes and short-term measures will not save or improve it. And yet, as many commentators have already suggested, perhaps that is this government’s point.

Surgeon who signed livers is punished but managers let off | Letters

I am an altruistic kidney donor and am appalled at the treatment of Simon Bramhall, the surgeon who initialled two livers in transplant operations (Surgeon fined £10,000 for signing his initials on livers of two transplant patients, 12 January).

I am particularly incensed at the comments of the judge and the whingeing of Patient A. For the judge to call it “an abuse of power and betrayal of trust” borders on the ludicrous.

If anything, they were acts of elation after two very difficult successful operations – the equivalent of a footballer pulling off his jersey after scoring a great goal.

And for Patient A to suffer an “overwhelming feeling of violation” is beyond ludicrous. Mr Bramhall had just saved your life! He did nothing to you. It was not your liver. It was the liver of a dead person who bequeathed it to you: a final act of great generosity. Where is your generosity?

If my brilliant Sheffield surgeon, Mr Shrestha, had initialled my kidney I would have been delighted. It would have been a celebration of a successful partnership between a gifted doctor and a donor to give someone a better life.

What has happened to this country that people take exception so easily, and any deviation from the norm draws so much approbation?
John Carlisle
Sheffield

In sentencing former Queen Elizabeth hospital surgeon Simon Bramhall, Judge Paul Farrer QC described those actions, which resulted in no physical harm, as “conduct born of professional arrogance of such magnitude that it strayed into criminal behaviour”.

Less than two years ago, your newspaper highlighted the Care Quality Commission’s damning report into cardiac surgery at the Queen Elizabeth hospital in Birmingham, estimating that 17 patients may have died unnecessarily as a result of the hospital’s failure to heed repeated patient safety warnings.

Yet no member of the hospital’s executive team has been held to account for their failings.

The contrast is striking: we are forced to conclude that, even where patient safety is at stake, there is one rule for the individual clinician, another for his or her organisation.

Less than five years since the publication of his report of the Mid Staffordshire NHS foundation trust public inquiry, the words of another QC, Robert Francis, appear to have already been forgotten.
Dr Richard Horton
Wolverhampton

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Surgeon who signed livers is punished but managers let off | Letters

I am an altruistic kidney donor and am appalled at the treatment of Simon Bramhall, the surgeon who initialled two livers in transplant operations (Surgeon fined £10,000 for signing his initials on livers of two transplant patients, 12 January).

I am particularly incensed at the comments of the judge and the whingeing of Patient A. For the judge to call it “an abuse of power and betrayal of trust” borders on the ludicrous.

If anything, they were acts of elation after two very difficult successful operations – the equivalent of a footballer pulling off his jersey after scoring a great goal.

And for Patient A to suffer an “overwhelming feeling of violation” is beyond ludicrous. Mr Bramhall had just saved your life! He did nothing to you. It was not your liver. It was the liver of a dead person who bequeathed it to you: a final act of great generosity. Where is your generosity?

If my brilliant Sheffield surgeon, Mr Shrestha, had initialled my kidney I would have been delighted. It would have been a celebration of a successful partnership between a gifted doctor and a donor to give someone a better life.

What has happened to this country that people take exception so easily, and any deviation from the norm draws so much approbation?
John Carlisle
Sheffield

In sentencing former Queen Elizabeth hospital surgeon Simon Bramhall, Judge Paul Farrer QC described those actions, which resulted in no physical harm, as “conduct born of professional arrogance of such magnitude that it strayed into criminal behaviour”.

Less than two years ago, your newspaper highlighted the Care Quality Commission’s damning report into cardiac surgery at the Queen Elizabeth hospital in Birmingham, estimating that 17 patients may have died unnecessarily as a result of the hospital’s failure to heed repeated patient safety warnings.

Yet no member of the hospital’s executive team has been held to account for their failings.

The contrast is striking: we are forced to conclude that, even where patient safety is at stake, there is one rule for the individual clinician, another for his or her organisation.

Less than five years since the publication of his report of the Mid Staffordshire NHS foundation trust public inquiry, the words of another QC, Robert Francis, appear to have already been forgotten.
Dr Richard Horton
Wolverhampton

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Surgeons don’t have to sign their names… in us | Barbara Ellen

Surgeon Simon Bramhall, who burned his initials on to the livers of two transplant patients while working at the Queen Elizabeth hospital, in Birmingham, has been fined £10,000 and given a 12-month community order.

Bramhall (now working for the NHS in Herefordshire) was fortunate not to have been struck off. It’s disturbing enough to think of your body being opened up for surgery, but to have somebody leave their mark there (“SB”) is grotesque; as the court found, it was “an abuse of power, and a betrayal of trust”. Bramhall’s defence argued that it was to lighten the mood in theatre. Really? In that case, put on some quiet background music – don’t sign a human organ, as if you’re some kind of rock star in scrubs being pestered for an autograph.

