Interview Notes

NHS Care Privitisation

NHS England are attempting to look after more patients in their communities rather than hospital. This is being done by forming Accountable Care Organizations, which holds contracts to provide services. Some fear this may lead to privatization. ACO’s evolved from sustainability and transformation plans. Outsourcing can involve nurses from agencies and equipment. There is a difference between privatisation of the NHS and the NHS commissioning in private services to deliver NHS care (remember GPs are private!)

Positives

Gives patients the right to pay for treatment if they wish.
Increases competition may drive an improvement in quality of care.
Less NHS waiting lists
Less “time wasters” due to cost
Some private healthcare subcontracted back to NHS so money is not lost.
Could supplement doctor’s income for more incentive. (Think about current problems with morale due to junior doctors contract).

Negatives

No competition would save money in the long run
Discriminates against the poor
Disadvantages those with chronic or congenital conditions
Less altruistic and more commercial which is a slippery slope for the doctor-patient relationship. Think about ethics- Charlie Gard case.

Obesity Crisis

How valid is a BMI? Related to diabetes and osteoarthritis.
Patients are more difficult to care for ie bariatric beds, hoists leading to often-longer hospital stays/slower recoveries and an increased risk to infections. They’re also more prone to take more medications which may cause contraindications with drugs prescribed in the hospital leading to more expensive drugs being used or none available. Also require more staff to look after them. Impact on quality of life.

Acting on the crisis

Public health campaigns like the sugar tax. When introduced into Mexico sugar consumption was reduced by 12%, however this later rebounded. How far are the government/health service responsible for intervening? There is an argument this is too paternalistic and we should give individuals their own autonomy. Perhaps instead of physically preventing people the money could be better used into educating people. An example of this is in children- there are 12 adverts of unhealthy foods/drinks in one hour of tv- we could manage this (ie not until watershed) as children are more vulnerable. It discriminates against the poor and those that rely on sugar such as type I diabetics.

Brexit

Positives

Potentially more money- however this is unclear EU cannot dictate, NHS solely under British control. More medical school places.

Negatives

Staff- reduction in nurses, less free movement of specialists, recognition of qualifications, harder to recruit EU staff. Less EU funding for research. European Medicines Agency- this will cut UK off from having their drugs approved from side effects, we will therefore require an independent assessment of drugs which will take longer. EUROATOM- supply radioactive treatments and tracers which will then be harder to obtain. Therefore some treatments and diagnostics may be limited.

7 Day NHS

Pertinent to extending non urgent operations and outpatient services. Patients are 15% more likely to die if admitted on a weekend. Stephen Hawking accused this figure Jeremy Hunt found to be “cherry picking”. This requires either more staff or pay, which would cause a decrease in morale if the right balance isn’t struck. We recently postponed 50,000 operations due to winter pressures so the 7 day NHS goal seems harder than ever. The 7 day NHS meant that consultants contracts were changed so that they could no longer opt out of non-emergency operations at the weekends. The government have increased medicine places to address the staffing issue. The plan is still unclear.

Positives

Less time for inpatients to be waiting in hospital for diagnostic or other services, ie discharges. This frees up hospital beds. Continuity of care over the weekends. Less backlog on Mondays.

Negatives

This could lead to the closure of other services. Unsure where the funding is coming from. Only an extra £8bn has been pledged whilst there is a £30bn funding gap between now and 2020. Are we able to staff it? MDT- not just doctors but affects many. If it can’t be staffed then this may affect patient care, which has a subsequent effect on staff morale. There has been resistance from BMA and royal college of GPs whom claim it is unachievable or destabilizes other services. If the government override the BMA this may have a knock on effect on morale further. With seven-day access will this effect emergency care? Where will the priority lie?

Junior Doctors Contract

All doctors below a consultant (~9 years to become a consultant). Previously, sociable hours ranged from Mon-Fri 7am-7pm, anything outside this was paid a premium. Now, the basic rate of pay was increased but sociable hours became Mon-Sat 7am-10pm. This was part of an attempt to create a 7 day NHS. Many believe this overall resulted in a paycut. Under the contract pay was not protected if a doctor chose to switch speciality. Many doctors felt this lead to an under appreciation, due to already feeling overworked. Strikes ensued as a result. Some doctors have reported decreases in morale, and have left to countries such as Australia. The contract was said to discriminate against females by putting them at a financial disadvantage for taking maternity leave. Due to the strikes being highly politicized, it may have decreased the publics faith in the NHS, with some believing areas such as emergency care wasn’t already working 7 days a week, 24 hours. The new contract could also discourage jobs related to unsociable hours such as A&E.

Mental Health Services

Postcode lottery over mental health treatment. Average waiting time for a first appointment with CAMHS is six months, with a 10-month wait until the start of treatment- consider that 50% of mental health problems are established by age 14. There are varying articles on whether the budget is sufficient for mental health in communities when compared with other healthcare budgets, and this discrepancy depends on which regions of the country an individual may be in. Have a recognition or awareness of how mental health can impact physical health. Ie patients with schizophrenia have double the risk of death from heart disease. This may be due to a discrepancy in treatment for those affected by mental health. It could also be argued that mental health is a key treatment area for those with long term health conditions – Around 30 per cent of all people with a long-term physical health condition also have a mental health problem, most commonly depression/anxiety. Mental health is also a social problem- economic instability can be expected to increase demand for mental health services, as there is a close link between unemployment, debt and mental health problems.

