Brilliant essay illustrating importance of clinical coding in managed healthcare system
In the immediate aftermath of the release of the Francis Report into events at Mid Staffordshire NHS Foundation Trust, I identified that David Cameron’s crocodile-tears and apparent humility were just a feint that would quickly turn into an attack on the NHS nationally (yet another front in their all-out war on it), using Mid Staffs as a template for attacking other hospitals – and Labour.
This morning’s headlines – covered by the BBC (website and news channel) and the right-wing press – about Professor Sir Brian Jarman’s claim that 20,000 NHS deaths could have been prevented come on the back of a 2-week long assault by Health Secretary Jeremy Hunt on Labour’s supposed failings leading to Mid Staffs.
The claims are utter nonsense – but they are being used by the press and the government as
A sledgehammer to smash the NHS – and Labour
I’ve already shown, at…
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Form filling and tick boxes
Do Not Attempt Resuscitation [DNAR] Form
End of life care is an important part of primary health care and general practice. There are strong ethical and moral arguments going back to biblical times to refrain from postponing inevitable death with futile treatment. For example, consider patient who is 93 years old and no longer recognises anyone because of dementia, and is always curled up in bed and seems to survive on vapours only because feeding is challenging. When this poor person has a cardiac arrest it is not ethically right to commence CPR. Common sense supports this attitude too. However in our ever increasing secular world with fear death such a patient as this is too often treated aggressively because of fear of upsetting a relative. To avoid such conflict, “DNAR” orders now prevail throughout the health service. The Liverpool Care Pathway for End of Life tells us how to use the DNAR properly because there have been concerns about abuses. A standard form has been developed in NHS to further reduce any misunderstandings and permit even better deaths with fewer futile resuscitation efforts.
The problem – another form
The mission creep with forms should not countenanced. We have enough to worry about without the insistence by jobsworths that their form MUST be used for whatever it is they are responsible for.
Doctors, especially General Practitioners already have allowed ourselves to be forced to use official forms for suspected cancer, chest pain clinic referrals, district nurse referrals, hospital transport requests, community COPD clinic, community diabetes clinic, dermatology Clinical Assessment and Treatment Service and many more.
I believe any referral a doctor writes the words matter more than whether or not they are written on a particular form. The words on a sheet of paper and signed by the doctor is a legal document. In my opinion, anyone who fails to act on our request is interfering with patient care and ought to be penalised. This is supported by GMC guidance “Good Medical Practice: Duties of a doctor”.
Who or what will stand up for doctors to halt the onslaught of forms from all directions before my profession drowns under the weight and has even less time to do what doctors do best which is assess people who come to the Doctor for help with clinical problems?
My concerns are covered by Recommendation Number 5 of the Francis Report
The Francis Report is nearly 1700 pages long; it was published on Wednesday 6th February 2013. The Inquiry is established under the Inquiries Act 2005 and is chaired by Robert Francis QC, who will make recommendations to the Secretary of State based on the lessons learnt from Mid Staffordshire. It will build on the work of his earlier independent inquiry into the care provided by Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009.
Why is everyone scared of missing cancer? [BBC Radio 4 PM, 30-Jan-2013]
Personally public needs to (wo)man up and face the fact we die. And most of us die from heart disease or lung disease.
Doctors know, though many politicians and public do not, that early diagnosis of cancer often fails to prolong life of patient. For example, read Prof Baum opinion about breast cancer screening
Medical industrial complex loves us diagnosing cancer early because lots of tests, procedures, and drugs will be thrown at the poor patient for “extra” disease free months/weeks. Has anyone stopped to check the ROI for the vested interests in the management of people who are diagnosed early?
Meanwhile, earlier diagnosis of depression may be useful though you know that many people with “affective disorders” and other psychiatric c condition’s are also a construct of the medical industrial complex – DSM V is an opportunity to medicalise more situations that are part of normal living.
Perhaps, earlier diagnosis of erosive arthropathy may have benefits for sufferers. This population of patients is tiny compared with cardiac and respiratory and psychiatric patients.
So to cardiac and respiratory disease. If the politicians are to be believed, people with BMI 19-25 who never smoke will not develop heart or lung disease. This is magical thinking. One patient at my cardiac rehabilitation class who was thin, young, with cholesterol < 4 and no family history of heart disease, and never smoked. Apparently cardiac rehabilitation clinics see significant number of such people.
Sadly there are a large number of people with chronic lung disease who never smoke – many of these people have asthma. Even with good inhaler use and compliance, many of these people will develop COPD which is supposed to be a disease of smokers only.