It seems that there was no lasting harm done – the marks wouldn’t have affected the performance of the liver and they would disappear in time. However, there’s always harm done; if nothing else, such incidents bolster the widespread public perception of surgeons being arrogant and superior.

Too many cases such as this and patient-surgeon trust would be in grave danger of breaking down.

Death and the cruel process that follows | Letters

Annalisa Barbieri was lucky to have been able to keep her father at home for 11 hours after he died (Family, 6 January). I found my mother (aged 90) who had died in her sleep at home. Not knowing what to do, I rang her GP. This started a legal process that whisked her body away before I had time to say goodbye. Because she did not die in hospital or hospice and hadn’t seen her GP in the last two weeks, the GP was required to contact the police, who had to come and keep guard on the body until the undertakers came to take it away, I assume in case she’d been murdered. They couldn’t even wait for my sister to arrive to see my mother dead in her bed.

If I’d been warned that this would happen, I would have spent an hour or two quietly with my mother’s body before I rang the GP.

It would be good to publicise this system so that others don’t have the same experience. Everyone was kind, but the process is cruel.
Christine Holloway
Winchester

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Shifting care closer to home will ease pressure on hospitals | Ewan King

New year is associated with hope and optimism. But for the NHS, the headlines tell a different story: hospitals at full capacity. As you might expect, these articles focus on what is going wrong: headlines such as “NHS in crisis”, stories of beds in corridors and stressed-out nurses. Clearly these problems are real, but focusing only on hospitals won’t solve the problem. We need to think more broadly if we are to find lasting solutions; we must think about prevention, and how far it is embedded in local systems.

For some time, health and care reforms have been about shifting care closer to home. The programme of vanguards and sustainability and transformation plans was intended to herald a greater focus on prevention and self-care to reduce pressure on hospitals. There is some evidence that these reforms are working: Hertfordshire’s prevention-focused Better Care for Care Home Residents Vanguard, for instance, led to a 45% reduction in hospital admissions and A&E attendances between April 2015 and May last year.

But we are not yet able to see the scale of change necessary to make a significant dent in demand across England and beyond, because of financial pressures, which make it difficult for organisations and commissioners to fund new, innovative services; inward-looking leadership teams focused on short-term goals and local evidence and solutions; a lack of integration across health and social care and housing; and outdated performance management and contracting systems.

A seismic shift – at the level needed – is not straightforward to deliver. As Nesta, Shared Lives and the Social Care Institute for Excellence (Scie) argue in a new report on innovation, we know a lot about what works to support independence in ways that reduce demand for urgent care, but less about how to extend the benefits to more people. As the report concludes: “New and better ways of delivering relationship-based care are needed, and already exist, but are inconsistently implemented or poorly scaled.”

So what can national policymakers and local health and care leaders do differently? First, we need to restate the case for preventive, community-based care and, as part of this, more clearly articulate how it will make a difference to people’s lives. For example, in our report we describe a place in the near future where people are supported to maintain their independence, improving their wellbeing at reduced cost to the NHS. What if you have a long-term condition such as chronic obstructive pulmonary disease; are you able to join a Breathe Easy peer support group to help you manage the condition?

We also talk about North Yorkshire, where an innovation fund has been used to fund initiatives reducing isolation, preventing falls and supporting people to stay at home when they want to. Local care and support providers say this has helped them to build their networks, and they are now working in partnership with more local services.

Second, we need collective local leadership focused on keeping people well and better supported at home, underpinned by a strong commitment to integrated commissioning and to changing funding flows to support more community-based care.

A hospital trust chief executive recently told me that investment away from beds and A&E services would support far better preventive approaches – but there has to be a system-wide strategy for all to lead and support if bed pressures arise.

Third, we need to make better use of the evidence we have, making a stronger case for investment in preventive care. In Scie’s prevention library, we have a mass of evidence-based examples of community-led care and support that helps to reduce demand for hospital care. Age UK’s personalised integration approach in North Kent is a model of holistic support targeted at older people with long-term conditions. It has led to a 26% reduction in non-elective hospital admissions. Commissioners need to use these examples to argue for spending more on preventive models of care and support.

Carrying on as we are is unlikely to succeed; we are firefighting in the face of growing demand in hospitals without always considering what wider changes are needed to prevent this growth. The social care green paper, to be published in the summer, provides a good opportunity for setting out plans for a more preventive, person-centred, health and care system, but there is nothing to stop leaders being more ambitious about prevention right now.

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