“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.
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…
Ha! Rid the millstone of NHS pensions to make privatisation a tastier option. Cannot be good for future of the service
I like patterns. They tell you a lot. And I’m generally good at spotting them – on psychometric tests various employers have put me through, one part I usually get maximum marks at is pattern-identification. Sometimes you look at a particular puzzle and it doesn’t seem to make any sense, and then all of a sudden one part will become meaningful and the rest falls into place.
I had a similar experience earlier this week when I saw a comment on Twitter by a friend of mine (@michaelh14 – I’d recommend following him). He was having a discussion with someone and mentioned that if NHS staff are transferred to a private provider their pension rights will be protected by TUPE but new employees taken on by the private employer would not be – and suddenly a lot of pieces started to fit. And they show that this government is making…
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In my job as a GP it is rare to learn that what one does really does change lives.
One of the first patients today hobbled in looking happier than when last seen by me over 4 months ago. “If it wasn’t for you, I would not have a place now”, he said. Struggling to remember I flipped through his chart on my screen. Then it came to me – this guy had been made homeless while in hospital for a broken hip. His landlord had not only given away his room, but also thrown away the tools of his trade worth many hundreds of pounds.
Homeless and with no means to work, he was in a dreadful state four months ago. At that first appointment, he was desparate and despairing. I spent nearly 40 minutes exploring his needs and contacting a couple of organisations. The local homeless charity and the local chaplaincy team. Within a matter of hours he had an emergency loan, accomodation and a few days later furniture and a fridge of his own. In short, he had regained some of his self-esteem.
My last patient today also looked a lot happier. 3 weeks ago he was very depressed suffering a relapse after more than 8 years. He was most upset by his denture problem. As far as he knew, the only solution would cost nearly £2000. An amount that was unaffordable on his income. I was dumbfounded.
This chap left my surgery with a copy of my assessment and encouragement to seek a new NHS dentist who would be compassionate enough to correct the problem paid for by the NHS. Today he tells me the denture problem will be resolved within the next couple of weeks and he does not have to pay a penny. His wife is also happier and so are his work mates.
Two different stories but with similar results. I was not practicing classical medicine for either man. What did happen was delegation and encouragement for both men to approach the right people and organisations armed with correct information. Two lives have been rescued by my work.
It is a lovely to have such a day as this.
As I write this, the e-petition asking that the Health and Social Care Bill be dropped as passed 132,000 signatures. This fantastic level of support is only surpassed by fuel prices, immigration and Hillsborough disaster.
With all the activity it has made me think about why so many people are worried about the implications of? the Bill. Last week in conversation with some business friends it became apparent that a key reason some businesses are resilient while others fail is the constancy of the core business.
What is the core business of the NHS? It is the delivery of health care. Who delivers this? Healthcare professionals.
Now, if your core business is fixed and the key people who deliver the product cannot go anywhere, your business will not fail even if the reorganisations, of which the NHS has known many, are destined to be short-lived.
UK readers may recall the launch of a fantastic sauce which was originally only available at Nottinghill Carnival: Reggae Reggae sauce. After a wonderful boost from members of the Dragons Den, Reggae Reggae sauce took off. Great! Yet, the key person involved in the product lost control of his business and sales and marketing folks thought to exploit the trade name by launching other products http://www.reggae-reggae.co.uk/go/products. Soft drinks and frozen snacks are not as catchy as the sauce – and the business is not thriving.
Back to the NHS. Imagine for a moment private firms and individuals are eyeing NHS businesses eagerly waiting for the opportunity to pounce to acquire profitable elements. What would make this attractive? To my mind, if employee costs were lowered by eroding General Practice profits and reducing value of pensions the prospect of assuming any NHS business would be more attractive.
It is clear the business itself will survive, if not thrive, while the core activity (healthcare) and the key people (HCPs) remain. A no-brainer. Whatever and whoever gets control of NHS cannot fail to make money.
This then is my concern about the NHS reforms which are proposed. There is a hidden danger inside this behemoth document – hidden within the document are opportunities to savage the public ownership of NHS.
The Trojan horse of privatisation is the risk faced by the country if the Health and Social Care Bill is permitted to pass into law. This must be stopped.
STOP PRESS – UPDATE Friday 17th Feb 2012
Along with RCR and RCPath, RCGP is not invited to crisis talks with Prime Minister on Monday 20th Feb 2012 to discuss the Health and Social Care Bill.
This is power politics in action and it shows HMG is running scared of the largest group of doctors who, BTW, are supposed to be in the driving seat for the reforms.
A cynical ploy to placate the medical elites. A blatant abuse of power.
A message to the public that this Government is unfit to look after the Country perhaps unless surrounded by sycophants.
So, will RCGP hold its own summit to defy HMG. I hope so! Come on Clare and Iona – continue our College’s defiance and get on the Social Media pages to launch an alternative to Cameron’s cosy gathering.
Calling all physicians and surgeons in UK, join the protest and get your name down here please