Absolute stupidity of NHS Reorganisation

Before the last general election in the UK the leader of the Conservative Party declared that he wouldn't impose yet another re-organisation on the NHS if he was elected as the new Prime Minister. Promptly on arrival as the new PM he handed control to a dubious politician called Andrew Lansley. This silly man promptly set about reorganising the National Health Service. He has this "bee in his bonnet" that is he removes layers of management from the NHS and hands control to General Practitioners (Doctors) they will magically reduce the public costs of the NHS. This man Lansley has the stubbornness of a dead donkey and the listening ability of a beach pebble when it comes to listening to the views of the massive majority of the health care professionals. Just about everyone says scrap the new new re-organisation.

Here's some of the problems:

• The GPs are independent contractors (I have a letter from the Dept of Health confirming that); their own profit comes first. Giving them control of the purse strings give them the opportunity to avoid any measure that would reduce their profit.
• The GPs won't have spare time to run the national organisation or even local ones. They'll just re-employ the bureaucrats who used to run the defunct Primary Care Trusts. It won't save money.

Here's a real life example of the changes in progress right now. A friend of mine is a Nurse Practitioner. She's a highly skilled medical practitioner who has a cluster of medical degrees, over 30 years experience who works without the need for clinical supervision at the level of GP/Registrar. Her costs are about half that of a highly paid GP. As a direct consequence of the re-organisation she is being made redundant. Well not exactly redundant, the patients she used to see are being redirected to the local A&E department. The cost the public purse per patient has increased by a factor of three and queues will lengthen in the A&E. 

This senior nurse's redundancy settlement has yet to be agreed, but by the Departmental rules the additional cost to the public purse will be close to £500,000 if an unfair dismissal claim is to be avoided. Meanwhile the same group of GPs who pushed for the closure of the Nurse Practitioner's department are looking to employ her on a freelance basis at a Doctor's rate of pay. The nurse didn't ask for the re-organisation and she doesn't want to be made redundant. She is a strong proponent of the NHS. How many times is this type of situation going to be repeated throughout the NHS?

GPs in charge of chaos in the NHS

I've posted before on the matter of NHS Walk-In Centres being closed in the UK, now I've experienced it for myself. Unusually I've come down with a cold which has migrated into a chest infection. For the first time in 15 years I've phoned my local GP Practice to ask for an appointment to see my GP so I can get a dose of antibiotics to knock this infection on the head. No appointments for 3 days, even then that would be with a locum doctor. GPs should not be allowed to hold the NHS purse strings.

What do they expect - should I let the infection progress until I end up in A&E?  There used to be a Walk-In Centre in the locality managed by experienced nurses where I could be seen fairly promptly, but that has been closed, the next nearest WIC closed a couple of months ago.

I'm going back to bed and hope that my body can deal with the infection. I've contributed money to the NHS all my life, and now when I need their assistance I've been let down. Nice one Andrew Lansley! He is so keen to listen to the well paid GPs and let the Walk-In Centres slide into oblivion.

Black Hole devours nurses

I've earlier written about the death of an NHS Walk-In Centre, I'm now watch the terminal stages of this process in one location. It's nothing new I've seen it before and I'm sure the remaining Walk-In Centres will suffer a similar fate.

This is a direct consequence of Andrew Lansley's misguided leadership of the NHS. Abolition of the Primary Care Trusts have left Primary Care Walk-In Centres without any real sponsors. The General Practitioners (GPs), who now hold the purse strings in advance of actual parliamentary approval, will not save the Walk-In Centres because it disturbs their Edwardian business model of private practice partnerships.

No, the WIC I'm watching has been handed over to the black hole of a local A&E department of an Acute Trust Hospital. The once highly efficient team of Primary Care Nurses is being torn apart. This is a team which has worked for 10 years, rarely breaching patient time waiting targets and almost zero serious patient complaints. Nurses who were trained to work as autonomous practitioners who are qualified and able to assess medical conditions and to prescribe treatment. Their clinical leader has been elbowed away and replaced by an A&E nurse manager who has no experience of Primary Care medicine. The remaining Primary Care nurses are looking for new jobs having been told they are "not competent" by someone who has no experience in their skills. The GPs who once worked as part of the team are refusing to work with the new management. Within a few months little trace will be left of what was once a strong team.  

One remaining question  is what happens to the funds assigned to the WIC Nursing team? Does it get buried in the A&E hoard? What happens to the (average) 200 people who used to go to the Walk-In Centre? Their needs don't go away.

Update May 2012:
The Matron of the A & E Dept which absorbed the WIC has resigned. She's tired of the bullying from senior managers and clinicians, meanwhile the Matron of the now closed WIC is in the final stages of redundancy. It all seems a silly waste of resource to me.

Lansley's NHS

Andrew Lansley has published his plan for privatisation of the NHS, ooops I mean health reforms. They cement my view that the concept of the NHS Walk-In Centre is thoroughly dead. There is no mention of Walk-In Centres in the Primary Care bit of the plan (item 44), the GP lobby in the Lansley advice coterie is getting its way. They are determined that the public will attend their [private partnerships] surgeries at a time convenient to the well paid  GPs rather than the needs of the public. People go to Walk-In Centres because they either can't get the service they need from their GP or the quality of service is so bad that they seek an alternative.

