To ask what YOU would do to help save the NHS?

[TamiTayorismyparentingguru]

I don’t care if you’re an HCP or not, I don’t care who you vote for, I don’t care what you think about Brexit - all opinions welcome.

Opinions on practical suggestions on how to save the NHS only though.

Our local hospital is getting worse and worse with regards to staff shortages and waiting lists getting longer and longer. I will say that our GP is really great and we’ve never really had a problem with getting appointments etc, but as soon as you are referred to the hospital things go massively downhill. (We did have a GP misdiagnose/miss DH’s cancer which was pretty shit - but I wouldn’t say that was a particular problem with the system - more just one of those unfortunate things that happens, that really shouldn’t happen, but that are just a matter of course.)

The hospital is a different story though - wait lists for some departments are insane (current wait time for an initial cataracts appointment is 42 weeks and then up to 18m for treatment, paediatric dermatology is a min of 30weeks, paediatric podiatry is approx 30weeks also. I have been on a wait list for max fax for 14mths so far. I also had an 8week wait for an appointment at the breast clinic after seeing the GP with a noticeable lump.)

DH has also had to fight for every single appointment since his cancer treatment last year - instead of the 4-weekly appointments he’s meant to have had, most of his appointments have been 7-8 weeks apart and have been cancelled at the last minute (sometimes just an hour before) at least 4 times in the last year.

It’s awful and yet I do trust that the doctors, nurses, receptionists etc etc are all doing everything they possibly can.

What’s the solution?

weneed - dementia - that was my father (NHS consultant) ' s view too Thankfully his physical health gave out too when he had dementia and he had certainly make his wishes known at least 15 years in advance about not wanting to be kept alive when in a bad state.

However he had to spend the last of his life savings (£130k on just one year of his own care at home despite devoting his life to the NHS but at least he was able to die at home) and every penny spare he'd put into his NHS pension which of course died with him before age 80 and he worked full time to 77!

If we could find what means I am never ill (GP once in 12 years), not even a cold for 2 years we could bottle it and revolutionise the life of the nation but may be I am just very very lucky.

I actually read an article on some blue sky thinking where studies focused on people who didn't get cancer or whatever, rather than those who did , so perhaps you could be a guinea pig, Xenia!

I absolutely would not support ‘ helping people on their way’. That remains a criminal offence and is very, very different from allowing people a peaceful and dignified death. Murder based on age cannot be acceptable and isn’t permissible even in countries where assisted suicide is allowed in certain circumstances.

Read the Gosport or Shippman reports. They are not about ‘helping people’ in their last days or weeks. Gosport was a rehabilitation ward and most were intended to return to independent living after post surgery rehabilitation. Many weren’t even particularly old.

The way dementia patients are kept alive only to suffer makes my blood run cold.

We couldn't let children in the family near two of my end-stage Alzheimers' elderly relations in hospital because the sight of their twisted skeletal bodies and terrified eyes was so 18-rated. Faces that really, really looked just like The Scream.

Naturally the hospital insisted on cutting them open to insert feed tubes even though the only thing they could do to protest was scream. and scream.

That's nothing to do with £, by the way - ethics gone wrong, cowardice, highly religious ward staff all contributed to their lingering, traumatic deaths.

So

So many areas of discussion

"When ds has been in nicu and picu, he had a qualified nurse with a degree changing bedding, changing his nappy, doing NG feeds, passing NG tubes, cuddling him because he's crying (all when I'm not there obvs) . Things that I, as a completly unqualified person do."

"Sometimes the nurses know more than the doctors anyway because they spend more time with the patient and have more experience." Do you not see the contradiction in your own post there? If the nurses weren't doing the above because "no qualifications needed" they'd be spending less time with the patient. All those tasks - even the cuddling - allows the nurse to get to know that patient better, notice when there's a change more quickly, know what's normal for that baby so that when eg his cry changes she picks up on it more quickly. Especially important with babies as they're one of those patients that really can't say "my X hurts" "I feel nauseous" so nurses have to spend time with them getting to know them well in order to pick up on cues. Also eg a nurse doing a nappy change seems just that a nappy change. When actually during that nappy change a good nurse will also be noting how wet/dirty the nappy is, the quality of stool anything notable, baby's temperature, skin colouration, temperament, responsiveness, any rashes, any tummy bloating or other swelling, any tenderness in tummy area, etc etc depending of course partly on why baby is being treated and what observations are necessary re the condition. Also if baby has tubes/wires in situ a good nurse will also use this opportunity to check they're still correctly in place and working as they should. Not just a nappy change after all.

