Good doctors Exploring the real life challenges experienced by today’s medical professionals and providing support that doctors want and need Wed, 28 Jun 2017 15:07:58 +0000 en-GB hourly 1 Good doctors 32 32 Does specialty training have a future in the NHS? Thu, 29 Dec 2016 16:28:06 +0000 I am currently working as an ST5 psychiatry trainee in an NHS community drug and alcohol service.

Over the past 2-3 years the addictions services run by this trust have significantly reduced so that now only my service remains. There are no longer in patient detox beds and the services in other boroughs that the trust serves have been handed over to the third sector.

This has had a direct impact on my training. This year I have not had any experience of managing an inpatient detoxification, the addictions service is depleted in money and this has put my post under threat for the April rotation, this would mean no further addictions training being provided by this trust.

The post has been saved at the last hour, but only for one more year. There were conversations about creating a post in the third sector, but clinical supervision would be insufficient and quality of training therefore not guaranteed.

I am aware that this is happening nationwide; there were previously 56 addictions posts across the UK now there are just 18. I am sure addictions is not the only sub-specialty that this is happening in.

Across all medicine and surgery portions of services are being siphoned off to the third sector that wins tenders by cutting costs – they don’t want to pay for training. And that’s not just training of doctors, it’s nurses, occupational therapists, physiotherapists etc.

We can only imagine the crisis of patient care that we are storing up for the future. What happens in 10 or 20 years’ time when we have no clinicians with the knowledge and skills that we have now? Today’s illnesses are not going to magically disappear. In addictions the types and numbers of illicit substances are going up not down; we need more skill not less.

The short-term financial decisions being made by our trusts and Clinical Commissioning Groups are being made due to the nature of the system being converted to run like a business rather than a self-sustaining resource. Financial targets are killing the NHS. Whatever replaces it will have to provide training, but what will that look like?

I am beginning to realise how lucky I am to have the bulk of my training days behind me now and to have had the opportunity and experiences I had before services disappeared.

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Read the Medical professionalism matters report Tue, 20 Dec 2016 08:48:05 +0000 Over the past 18 months, a partnership of healthcare organisations led by the General Medical Council (GMC), held a series of events to explore some of the challenges facing the medical profession today. This programme is called Medical professionalism matters.

Six events were held across the UK – from Glasgow and Belfast, to Newcastle, Cardiff, Birmingham and Bristol – with each one focusing on an issue that presents particular challenges for the modern doctor. Those issues were: ethics, resilience, collaboration, compassion, scholarship and patient safety.

Almost 600 doctors and other healthcare staff and patient representatives attended the events, which included presentations, panel debates and facilitated table discussions. Hundreds more joined the discussion online, taking part through videos, blogs and social media exchanges.

The Medical professionalism matters report gives an insight into the result of the discussions.

Read the report

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Round up – the morale maze and patient led decisions Fri, 28 Oct 2016 13:41:58 +0000 Here’s some interesting articles from this weeks healthcare news:

The end of doctor knows best as medics are told to let patients make their own decision about treatment –article in the telegraph talks about new guidelines published by the Royal College of Surgeons (RCS).

What is the state of medical education and practice in the UK? The 2016 report released by the General Medical Council this week highlights the current challenges facing the profession and the system in which it works. It also looks at how the make-up of the profession continues to change.

The morale maze: what’s to be done to improve workforce morale? Clare Marx, President of the RCS and Nigel Edwards, Chief Executive of Nuffield Trust look at the actions that NHS staff can take to increase morale, as well as the areas that need action from those in more senior positions in the health system.

Online services: ‘Patient-powered’ health will make care safer and more efficient – Dr Brian Fisher London GP talks about the benefits of patient facing services in this article on GP online.

Do nothing without appearing there is nothing to do Dr Damian Roland reflects on the Academy of Medical Royal College’s list of 40 treatments and procedures that are of little or no benefit to patients.

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Round up: EOLC, professional standards, accountability and realistic medicine Fri, 21 Oct 2016 15:01:36 +0000 Here are the stories that got us talking this week:

Isn’t palliative care just for people near the end of their lives? Dr Clare Rayment, Consultant in Palliative Care at the Marie Curie Hospice, Bradford, looks at some of the common myths about palliative care, and explains why it’s important to understand who should get it, and when.

How can the right standards empower doctors? On the GMC Blog, Professor Namita Kumar, Postgraduate Dean at Health Education North East, writes about how the right professional standards can encourage doctors to drive improvement.

Simple, clearer, more stable: making accountability work across health and social care Andrew Hudson in this blog discusses accountability and how it is not just of theoretical interest: but it matters in the real world.

