IOM DHSC & MANX CARE

[2112]

50 minutes ago, Boo Gay'n said:

The phrase 'what goes around, comes around' pops into my mind!
https://www.manxradio.com/news/isle-of-man-news/callister-prescription-charges-need-complete-review/

Is the cycle to say every five years that "something must be done"?
https://www.bbc.com/news/world-europe-isle-of-man-41348242

I reckon that increased prescription charges are already planned, or decided as going ahead. The notion that it is under review I would say is somewhat misleading. I would also predict that as well as a significant increase in charges, the criteria of those exemptions from charges will be eliminated and people encouraged to buy prepaid certificates. The idea of the DHSC and Rob Callister it’s ‘Leader’ conducting a review, doesn’t bear thinking. Rob Callister, Minister of the Department will do as he is told. The outcome has probably been decided.

[Jarndyce]

38 minutes ago, Apple said:

 I bet DA would love to have another crack at DHSC Minister to finish what he started.

You intrigue me - did he start anything specific while in the DHSC?

[Moghrey Mie]

4 hours ago, Boo Gay'n said:

Am I being unfair if I say 'working to try and tackle' but not succeeding?

https://www.manxradio.com/news/isle-of-man-news/gastroenterology-service-experiencing-real-challenges-says-cope/

How many should there be for a population of 85,000?

[Boo Gay'n]

24 minutes ago, Moghrey Mie said:

How many should there be for a population of 85,000?

Slightly old data here, but -

The number of gastroenterologists per 100,000 of the population was 3.9 in the United States, 3.48 in France, 2.1 in Australia, 1.83 in Canada, and 1.41 in the U.K.

That would mean that we are not too out of whack with the UK really - maybe just a very ineffecient service?

[Banker]

3 hours ago, 2112 said:

I reckon that increased prescription charges are already planned, or decided as going ahead. The notion that it is under review I would say is somewhat misleading. I would also predict that as well as a significant increase in charges, the criteria of those exemptions from charges will be eliminated and people encouraged to buy prepaid certificates. The idea of the DHSC and Rob Callister it’s ‘Leader’ conducting a review, doesn’t bear thinking. Rob Callister, Minister of the Department will do as he is told. The outcome has probably been decided.

They need to scrap the free prescriptions for lots like all pensioners & make them means tested eg under £25k income  free .

[cissolt]

Legalise cannabis and use the tax to pay for health services, but apparently we can't do that because we forgot to ask the home office for permission.

[wrighty]

2 hours ago, Boo Gay'n said:

Slightly old data here, but -

The number of gastroenterologists per 100,000 of the population was 3.9 in the United States, 3.48 in France, 2.1 in Australia, 1.83 in Canada, and 1.41 in the U.K.

That would mean that we are not too out of whack with the UK really - maybe just a very ineffecient service?

I don’t know how you conclude that having one gastroenterologist, a lower per capita figure than the adjacent isle (who are bottom of the league themselves), represents an inefficient service.

I used to be Clinical Director for the gastro service (during one of the previous structural reorganisations) and it was fairly clear back then we needed two consultants. I don’t think much has changed, and we still have a service that is doing its best with demand for service outstripping supply. Recruitment in this specialty has proven very difficult. 

[Boris Johnson]

1 hour ago, wrighty said:

I don’t know how you conclude that having one gastroenterologist, a lower per capita figure than the adjacent isle (who are bottom of the league themselves), represents an inefficient service.

I used to be Clinical Director for the gastro service (during one of the previous structural reorganisations) and it was fairly clear back then we needed two consultants. I don’t think much has changed, and we still have a service that is doing its best with demand for service outstripping supply. Recruitment in this specialty has proven very difficult. 

 

I don't have a problem with having a higher per capita figure for anything like this.

We are an island, one guy is never enough in a 24/7 specialism like health. (This is also true of many things on the island I know.)

It's only lawyers that we have far too many,  mostly practicing at a very low standard.

You could argue even 3 gastroenterologists were not enough, but at least 2 would make the service much safer.

When you were involved we did not have post Brexit/ Covid recruitment problems, what was the reason then we could not get more specialists back then?

Edited October 24, 2022 by Boris Johnson

[wrighty]

55 minutes ago, Boris Johnson said:

 

When you were involved we did not have post Brexit/ Covid recruitment problems, what was the reason then we could not get more specialists back then?

Recruitment issues go back much further than Brexit/Covid, although they’ve not helped. 
 

From memory (and I was directly involved only from 2019), the previous gastroenterologist was appointed to replace a consultant who had a part time interest. This was about 2007. From the outset he argued that he needed a colleague, and came up with business cases, and argued for further appointments, but these were not supported. About 10 years later it was accepted that having two might be helpful, and a second job was advertised. There was minimal interest and nobody appointed. We finally recruited into a fixed-term position in 2019 and then the permanent guy left. Leaving us where we are today. 
 

I haven’t had any involvement in that area since mid-2020, and covid took over everything from March that year anyway. My recollections may be inaccurate - I don’t keep the entire Noble’s HR record in my head. 