Role of Public Health

Social media- 1 in 3 women don’t attend cervical cancer screenings due to embarrassment, we therefore need increased awareness of the importance. Increasing iron in flour to decrease spina bifida. Raises questions for autonomy- could educate individuals on the importance of folic acid. There are negative effects for people that may be having too much folic acid. However, it is being carried out in 81 countries (not in Europe). Cost effective for health services? Spina bifida is a costly condition. Also think HIV prophylaxis, sugar tax, alcohol minimum pricing in Scotland. As well as vaccinations (polio, smallpox especially).

Extending Role of Nurses

Doctors and nurses complement each other. Extended roles means that nurses can become more specialised, and more efficient. This can free up doctors for other things, and further extend their roles. Ie nurses prescribing contraceptive pill saves a lot of doctors time. This could, however, force many GPs to specialise. If nurses roles are too far expanded this can blur the line between the differences of consultant, GP or specialist nurses. Professionals should not act outside their competency. The extended role of nurses may be undervalued by the public who may have more of a traditional view of nurses. 1 in 10 nurses are quitting each year, perhaps specialist nursing position may encourage more to stay.

A&E Pressures

There has been some accusations of altering of figures so A&E’s appear to be improving. Despite being the joint worst month on record in December, the figures may actually be even worse than thought. Targets originally went from 98% patients seen in 4 hours, this was then reduced to 95%. This hasn’t been met in some trusts in years. What are these targets doing to staff morale? Targets may not necessarily be the answer- from my experience I was handed over a patient with no discharge destination and no staff for his care, due to not wanting the patient to breach. The pressures are argued to come from an underfunding, understaffing, the way A&E is misused and a lack of hospital beds. Too many patients being treated? 84% of doctors order needless tests or medication as they are worried about being sued. Think of questions relating to whether we should charge patients who come into A&E wrongly? Or whether patients should be required to consult 111 before coming into A&E.

Organ Donation/Opt Out

Introduced into Wales.

Positives

Deficit of organs, and this would provide us with enough for patients. Due to many people not knowing about the register, or organs not being viable etc. Many patients with viable organs die and these are not being used ie young people dying suddenly. Welsh donations rose by 1/3. Many people forget to join the register. Some people see the body as an inanimate object therefore they see the effect of a loss of an organ after death as negligible. Utilitarian- greatest good for the greatest number.

Negatives

Consent- cannot be certain that the patient had capacity to have assumed consent. Assumed consent leaves problems ie do we know that the patient was not coerced? If we can imagine people might have forgot to actively join the register before, it can also be assumed that people might have forgot to actively leave the register. People may feel guilty actively refusing. Do we have the facilities to even carry out that many operations with a high influx of organs should the laws change? What would happen to those organs that couldn’t be used? Deontological. Alternatives- could work out a plan to recruit more donors. Distressing for families who are aware patients would not want organs being shared. Could death be hastened for a donation? It is a system that is open to abuse.

Abortion

24 week threshold unless a serious threat is posed to mother or babies health. Doctrine of double effect- sometimes ‘killing’ a foetus may be deemed acceptable/appropriate if the mothers health is compromised, ie an ectopic pregnancy. In favor of abortion is the idea that it gives women the right to reproductive choice, and reduces the rate of illegal abortions, which can result in injury/death. A moral argument in favour is posed by Judith Jarvis Thompson (look this up). However, some may see this as killing – Hippocratic Oath/maleficence and therefore a slippery slope.

Euthanasia

Active euthanasia- actively taking steps to ending a patients life. Passive euthanasia- do not use this term, contradiction in terms. Euthanasia means to intentionally end someone’s life. Passively doing so/stopping treatment in the patients best interest is good clinical practice. Lillian Boyes- assisted suicide by Dr Cox, who was given a suspended sentence for manslaughter. In the hearing one of his colleagues said he had wished he had the courage to do what Dr Cox did. There is a hypothetical argument which exists (doctrine of double effect) that suggests if administering a high dose of pain killer/drug to give patient some comfort also has the unintended effect of killing the patient then this is allowed. This is hypothetical as in modern medicine our painkillers are very effective and we usually have the means to relieve their pain without shortening their life. Go through 4 pillars.

Assisted Suicide

Physician assisted suicide- provides patient with treatment to kill them but doesn’t administer it. Illegal. Family assisted suicide. Illegal for anyone to assist someone with suicide.
Diane Pretty- motor neurone disease- suggested to the courts that by not letting her partner help her commit suicide, they were condemning her to torture, which is against her human rights. The court decided it was her disease which was doing this, and her case was dismissed.
Debbie Purdy- MS. Argued that if her husband was to be prosecuted for helping her end her life when she was not physically able to, then she would have to prematurely end her life when she was physically able to. After this case, it was decided that there were guidelines that had to be in place for prosecution to occur. It must be the very last option and the relative must not be gaining financially. Healthcare professionals are exempt from these rules, even if not acting in this capacity.

Positives for assisted suicide and euthanasia

If we look as a consequentialist- the consequences are actually the same as withdrawing treatment which, as said, can be good clinical practice. Not letting a patient do so infringes on autonomy. Non discriminatory against those that are not physically able to commit suicide.

Negatives for assisted suicide and euthanasia

Palliative care- some patients glad they had extra time despite previously wanting to die. The law protects the vulnerable/those that might feel a burden to families or the NHS. Deontologist- killing people is bad. Aim of medicine is to preserve life and this is therefore a slippery slope.