So in spite of the propaganda, seeing your doctor at your time and choosing is actually not going to save your life. Remember healthchecks are useless. Thus, the media and many public voices should stop whinging about access to primary care and GPs.
“Pressed by their leaders, external stakeholders, and a public troubled by lapses in the quality of care and unsustainable cost increases, physicians are facing stiffer challenges in initiatives designed to link more closely the goals of learning with the delivery of better care and measures of greater accountability… ”
So begins Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer? in this week’s issue of NEJM .
While the essay focuses on US system of reaccreditation, the opening remarks could apply to any (Western) healthcare system which desires its doctors to deliver best possible healthcare to citizens with greater accountability for the medical profession.
I want to know how my leaders allowed the demise of self-regulation to occur after several hundred years of autonomy.
Why does the author of the article believe there is no chance the medical profession can return to less fettered self-regulation?
Is it really in the public’s interest for politicians and healthcare payers to control medical profession ever more tightly? Is the cost for such regulation really affordable?
It is my opinion, that the majority of doctors are self-directed learners who perform better under less scrutiny rather than more. Healthcare innovation may well be stifled by the drive to tighten regulations for physician practice.
This is apparently a global phenomenon at least in the rich countries with managed healthcare systems. National medical bodies may need to work together to fight this threat to the effective care of our patients.
The increasing threats to independent practice and the profession of medicine are contrary to the human values in healthcare that is at the heart of what we do.
Here is a list of my objections to the proposal by Commissioning Board medical director Sir Bruce Keogh announced in today’s Sunday Times for general practice in UK to be open for business at weekends
- For GP, it may be practices, not doctors ordered to be “open”
- Cannot see this working unless adequate resources released to pay the support staff, let alone the extra doctors. And the support staff will need to agree to work too!
- Will not be helpful for patients unless hospital services are also fully open for business when we are. At least Bruce Keogh understands this
- The idea that this is necessary is politically driven and not based on evidence. Accept that some areas may benefit from this (e.g. inner city populations) but rural areas and leafy suburbs unlikely to benefit.
It would be better to spend the money on a EHR which OOH GPs can access at any time (and write in!) – allows centralised OOH service allowing those who wish to work unsocial hours to do so.
In short, the proposal should be strongly resisted at the present time. Doctors (and nurses) need to be nurtured not threatened to get the best from us!
Finally, does the public really want their GPs to be available 7 days a week?
Sadly what surprises me about this news is that no-one has spotted such a working party earlier, say at the start of the NHS in 1948.
Enquiries by The Slog in the later hours of yesterday evening confirmed that an informal but extremely powerful Working Group has been set up by the Coalition – separate from both NHS management and the Department for Health – to assess the best way to facilitate the handover of NHS Hospital Trusts to the private sector.
Although details are hazy as yet, a picture is emerging of a Group very obviously dominated by privateers and anti-State lobbyists. To the best of my knowledge thus far, not a single member of it is closely associated with (or technically proficient in the understanding of) Britain’s rapidly expanding mutuality sector.
In the midst of blanket 24/7 coverage of paedophiles under every care home bed alongside easily the most boring Presidential election since 1972, this NHS story may not gain much traction immediately; but it is nevertheless the clearest sign yet to emerge of…
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Here is a great example of mLearning in action but the local NHS managers insisted on practice teams send delegates to a meeting somewhere in my town. Clearly this was a poor use of time for my practice manager. With such a good presentation created, it is clear to me that the time taken for many people to get to the meeting would be better spent watching the slide show. How patronising of our service managers! There is apparently good evidence that the new system will be good for patients and reduce some of the demand on emergency services from (trivial) emergencies.
It does look like no-one locally is aware of mobile learning project management. Here is an excellent opportunity which has passed us by! Notice there is no system on the website to help visitors assess their learning after reading the transcript while watching the slide show. Why is the slide show an embedded video rather than posted on Slideshare, Brainshark, or other public cloud service? How hard would it be to have a feedback form?
Whether the UK really needs another emergency number is a moot point now. As a GP, this system looks to me a threat for the future primacy of General Practice as the first point of contact for health care questions by UK citizens. This is sad. In the not too distant future UK may come to regret the demise of the family doctor as an independent gatekeeper to healthcare services. That is a discussion for a future post.
Electronic Prescribing System
I wish to share the following from my local medical committee concerning the roll out of the new electronic prescribing service because the rational behind it is described and the questions from my representatives focus us on another opportunity for eLearning.
NHS Bedfordshire and NHS Luton are working for Electronic Prescription Service (EPS) Release 2. This will mean that the PCTs would then be enabled to allow practices and pharmacies to take part in EPS, if the practices and pharmacies want to. This is part of a national programme. We were told that EPS has been available in Hertfordshire for some time and that just under 30 practices are taking part in EPS there.