Catherine Calderwood: champion of ‘realistic medicine’ Bryan Christie talks to Scotland’s chief medical officer about her ambitions to change the way doctors treat patients.

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Round up: talking to your patient’s family and friends Fri, 07 Oct 2016 18:39:22 +0000 Here are the stories that got us talking this week:

User feedback in maternity services – This report from The King’s Fund looks at what maternity services are doing locally to collect, analyse and act on user feedback. It describes the challenges of adopting the different approaches and highlights the features of organisations that are successful in user feedback activities.

Talking to your patient’s family and friends – On the GMC blog, Professor Bill Noble, Executive Medical Director at Marie Curie, discusses the difficulties doctors face when dealing with a patient’s family and friends.

Schwartz Community Conference – The Point of Care Foundation is organising a Schwartz Community Conference which is taking place in London on 27 October. Click the link to find out more.

No hospital is an island: new models of acute collaboration in the NHS – Nigel Edwards, Chief Executive at the Nuffield Trust, and Jacob West, National lead, NHS England New Care Models Programme, blog about how hospitals are looking for creative solutions to clinical and financial challenges that they can’t solve on their own.

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Round up: learning from remote practice, charging to see your GP Fri, 30 Sep 2016 09:45:26 +0000 Here are the health care stories that have got us talking this week:

Finding innovative solutions to health care challenges in remote areas of the UK – Tim Horton from the Health Foundation’s Improvement team blogs about the improvements we can learn from those working in remote locations

Journey of an international medical graduate – Consultant psychiatrist, Dr Deji Ayonrinde, reflects on the challenges faced by international medical graduates who come to practise in the UK

What if people had to pay £10 to see a GP? – The Nuffield Trust’s John Appleby considers the pros and cons of charging for GP appointments

Establishing the state of medical professionalism in New Zealand – The Medical Council of New Zealand (MCNZ) compares views on professionalism of doctors in New Zealand, USA, UK and Ireland

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Quality in general practice: measuring vs. improving Fri, 30 Sep 2016 09:36:26 +0000 Jonathon Tomlinson reflects on the difficulties of measuring the quality of general practice and the prospects of improvement.  

In recent years I’ve seen the NHS from a patient perspective. I’ve had a few fractured bones, been present for one son’s home delivery and another’s emergency admission after being run over. I’ve seen my dad admitted to hospital with pneumonia and dementia, and a friend’s daughter admitted with type 1 Diabetes. Quality care in the case of a fractured finger, a home-birth, a delirious older person and a child with diabetes vary so widely that it is almost impossible to compare one with another. For example, mortality rates are too low to help, diagnosis was obvious, self-management support not always needed, waiting times not really significant and so on. Nevertheless in every case the professionals involved had to spend a lot of time collecting data, and we (the family) were asked for feedback. I even made a complaint. I have no idea what, if anything, was done with the data, the feedback or the complaint to improve quality.

There is a problem in that quality is so hard to measure, in any meaningful and universally comparable way, that regulators and politicians have embarked on a Sisyphean task of measuring almost everything in the hope that somehow quality will improve. The result, as Don Berwick says, is “massive, ravenous investment in tools of scrutiny and inspection and control, massive investment in contingency, and massive under-investment in change and learning and innovation”. And he adds: “This isn’t going to work, we cannot possibly inspect our way to excellence” – a conclusion echoed in a report from the King’s Fund earlier this year.

The enormous burden of data collection and inspection in general practice, at both organizational and individual levels, leaves very little time or energy for quality improvement. In the last year my practice has had a Care Quality Commission (CQC) inspection, submitted vast amounts of data for Quality Outcomes Frameworks (QoF), Enhanced Services, Prescribing Audits, Friends and Family tests, etc. Every member of the practice has compulsory training and certification several times a year. At an individual level, last year I was revalidated and this year I have already been through two appraisals, one to be able to continue as a GP and another to be allowed to supervise a trainee. Every GP has an annual appraisal – which takes about 3 hours face to face, and a dozen hours at least in preparation. Recently we had to close the practice for 3 hours while we all had mandatory cardio-pulmonary resuscitation (CPR) training. A question that always comes up in appraisals is, ‘how do you know that you are providing good quality care / teaching?’ This question is not about quality improvement, but about quality control, and ultimately about control of the medical profession by regulation and inspection. It raises other important questions, such as ‘what aspects of quality can be measured?’ And ‘for what purposes are we measuring different aspects of quality?’