"I disagree. What you describe is the foundation of a good nursing. Every single nurse I know would love to get back to doing some of the more basics you describe but the sheer amount of paperwork prevents that." That's what I hear too. Too much bureaucracy not enough patient contact time.

Re the push to treat elderly patients past a point where quality of life is really there. I too had difficulty with this. Especially I felt there were times when elderly people, even lucid ones with ability to make their wishes clear, were being overruled into having often painful/invasive treatments when really they were done. They'd had enough. And I felt they were being treated not for their own sake, but because their families (understandably) weren't ready to let them go. Imo that's not how it should be, it should always be the patients decision and it seemed (and it sounds like this issue has worsened) like after a certain age the patient just wasn't listened to. Any patient who is lucid and able to communicate clearly should have the right to refuse treatment. I've experience of this within family too. 2 close relatives, one very elderly and the relative caring for them there came a point where there was little more could be done but it could've been but was stressful/painful and for little gain. The "patient" and their carer agreed to not bother - other relatives (who weren't very involved in their care) were not happy about this. I feel it was right they were overruled and patient made comfortable and allowed to let go. Still some bad feeling in family over this. Another relative, younger but still oap, dx with life limiting illness, could have had treatment which would have given them a bit longer but not much and that treatment would have seriously reduced quality of life, chose to refuse treatment. Family supportive and as a result they were able to do things in their final months that mattered to them. A strangely positive experience, that their end was on their terms as far as possible and the worst stage was quite short lived too. There definitely needs to be better guidelines on how end of life options are managed.

"Spot on and it’s not just dementia. We seem to have lost touch with the truth that people die and should be supported to do so with compassion and dignity rather than be forced into an existence that robs them of humanity for fear of a family getting upset." Excellent way of putting it. Dying is part of life, it will happen to all of us we need a more positive and open approach to it in this country. But that's not just an nhs issue its a cultural one.

CherryPavlova - that's always the difficulty with the euthanasia debate isn't it? How to prevent abuse of the situation.

A big thing that would help is something that is free and easy to do and we can and should all do it - TELL your family/loved ones (whoever's likely to be asked!) what you would like to happen in the event of serious illness/injury where you can't/can no longer communicate your desires.

My dad is very ill, still occasionally lucid, but bed bound. When he was still well enough to do so he "got his affairs in order" - will, funeral is all arranged and paid for, power of attorney arrangements made, organ donation organised (not that there's much of use due to the nature of his health issues), all documents held at solicitors. Mum will likely be the one dealing but as she's ageing too that's why the paperwork is at solicitors rather than in a "safe place" in the house. They've told us (siblings) which solicitor and solicitor knows our details. As dad got worse he's also organised an ADRT (living will) I don't know the full details but I do know essentially he's dnr and doesn't want to be ventilated.

Anyway - my point is anyone likely to be asked, mum, me, my siblings, his siblings have all been told what the situation is so if we're asked we know what he wants.

Mums done similar but is still much more well than he for now, but his situation has motivated her to get organised. All her affairs are in order and she's told us all her wishes re near end of life/in event of death eg she's got a weird thing about eyes, she is happy to donate all other organs but doesn't want anything to do with her eyes touched.

I'm only 46, in relatively good physical health as in nothing life limiting (just bloody sore!!) but I've already told dd my wishes and organised as much as I can at this point (tight finances so don't think I can afford to start paying off funeral till I'm 50). BUT you never know what's around the corner. I've lost friends/colleagues/relatives at shockingly young ages to asthma, car accident, undx genetic issues, brain aneurysm... It's taught me nobody is immune to an early death.

