Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Community specialists
- Debashis Bhattacharya (18 September 2007)
-
Deafness as well as blindness?
- John P Toby (19 September 2007)
-
Klein's rule
- Neville W Goodman (19 September 2007)
-
None so blind
- Martyn C Wake (19 September 2007)
|
|
|||
|
Debashis Bhattacharya, Specialist Registrar, General Surgery North Western Deanery
Send response to journal:
|
What Prof.Darzi has tried to usher in is the concept of the community specialist, who will be able to deal with patients who are at a minor or intermediate level in the community.He can now decide which patients need referral to a more specialist unit. He also will be involved in the community care of the patients, who are referred back from tertiary care.In other words, it is a kind of an amalgamation of primary and secondary care. This will smoothen and decrease the workload of primary, secondary and tertiary healthcare workers. This will also lead to better distribution of funds.
This also has implications for surgical training. Being a trainee, this is the subject of my major interest and concern. The exposure can now be in two different groups of care levels. The experience can be provided in one of the levels and finally a trainee maybe mentored in the area he and his mentors so decide.Thus, the training can be focussed and more intense. We will be able to train more effectively in the shortened time limits , given the legal implications of working hours.
Competing interests: None declared |
|||
|
|
|||
|
John P Toby, Sessional GP Northamptonshire
Send response to journal:
|
I agree with the main thrust of Iona Heath’s reflections on Professor Ara Darzi’s proposals for reforming health care in London, especially as there seems a high probability that similar proposals will be made for care elsewhere in England. I also agree with most of her earlier observations on the potential for general practice to “save the NHS”.(1) However, I have recently chaired a Primary Care Trust and, latterly, have observed at close hand the search by individuals for comprehensive primary care and the willingness and ability of practices to support and coordinate this. This leads me to question the capacity of some practices to deliver a coherent vision of primary care and overcome the variation in quality that, alongside its virtues, has been a feature of general practice. The current arrangements are certainly not all favourable to generalist practice and it is clear that there is a serious potential for further fragmentation of primary care. Some of the reductionist aspects of the current contractual arrangements already encourage this but these could be used to support practices better. The focus on general practice is likely to increase as a result of a number of current trends including the concerns of the Prime Minister about access, the Darzi Review and the increased emphasis on effective commissioning. There is a need for general practice as a whole, and for individual practices, to set out the services that they wish to offer including coherent plans to meet the needs of individuals for comprehensive primary care in the context of current society. It is incumbent on the NHS to give these proper consideration and for all sides to use the contractual arrangements that provide the best solution for patients within reasonable limits and especially the constraints of finance and the workforce. Pursuing the sensory analogy introduced by Heath, I fear that, in addition to the problem of blindness, we may also be witnessing a dialogue of the deaf. While this may be a trite reflection, it may have very serious implications for health care in England, and, potentially, in the rest of the UK. On the one hand, the government may increasingly espouse arrangements that offer simplistic and short-term solutions to issues posed by the delivery of primary care, often in the face of contrary evidence of effectiveness. On the other hand, the profession may rely on traditional support and opinion polls whose headline figures disguise a variety of concerns that will be quoted as supporting changes which will have unintended consequences. Evidence from the UK and overseas suggests that general practice is the most effective and efficient way of providing primary care which should be, in turn, the fundamental component any healthcare system. This requires both the government and the profession to consider the interests of patients and the wider public; engaging them in a fuller debate about the services and the best ways of delivering these. 1. Heath I. Only general practice can save the NHS. BMJ 2007;335:183 (28 July) Competing interests: None declared |
|||
|
|
|||
|
Neville W Goodman, Consultant Anaesthetist Southmead Hospital, Bristol, BS10 5NB
Send response to journal:
|
Rudolf Klein, who no doubt is at this moment preparing the next chapter for the next edition of his book (1), wrote on page 150: "...there is no magic formula for health care reform and ... any attempt to devise one inevitably turns into a conflict between competing claims and interests." But what else can managers and politicians do? Secure their position, leave all as it is, and claim when they move on that it was for the best? No: the working life of managers and politicians consists in change. However it is painted, Lord Darzi's ideas are yet another formula; it is unlikely to be the magic one; and in Iona Heath's article are the seeds of conflict. Reference: 1 Klein R. The new politics of the NHS: from creation to reinvention. 5th ed. Oxford: Radcliffe, 2006. Competing interests: None declared |
|||
|
|
|||
|
Martyn C Wake, GP and joint medical director Sutton and Merton PCT Sutton and Merton PCT,Nelson Hospital, London, SW208DB
Send response to journal:
|
Iona Heath puts forward some solid arguments against the polyclinic concept proposed in Lord Darzi's review of healthcare in London, though it is a pity that she makes so much of the non-primary care backgrounds of some of the authors,as if they have no valid position from which to speak (though I accept the fact that the mental health recommendations lack an adequate emphasis on primary care). She rightly points out that there are many examples of excellent primary care services in London already on which we can build, but she is sadly blind to the deficiencies in our services which are reasonably cited in 'A Framework for Action'. In some places access to GP services,even by telephone,is inadequate. There are practices still who close for half a day each week and some who are not open throughout the day. The problem of poor access and availabilty is perceived by public and politicians as unacceptable in a service which has received so much investment in recent years. These are also seen as major contributors to the rise in emergency activity and in attendance at hosptal accident and emergency departments. There is mounting pressure on us to increase our hours of routine availability. Polyclinics will not solve all these problems but they will facilitate groupings of clinicians sufficient to offer extended hours and types of care and to act as the front door to A & E in some locations. Heath misses the point here that over 50% of A & E attendances would receive better care from primary care practitioners rather than being seen by junior doctors, over-investigated and even admitted to hosptal. A & E is also the preferred place of attendance of some of our most vulnerable and disadvantaged patients including those with multiple physical, mental and social problems, who will be much more appropriately assessed and treated within primary care. The trick though will be to ensure that such urgent care practitioners maintain their primary care credentials rather than defaulting to hosptal A & E behaviours. This model of care can also deliver some of the productivity improvements demanded by Derek Wanless in his recent King's Fund review.I am not convinced that the 'incremental change' advocated by Heath will bring about the degree of change which is now required. We will be foolish as GPs at this time to fail to recognise this. In chairing one of the clinical working groups for the report I found a strong consensus among primary and secondary care clinicians about what is required to transform London's healthcare and this was about much more than just polyclinics, laying great emphasis, for example, on the need to transform the infrastructure of local intermediate care and social services to support patients out of hospital Heath fails to acknowledge those changes which have taken place in primary care, such as GPSIs and the management of long term conditions, which are already taking us down this road. I believe we are not talking about an imposed polyclinic model mapped systematically onto populations of 50,000 but we are already moving steadily to the situation where larger numbers of clinicians work together with advanced diagnostic facilities to provide more care at local level. We must now understand that significant and not just incremental change is required to bring into being the excellent services that we all wish London to have. Competing interests: Chaired clinical working group for planned care for the report 'A Framework for Action' |
|||