In 20 years of medical practice I have never been asked about or taught the methods of quality improvement, and this is the case for the vast majority of health professionals who are now regulated, examined and assessed more than ever before. And as Don Berwick also says,“Inspection does not achieve continual, pervasive, never- ending improvement. It doesn’t foster creativity or learning or pride, it poisons them, because the main harvest of inspection isn’t learning, it is fear.”

Data for patients as consumers

One justification that is often given for all this measurement is that patients are increasingly seen as consumers of health services, and therefore require information about the services available to them. But what information would this mean supplying in general practice? In general practice patients range from those not yet born, to those who are dying, and almost every stage of every imaginable disease is represented. One approach to this problem, illustrated by a 112-page-long 2015 Health Foundation report, is to use as wide a range of measures as possible. Another 2014 Health Foundation report on improving quality in general practice was commissioned to inform the design of the My NHS website, which was supposed to encourage patients to choose a practice, and practices to compete with one another. The website is even less helpful than the literature used to inform it. The NHS Choices website has been collecting data from millions of patient ratings of GP services since it was launched in 1998, most of which has never been analysed or published.

And there is little evidence that attempts to measure quality for the purpose of supporting patients’ choices and decisions are helpful. Different patients need and want different things from their GP: some value access 7 days a week, others want continuity with a GP who knows them well, or home visits, mental health support, specialist referrals, dementia care, sexual health services, and so on. Moreover, healthcare demands can change rapidly and unpredictably with the onset of serious illness, so the criteria you use when you register may be irrelevant when you find yourself needing antenatal or palliative care. I am fully in support of transparency, but data collection takes time away from other important activities and it is unlikely that we could ever collect enough to satisfy every type of patient consumer.

Quality assurance by meeting basic standards

Given the diversity of patients’ requirements and the variety of ways in which quality can be conceived, it would be reasonable to conclude that measuring everything that counts for quality in general practice is simply too difficult/ broad/ contextual a task. Yet there are some fundamental, universal, comparable, and where appropriate measurable, standards that every practice should meet, and which would give some assurance of its quality: things like good access to the building, immediate access by phone for urgent problems, safe storage of drugs and vaccines, safe waste disposal, hygiene and cleanliness, confidential record-keeping, an up-to-date practice website, and so on. I would also include providing patients with access to their records, accurate registers of patients with chronic diseases, routine clinical data, and records of serious incidents and complaints. And to provide quality assurance, all these measures should be published for patients to see.

Beyond such standardisable things, though, there are few other things that matter to patients that can also be considered ‘taken-for-granted’ standards of quality. It is not as if we cannot comprehend or describe quality in patients’ experiences; but they are so entangled in individual circumstances that they are very difficult to compare. This is why, as Angela Coulter pointed out recently in the BMJ, the Friends and Family Test is ‘a mixed bag of poorly evaluated methods that leaves patients frustrated, and doctors little wiser’. Greenhalgh and Heath’s paper on measuring quality in the therapeutic relationship concluded, “although little useful or meaningful is achieved by trying to reducing experiences and relationships to simple metrics, we should nonetheless remember that underpinning good-quality therapeutic relationships are continuity of care, from a doctor the patient knows and trusts, and sufficient time – and these can be measured”. As Coulter also concludes, we already know that patients value continuity of care, access, involvement in decision making and self-management support- all features of patient-centred care.

Quality as ‘patient-centred’ care

One way around the problem is to focus on patient-centred care. There is a general consensus that patient-centred care matters to patients. This term does not mean forcing unwelcome responsibilities on patients, or conversely, doctors having to agree to unreasonable patient demands, as has sometimes been supposed. Patient-centred care is about how patients relate to and interact with people, organisations and materials.

Good relationships between patients and people depend on a wide variety of factors, from simple courtesy, as promoted in Kate Granger’s “Hellomynameis”campaign, to knowing patients as people and sharing decision-making with them. It can be enabled by education, continuity of care andshared-decision making tools.

Good organisational relationships with patients depend on factors like making access to care easy, communication clear and helpful, and integrating care between different specialties and between different organisations, for example between hospitals and community providers, and organising how services are delivered. In my practice we improved organisational relationships by arranging to do a full annual review for all of a patient’s long-term conditions at a single visit instead of arranging separate appointments for diabetes, heart disease, lung-disease etc.

Good material relationships include how the built environment, equipment and so on affect patients. We invited a patient with expertise in healthcare architecture to show us how we could make improvements to make our building more welcoming and anxiety-containing by, for example, making the toilets easier to find. Just as staff can be courteous and kind and an appointment letter can be helpful and reassuring, a building can be welcoming and contain anxiety.