Meanwhile I've been contacted by a Nurse Practitioner (30+ year's experience, Masters degree in medicine) who tells me his future employment is so uncertain that he's stopped buying a season ticket for travel to work. He now only buys a weekly rail ticket.

The death of the NHS Walk-In Centre

One of the better changes introduced to the UK National Health Service (NHS) was the concept of Primary Care Walk-In Centres. They were located primarily in urban or city locations and were available to the public from 7am to 10pm for 364 days a year. In other words they were available at a time convenient to the public rather than a time convenient to local General Practitioners (GP).

The Walk-In centres were staffed by teams of highly skilled primary care nurses and led by autonomous Primary Care Nurse practitioners. The procedures and skills of the nurses, who were qualified to prescribe a full range of drugs and medicines, mean that they could deal with 98% of the cases without the need for a medical GP. For those few where the nurses could not handle a GP would be be employed on a part time basis by the lead Nurse Practitioner.

No appointment was necessary, people could literally walk in off the street and receive a medical consultation. Those with long term medical conditions would be given any necessary urgent treatment and referred back to their GPs for long term primary care.

The concept was extremely successful:

• The costs were low. A WIC patient consulation was about £25 cost to the NHS. If that patient had gone a GP it would have cost at least the NHS at least £35. If the patient couldn't get to see a GP and decided to go to the local Accident and Emergency the minimum cost to the NHS would be £105.
• Waiting times were good. Patients were seen within an average of 20 minutes or less in a fully staffed WIC.
• The GP practices in the UK are run by independent contractors. They could turn patients away or close for the day at the whim of the GP Partners. The WIC teams were obliged to stay open, requiring permission from the local Primary Care Trust (PCT) and the Dept of Health before they could close.
• The WICs helped to reduce queues in the local Accident and Emergency departments when patients with minor ailments were "streamed" away from the Hospital to the Walk-In Centre.
• The WICs had a very low medical error/claim rate.

Sadly now most of the Primary Care Walk-In Centres have now been closed and their skilled teams of nurses dispersed. There are other reports on the Internet. In some cases the closures are hidden by the retention of a couple of junior staff and assigning them to a local GP or an A&E department. With the GP led Walk-In Centres you will see the daily open hours change from 0700-2200 to something like 0800-1900. In some cases the nurses are transferred to Acute Trust (Hospital) where the nurses role is subtly changed from being trained autonomous medical practitioners who diagnose and prescribe. Now they have to double check any decision with expensive doctors.

Originally the funding of the WIC team came centrally from the Dept of Health, it was ringfenced and could not be diverted to other purposes. Subsequently the ringfenced funding was merged into the general funding of the Primary Care Trusts. Opponents of WICs soon diverted the funding away from the WICs and the closures started. Remember the WICs often dealt with the failures of the GPs. They were seen as a threat to their profits. When the Conservative/Liberal coalition government came to power the scourge of the NHS in the shape of Andrew Lansley was released. He decided to wipe out the Primary Care Trusts and to hand the financial reins to the local GPs.  GPs see WICs as financial competition. It signalled the end of the PCT funded Walk-In Centres. Some have been absorbed by the budget hungry Acute Trusts (hospitals) to act as a streaming front end to A&E purely intended to prevent breaches of the waiting time targets. The Acute Trust, typically struggling under the financial burden of a PFI project, gains the funding from the Walk-In Centre, but the public lose the benefits.

These facilities are closed without public consultation, possibly leaving a ghost service to protect against public follow-up. The health administrators hate having their closure plans examined in public. Hundred's of thousands of pounds will have been spent in creating each of these Centres. It is often wasted. In one case the building was handed over to a local GP (private) in another the buildings will be demolished to provide parking spaces.

The consequence of these widespread WIC closures in London will be felt with greater queues in A&E, particularly at the time of the Olypmics 2012. Some of these walk-in centres were due to provide support to visitors. Here's a BBC report of a typical example in Surrey. They used to have a local WIC but it closed. You'll see a similar pattern in Croydon, New Cross, Whitechapel (E1), Homerton, Canary Wharf, Liverpool Street, Victoria and many other locations such as Stapleford, Ashfield, Leeds, Derby, Bradford, Salford, Harrow, Nottingham, Kirby, Trafford, Bromley, Manchester, Southampton , Barnsley, Warrington York Haverhill (Suffolk) Loughborough

An attempt to close Peterborough WIC.

Update: Late Nov 2011  One of the Walk-In Centres scheduled for closure soon,  as usual had a busy day as people attended for treatment yesterday. Many of those people would have gone to the local A&E Dept. Needless to say, the nearby A&E Dept managers are wetting themselves at the prospect of a 40% uplift in visits when the Walk In Centre closes. The A&E waiting time targets are going to be shattered, they already fail to meet waiting targets frequently enough as it is on present levels of patients.

Update Feb 2013: To make matters worse the local A&E Departments, which were protected by the Walk-In-Centres taking part of the load, are getting closed down as part of the service cuts. The (private) GP led Walk-in-centres open just 13 hours a day 8 - 7pm compared with Nurse led (NHS) 16 hours and the GP WICs have significantly reduced staff levels.