Important not only "just in case" but because it's healthy and realistic to acknowledge and discuss death.

Lanaor - so sorry you witnessed/experienced that with your relatives. Staffs own religious/personal moral beliefs shouldn't even be a factor!

"We hear so much about patients abusing the NHS but the higher paid staff are often just as guilty imo." Agree (unsurprisingly) the attitude of "90k ain't that much" is appalling! Out of 8 Gp's at my surgery 2 are full time and they are FREQUENTLY on holiday. I have certain GP's I prefer to speak to the my mh stuff but I swear 8/10 when I try to get an appointment with them they're on holiday. They're nice good GPS on that particular issue, but that's no good if you can't get an appointment with them! One of them one year only worked one week the whole school summer holiday. That's unacceptable imo. And when it comes to hospital Drs I know several people frustrated by the fact they've had to take time off/longer off work because non-emergency surgery never happens at bank holidays or weekends. Seems to me that for minor/routine surgeries on working people this would actually be the PERFECT time to do them. Yes it's partly lack of staff/funding but it's ALSO because surgeons are so resistant to working these hours/days.

"All that experience and knowledge is lost." As a mh patient I find this so frustratingly true. On the rare occasions I've ended up with an hcp I click with (hugely important in mh) and has the experience AND the right temperament (basically bolshy enough to get me the help I need from others AND to deal with me as when I'm very anxious I close down) - frankly as rare as unicorn poo it feels at times! To then have staff like this leave because they're unsupported is not only unacceptable it's financially irresponsible. Again - it's short term savings that lead to far higher long term costs. Where I live we had an EXCELLENT psychologist - yep ONE for a whole county, a county which is classed as a deprived area and with major mh problems. It got too much for him and he retired to protect his own mh, he was early 60's so not particularly young either. Ever since its been a revolving door of locum placements because it's not a desirable area but the nhs authorities aren't acknowledging that and providing incentives to attract the right person (unlikely to be someone local as few round here even go to uni), particularly the right support to do the job. Really there needs to be at least 2 to cover the whole area. Result is crazy long waiting list, patients getting more ill and so using GP and a&e more, so arguably not even really a short term saving.

But then mh has always been the poor relation in terms of nhs funding, I believe largely because the patients are seen as less deserving, their illness being self inflicted, lack of compliance with certain treatments being seen as belligerence rather than pathology, even by some hcps. That attitude HAS to change.

Sidge - I can assure you that did happen one year. There was uproar! It had building up to it, each year closed longer and longer. Following the uproar now "only" 2 weeks this year closing 21 Dec re-opening 4 Jan.

"this whole "GPs work for a few hours a day and rake in 6 figure salaries" is utter bollocks." Nobody's said anything as extreme as that. 5 figure salary for 3-4 days work a week I'm pretty sure I've come across though.

I agree with pp - it shouldn't be per patient, this leads to GP surgeries accepting more patients than they can reasonably cope with.

0800-1730 here, often closed wed afternoons, no late evenings, no weekends.

I don't understand why recruitment/retention of GP's is a problem. Sorry I can't see the salaries and hours as unattractive.

I don't expect 24/7, I do expect full coverage mon-fri MINIMUM, at least one late evening and Saturday morning would be good too.

I expect (when I'm attending in person, currently housebound) not to be kept waiting after arriving politely on time myself for up to 3 hours regularly - and no this is not usually due to GP was dealing with an emergency etc. I feel it's because appointment times are unrealistically short. I've also had times when I've been there for one of the first appointments of the day and witnessed GP arriving AFTER start of surgery and overheard then saying in a blase way that the reason they were late was unnecessary eg "couldn't not get my latte" yes I know SOMETIMES it's GP's certificating death, attending emergencies etc - but it's certainly not always the reason.