We’ve seen documentation from Bedfordshire and Luton about what EPS is; what practices would have to do under EPS; what the criteria would be for selecting patients who could use EPS and what participating practices would need to do to support patients in making their choice; how patients would nominate which pharmacy they want to use for EPS and what the participating practice would need to do to facilitate this.
Beds LMC members recognised the positive objectives of the scheme, e.g.
It is supposed to reduce GP work load ultimately
It may be more convenient to the patient
It may reduce waste
It is understood that EPS will be optional for practices.
But Beds LMC members did have some concerns:
To what extent is it a whole new area of unfunded work in general practice?
Beds LMC members thought that EPS would create the following work:
1. GPs will be expected to identify suitable patients.
2. The GP has to look at all applications for it and make sure they do not have any of the exclusions (large groups of patients such as those on controlled drugs, anticoagulants and some others).
3. The GP or GP staff will be expected to promote and explain the process and follow this up in writing and collect a signature
4. The practice will be expected to telephone suitable patients and offer it to them.
5. Time will be need to train GP staff. Nothing about backfill for this.
6. All prescribers will have to use smartcards and be wary of prescribing some formulations or brands of medication which do not have a suitable barcode. Not all practices use their “smartcards” when consulting because they cause their system to run slow and time out. So clinicians log in and work offline.
Patients with regular repeat prescriptions tend to be patients on chronic disease registers.
On the rare occasions when patients such as this come in “just for a repeat prescription” it gives the GP an opportunity to pick up on preventative care, QoF items and other aspects of the health and wellbeing agenda. In other words, the aspects GPs do not always have time for when dealing with acute illness in a 10 minute consultation. Could the use of EPS actually reduce the level of care available for some patients?
Concerns that the EPS will not be a simple scheme, as some items cannot be included in EPS, so there would have to be two prescribing systems for EPS patients: one for EPS-included medications and one for EPS-excluded medications
Is there any evidence that EPS has saved time for GPs or staff in primary care?
If any Hertfordshire practices who are using EPS would be willing to share any of their experiences or would be able to answer any of the specific concerns listed, it would be very interesting to hear from you?
Here is my response:
Wow! How can such a simple idea as electronic repeat prescribing become so complex?
FIrst thoughts: I want nothing to do with a system with more bureacracy to set up. We have enough to deal with without this additional burden.
Second: The system is doomed unless bandwith of broadband connections is increased to cope with the demand from our desktops (and mobile devices). Currently broadband speed is around 10megabits per second down and 0.5 mb/s up, at least in Watford. Divide this by 8 prescription terminals and you can see the speed drop makes the system inoperable.
Third: Barcodes are not immune from corruption; at least several times a week a popup warns there has been a problem and the barcode should be scratched out. How do you do that with an electronic script?
Fourth: The main benefit of EPS is prescribing from mobile devices. With 4G/LTE imminent this seems practical so long as all prescribers have feature phones with the necessary hardware. I fear the powers that be are focussing on the wrong systems. We need secure login systems for iPhones/iPads and android devices to make EPS useful (e.g. prescribing urgent scripts on home visits, or residential facilities)
FIfth: How are pharmacists supposed to be persuaded to adopt this?
Sixth: Prescribing2U is already available. How does this differ from EPS 2?
Seventh: All HCPs who access clinical system must log in with NHS Smartcard. If there are hardware problems managing this, the IM&T teams across our area must fix these before rolling out EPS.
This system is being imposed on us on the background of a longterm agenda to cut the printed script costs. There is also an agenda to improve security of prescribing. Since proposed several years ago, IM&T systems and devices have evolved. Mobile devices are so much more capable than before. For example, my smartphone (HTC One X) is more powerful computer than my desktop system 10 years ago!
There is nothing in my local medical committee concerns nor in the NHS EPS background documents to indicate any desire to develop a mLearning project to aid in the implementation of this system.
Two new systems are being implemented shortly with the intention of improving patient care in an NHS region. Two sophisticated organisations are responsible for the roll out of NHS 111 and EPS. Neither seems to embrace education technology which, in my opinion, would ease the pain involved in changing behaviour of health care professionals and the public.
There is clearly a very long way to go to embed eLearning into the NHS. This is a terrible state of affairs for a developed society. It is ironic that some countries with large health care burdens (e.g. sub-Sahara Africa countries; South America countries) may be receiving superb instruction in mLearning systems.
I would love to see some discussion about the particular systems described above – your experiences of similar systems in your country, ideas on how to improve implementation, or anything else you think would be interesting.
Thank you in advance…