Attention to all three aspects of relationship-based, patient centred care can help to alleviate some of the inevitable fear and anxiety that accompanies illness. And neglecting any one aspect can undermine a patient’s experience of care, no matter how good the other aspects are.

From quality measurement to quality improvement

In a keynote presentation and a paper for Journal of the American Medical Association, Don Berwick explains that we need to shift our efforts and resources from measurement and control to quality improvement. He describes how we have moved from a historical Era 1, in which professional knowledge was shrouded in secrecy, paternalism was unquestioned and external scrutiny frowned upon, to Era 2, in which managerialism, inspection, regulation, markets and financial incentives have taken over. The majority of NHS clinicians (and not only GPs) feel overwhelmed by regulation and bureaucracy. The government is mistaken in the belief that this reassures patients or motivates professionals. Berwick proposes Era 3, the Moral Era, which retains the professional pride, commitment and beneficence of Era 1 and the transparency and patient-engagement of Era 2, leaving behind arrogance, secrecy, complex incentives and excessive data collection and burdensome regulation. We can do quality improvement in the NHS. It is backed up by forty years of research, it can be taught and we have leaders and enthusiasts waiting on the side-lines. If we can clear away the excessive and unproductive burdens of Era 2 we can make time and space to embark on the quality improvement we really need.

Jonathon is an NIHR In Practice Research Fellow studying moral development in medical education and clinical practice. He is also an NHS GP partner at the Lawson Practice in south west Hackney. He writes a blog about the relationships between doctors, patients and health policy at

This blog was originally posted on 26th May 2016 on the Centre for Health and Public Interest.

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Round up: professionalism, shared decision making and collaboration Fri, 23 Sep 2016 13:36:57 +0000 Here are some of the stories that caught our eye this week:

Professionalism: notes for physicians in training – Angela Jarman is a graduating Chief Resident of the University of Utah. In addition to a few very important mentors, she blames her mother, a school principal, for her ideas of professionalism.

Patients should be more involved in decisions about their care, says NICE – Research has shown that when clinicians and healthcare professionals work together with their patient, more appropriate decisions are made about their care.

A collaborative approach to end of life care – In this short video, we learn how Salford Royal NHS Foundation Trust and private care home, Broughton House, brought significant benefits to staff and patients by adopting a joined-up approach to training in end-of-life care.

New programme develops health leaders in Lambeth – A highly innovative programme to develop leadership skills across primary care in Lambeth and Southwark has had a substantial impact on new models or care in the area, says an independent evaluation report.

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Round up: medical professionalism stories from across the internet this week Fri, 16 Sep 2016 14:56:43 +0000 Here are some of the stories that caught our eye this week:

Staff care: How to engage staff in the NHS and why it matters – Jocelyn Cornwell, Chief Executive of the Point of Care Foundation, introduces the Foundation’s inaugural report which argues that caring about the people who work in healthcare is the key to developing a caring and compassionate health service.

Evaluating the big bang: the impact of introducing named accountable GPs – Adam Steventon, Director of Data Analytics at The Health Foundation, looks at the impact of the named accountable GPs policy introduced in England in April 2014.

District nursing – it’s not just an injection… – Rebecca Myers, Community Staff Nurse, shares her thoughts on what ‘good care’ looks like in district nursing services.

Where is the public pressure for social care reform? – Ruth Thorlby, Deputy Director of Policy at The Nuffield Trust, asks whether there will ever be overwhelming public pressure for social care reform.

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Round up – Medical professionalism stories from across the internet this week Fri, 09 Sep 2016 15:15:49 +0000 Here’s some of the stories that caught our eye this week:

Junior doctors’ row: the basics of the dispute – Ministers and junior doctors have spent several years locked in a dispute in this helpful article the BBC explain what exactly is the row about.

I’m a better doctor for accepting that I have a mental health problem – Dr Zoe Norris was 34 years old when she got ready to walk away from a career in medicine.

What’s going on in the mind of a suicidal person?  – September 10th was world suicide prevention day. In this article, written anonymously, tells her story.

Quality first: delivering safe patient care – the BMA have updated their ‘quality first’ portal which provides practical support to help doctors manage their daily work and examples of different ways of working under pressure and at scale.

William Cayley: Where is our faith? – how often is a patients religious views thought of as a barrier to be dealt with in a plan of care?

Why not just text them? – an American blog, but an interesting piece on whether texting patients medication reminders would be useful.

Hip fracture patients need better post-hospital care – a good one for collaboration, report from National Fracture Database has found not all patients are receiving planned care and rehab after leaving hospital, inc. examples of good, collaborative practice.

Comment below to share your views on them, or add your favourite pieces from this week.

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