I'm older than many on mn and remember when you didn't have to basically be almost dead to get a home visit! When you could ask to see YOUR dr and get an appointment in a reasonable amount of time without having to redial for HOURS several days in a row, calling as soon as the surgery opened. I remember that seeing the SAME dr regularly meant a lot of time saved due to not having to repeat yourself when seeing GP for long term conditions because the GP doesn't know you from Adam because now you rarely get to see the same dr twice! Continuity of care at primary level is much easier to achieve if your dr actually KNOWS YOU. Every time I have an infection requiring antibiotics I have to tell them the long list of the ones I'm allergic to, before they can prescribe because they don't know me and because the IT systems seem to make it hard to easily and quickly access this info (genuinely had SO many times GP say "it's probably quicker if you tell me"). I remember developing a rapport, a relationship with your GP which then makes it easier to discuss more embarrassing symptoms/ailments. I remember not being made to feel like I'm expecting too much when I ask to see a female dr for certain things. All this should NEVER have been allowed to disappear.

Personally I notice a lack of district nurses too who could cover a lot of the home visits needs.

"It's far harder to fire someone in the NHS than you can imagine" I'm sure this is true. It's a problem throughout the public sector. BUT it also shouldn't reach that point! Because sacking someone means losing their knowledge and experience (if not their work ethic!) sick leave should be getting managed better. I suspect there's an element of nhs workers being able to get signed off sick more easily than other industry workers due to a combination of sympathy from fellow hcps and they know what to say. But also there must be increased sickness due to lack of staffing/support so workers are also genuinely burnt out.

Personally, as someone who also trained in the 90's

"Nursing is a totally different profession to what it was 30 years ago" I think this is where a lot started to go wrong.

The junior dr crisis should have been dealt with by recruiting more Drs, NOT by turning nurses into "semi-Drs". I agree HCA's are the ones that are really doing the nursing now but they're not getting the support or recognition/appreciation for it, either from the public or other healthcare staff.

We very much need to change society's attitude to health/life/death and the NHS.

People call ambulances when the don't need them because they're entitled, they feel they should get care there and then do they call.
It is also because our community spirit has gone and you don't find next door neighbours volunteering to take the elderly lady next door to an appointment anymore so they then rely on hospital transport.
Everyone is so insular and 'me, me, me' now and it's caused a raft of issues and the attitude of 'well why should I?' Stinks.

As for life/death, people need to understand that people die, life isn't forever. I am a community carer, not qualified and I have no degree but I do a lot of what a community nurse would do.

I always die inside when I go to see a new family and they are horrified when I ask if their 90 year old mum with severe dementia and god knows what else has a DNR, they say that, yes she must be resuscitated, she must have her ribs broken from compressions and be bruised and bashed around to get her heart beating again, she must be taken to hospital where she will be frightened and confused all because they can't bare to say goodbye. It's disgusting! Dignity in death needs to be seen as a positive thing not prolonging life until the bitter end regardless of the patients wishes.

I genuinely believe anyone who is willing to work hard and has a willingness should be able to train to nurse on the job with a day or 2 at college, no degree needed.

I don't understand why recruitment/retention of GP's is a problem. Sorry I can't see the salaries and hours as unattractive

Its a problem because its an exhausting, relentless, stressful, emotional job that no amount of money can compensate for. And GPs, by definition, are quite bright individuals and have options. I don't think most GPs think they are badly paid, but if they look around they (and other NHS staff) can get significantly less stressful jobs, with no on call or weekend commitment for the same if not more money. I had a junior colleague who left medicine completely last year to work for a pharma company. 9-5 Monday-Fri, double the salary. What would you do? Its not rocket science. Its not a bad salary, so clearly there is something wrong with the job otherwise there wouldn't be a recruitment crisis. There is lots of evidence to show that with many jobs, especially vocational ones, increasing the salary doesn't incentivise workers. On a bad day, when I've missed lunch, haven't wee'd and am late to pick my kids up £100 wouldn't entice me to work one. more. hour. and anyone who works in healthcare will understand this.

There is lots of evidence to show that with many jobs, especially vocational ones, increasing the salary doesn't incentivise workers.

So why do so many people whinge about the wages?

I don't understand why recruitment/retention of GP's is a problem.

Recruitment isn't a problem, Medical schools are massively oversubscribed and it's very competitive to get a place. Plenty of newly qualified doctors want to be GPs, but I'm not sure they're the "right" ones. A lot of them want family friendly hours, etc. As for retention, again, a lot want to work part time, and a lot want to wind down or take early retirement. I'd say the main problem is not enough medical school places, which is nothing new - we've not been training enough for 40 years. If we double or treble the training places, there'd be more people coming through to cover for part timers.

I’d split it into 4 separate services:

1. Chronic diseases (inc. mild and moderate mental health) and preventative health care. Served by polyclinics.
2. Acute care. Served by hospitals and “minor injury and infection” units.
3. Severe and acute mental and neurological disorders care. Served by hospitals, community outreach teams as well as group and care homes. This would cover disabling mental health conditions (severe depression, psychosis etc) as well as dementias and severe drug and alcohol addictions.
4. Non dementia geriatric service. Served by care homes, specialist geriatric hospitals and community outreach teams.

Each would have entirely separate funding pools and have spending autonomy.

I would also push massively for automation of all automatable tasks. Like say you have a throat infection, you put a swab in the computer, it tests for bacteria, if it finds them it tests for known bacteria, if it recognises the bacteria it prints off a prescription for an antibiotic that is suitable for you based on your medical records (drug interactions and allergies etc). Then the pharmacist checks it over and runs over the side effects with you and dispenses. No need for a doctor unless it detects and unknown bacteria or finds nothing (in which case it’s probably just a self limiting viral infection but worth checking with an expert in case it’s something rarer). Even stuff like cleaners - you can get cleaning robots now, they can’t do everything but if they do 10% of what’s doing that’s 10% less cleaning staff you need. Disinfecting surfaces could be partially automated. All kinds of stuff currently done by people could be done by machines, that’s before we even get to data management which is the most obvious area.

I’d get rid of pay bands and allow the market to set wage rates.

"Its a problem because its an exhausting, relentless, stressful, emotional job that no amount of money can compensate for" as is nursing and other hcp roles which are far worse paid and respected! So what makes GP's think they deserve better treatment than them?

"And GPs, by definition, are quite bright individuals and have options" also true of other hcps

"so clearly there is something wrong with the job otherwise there wouldn't be a recruitment crisis." You don't think the expectations of those going into the job is problematic at all? That people who chose to go into healthcare which by definition is mainly a 24/7 role shouldn't expect mon-fri 9-5 hours?

Lack of staffing/support/funding meaning staff don't get breaks on time etc isn't though I don't think why people aren't opting to be GP's.

"So why do so many people whinge about the wages?" And still a good question.

Would more realistic information on what the job entails help? Would changing the expectations of those going into GP roles be better?

I know there'll be the problem of not being able to change the contracts of current GP's but I don't see why expecting future GP's to be more flexible is such a big ask!

DieAntword - curious to know your background.

Personally I can see all you're suggesting costing MORE and with more potential for mistakes. Great as computers and robots are, they're still nowhere near as capable, skilled or adaptable as humans.

On the IT, data management side we do need HUGE improvements! The systems need to be much more user friendly, cross department interactive, logical, streamlined and accurate.

And separating services according to dx - personally I think clinically unworkable and administratively MORE complex and expensive. Clinically too, human bodies don't have separate "departments" most people, especially the elderly, have several comorbid factors. Throughout the thread many posters have said that currently that's actually one of the problems. Including me. Most conditions don't exist in isolation not affecting other biological systems. Same is true with meds.

Eg diabetics the problem isn't only within the endocrine system, it also affects just about every other bodily system. Cardiac, reproductive, digestive, muscular...

So particularly for diabetics with another major condition it's better to get the Drs treating working together collaboratively rather than the current imo adversarial set up - and that's without clear X dept gets more funding issues.

Personally I still think a lot of mh issues are caused or exacerbated by misdx or underestimated physical factors. Eg I'm in Scotland, have come across several hcps who think vit d should be added to the water supply!

Pps have already mentioned b12 deficiency not being taken seriously, I've met hcps and sufferers who think thyroid disorders are woefully under-dx and treated in the uk particularly hypothyroidism.

All of these are easily and cheaply treated IF tested for and dx which doesn't seem to be happening.

Back to hard costs -

I'd love to know the cost of testing, diagnosing and treating vit d deficiency vs treating the symptoms if its undx which could well inc many years of depression meaning anti depressants but also possibly relatively expensive talking therapies. When MAYBE if the patient had the underlying deficiency treated they'd at least need LESS treatment for depression? - again - short term savings long term higher costs!

MorbidlyObese great post. That level of pension is crazy!

I think that a lot of what you’re talking about would all come under the remit of the first branch (chronic and preventative) and would be able to be joined up there. If the problem is severe enough to need acute care then it needs addressing immediately as symptoms not just the underlying causes which can be continuously addressed by 1.

Honestly I think a good knowledge based system makes less diagnostic mistakes than a human doctor for all but the most specialist cases. So to me it makes sense except when there’s significant risk of it being a specialist case, or severe harms if it is and missed, to let the knowledge based system handle it. For other stuff like cleaning or whatever I imagine you have one human whose job it is to make sure that nothing obvious has been overlooked, systems melted down etc.

Why can’t I put my symptoms into an app and get a prescription? Why do I need to go to a doctors office and wait to be told, often what I already know and prescribed things I already know I need

The NHS is the victim of it's own (and medicine globally) success. The average life expectancy when it started was 71, it is now 81+.

I don't know what to suggest without sounding startling harsh but most wards I've ever been on are full with the v.elderly who are being kept alive by 20 tablets a day, oxygen and breathing apparatus. When do we actually draw a line and stop stopping people from dying when they're a century old and so ill.

My grandmother has wanted to die for about 5 years. She can't see, she can barely hear, she has heart problems, she's frail and can walk 1 or 2 steps. She goes into hospital at least 3-4 times a year for more than a week at a time. She hates it. She is 97 and miserable.

I think free prescriptions should be massively reviewed. If you can afford it, you pay. If you genuinely can't then you get it under the NHS. I know plenty of people who could certainly afford prescriptions themselves but still claim free ones "because they can".

The concern about an app/automated diagnostic computer would be that it doesn't examine you. Yes, you may present with all the symptoms of a UTI but the app can't have a feel of your abdomen and find that palpable mass that needs further investigation, it can't see that this is your fourth ear infection in the space of three months, it can't see that you're looking rather tired and a little unkempt and when combined with your symptoms ask if everything is okay at home/how are you emotionally, and so on. Machines would have fixed parameters and there'd be a large potential for harm when patients present with conditions outside of those parameters.

Then there are the people who don't trust "robots" and instead of popping along to the diagnosis machine at the pharmacy would still attend at the GP or A&E because they think an actual person is better and safer than a glorified toaster.

CC I understand why that would seem a sensible option.

Unfortunately many patients would forget to include otc meds or preparations like St. John's wort when asked on an app "what other medications are you currently taking?"

Or else there's be the situation (similar to all the t&c's we all agree to but haven't read! Where the app even says "do not take with X y z"

Drs/other prescribing hcps, generally know of "quirks" within the system - eg that many patients won't consider SJW a factor and so either not notice or ignore advice on this.

There's also the experience factor - eg patiejnts in X demographic/personality type are more/less compliant and so if compliant types they'll be fine on a 7-10 day course of antibiotic and will probably complete the course, or are a less compliant type therefore prescribe a higher dose for fewer days.

These are nuances an app couldn't cope with.

I think also (not an IT expert) apps also more vulnerable to hacking so data security, plus the possible abuse of the system if addicts figure out the "right" answers to get sought after drugs.

Plus - and I think anyone with a smart phone will grown at this one - it would need CONSTANTLY updating due to the vast number of drugs coming and going out of what's prescribable plus guidelines on dose, what they can be prescribed for (off book prescribing I don't think would be possible via this) and contraindication knowledge...

Have you SEEN the size of the BNF?

Just looked and there is a BNF app available to professionals, but going by reviews there are problems each time it updates