[Boo Gay'n]

2 hours ago, wrighty said:

I don’t know how you conclude that having one gastroenterologist, a lower per capita figure than the adjacent isle (who are bottom of the league themselves), represents an inefficient service.

I used to be Clinical Director for the gastro service (during one of the previous structural reorganisations) and it was fairly clear back then we needed two consultants. I don’t think much has changed, and we still have a service that is doing its best with demand for service outstripping supply. Recruitment in this specialty has proven very difficult. 

Thanks Ian

You are closer to this than I will ever be, of course.  But - efficiency and service redesign (continuous improvement, God forbid!) should not be anathema in health and care services.  Rather than trying to recruit another member of the elite club at £250k a year, can we not try to understand what is driving the increased load on gastroenterology?  I was at the infamous Ramsey public meeting about endoscopy and, IIRC, the manager of Noble's (or maybe even Saint Kate) said that the number of procedures was soaring.  Why was/is this?  Are people getting more bowel problems or are medics booking more endoscopies for people, or something else?  If we understood that variable, we could possibly work to reduce the load without further tooling up the hospital.  Just some thoughts.  I might be talking out of my ****, cue the need for the bottom telescope.

[Jarndyce]

5 hours ago, wrighty said:

My recollections may be inaccurate

No: your recollection is right on the money.   Or at least it matches my own.

[Newbie]

16 hours ago, Boo Gay'n said:

Thanks Ian

You are closer to this than I will ever be, of course.  But - efficiency and service redesign (continuous improvement, God forbid!) should not be anathema in health and care services.  Rather than trying to recruit another member of the elite club at £250k a year, can we not try to understand what is driving the increased load on gastroenterology?  I was at the infamous Ramsey public meeting about endoscopy and, IIRC, the manager of Noble's (or maybe even Saint Kate) said that the number of procedures was soaring.  Why was/is this?  Are people getting more bowel problems or are medics booking more endoscopies for people, or something else?  If we understood that variable, we could possibly work to reduce the load without further tooling up the hospital.  Just some thoughts.  I might be talking out of my ****, cue the need for the bottom telescope.

I should imagine that bowel cancer screening (introduced in 2011 iirc) has had a significant effect on the number of endoscopies. There are all sorts of things apart from bowel cancer that can produce a positive bowel cancer screening test, but they will nearly all need an endoscopy to either exclude or confirm cancer.

Changes in the way that symptomatic problems are investigated have also had a big effect on endoscopy numbers. Both upper and lower gastrointestinal symptoms were historically often investigated by GPs referring for barium xrays, but endoscopy is a much better investigation, so now all of the people who have symptoms get referred for that

Edited October 25, 2022 by Newbie

[wrighty]

16 minutes ago, Newbie said:

I should imagine that bowel cancer screening (introduced in 2011 iirc) has had a significant effect on the number of endoscopies. There are all sorts of things apart from bowel cancer that can produce a positive bowel cancer screening test, but they will nearly all need an endoscopy to either exclude or confirm cancer.

Changes in the way that symptomatic problems are investigated have also had a big effect on endoscopy numbers. Both upper and lower gastrointestinal symptoms were historically often investigated by GPs referring for barium xrays, but endoscopy is a much better investigation, so now all of the people who have symptoms get referred for that

And to add to that, endoscopy will also often find bits of inflammation, polyps etc that then needs follow-up by a gastroenterologist.  Not to mention the explosion in (sometimes dubious) diagnoses of food allergies, gluten intolerance, IBS etc which GPs will refer on to 'a specialist'.

[Newbie]

10 minutes ago, wrighty said:

And to add to that, endoscopy will also often find bits of inflammation, polyps etc that then needs follow-up by a gastroenterologist.  Not to mention the explosion in (sometimes dubious) diagnoses of food allergies, gluten intolerance, IBS etc which GPs will refer on to 'a specialist'.

I would largely agree with that, although it is easy to blame GPs for inappropriate referrals. Over the years the recommended way of investigating GI symptoms has changed (endoscopy rather than Barium xrays being an example). The problem for GPs is that they do not now generally have direct access to the recommended investigations so have little choice but to refer on. If a referral is genuinely inappropriate, then it shouldn't result in further investigations. The patient should be referred back to the GP. What actually tends to happen is that the 'specialist' moans about inappropriate referrals and then investigates them anyway. It is a bit rich to moan about dubious/inappropriate referrals whilst at the same time ordering inappropriate investigations.

The problem is that the general public expect a Gold Standard service, and at the same time clinicians are trying to avoid getting sued. The service however, is (at best) resourced for a Bronze Standard service, and is therefore coming apart at the seams. Resourcing isn't just about annual budgets either. It is much deeper than that including number of doctors and nurses being trained, specialist training programmes etc. etc. If you were to set about solving it now, it would probably take 15 years to see the results. The short term view taken by politicians, and the fact that the public don't vote for political parties (in the UK anyway) that want to raise taxes, means that they all try to solve the problem with 'efficiency savings' which doesn't work. It's way beyond that.

[Boo Gay'n]

1 hour ago, Newbie said:

I would largely agree with that, although it is easy to blame GPs for inappropriate referrals. Over the years the recommended way of investigating GI symptoms has changed (endoscopy rather than Barium xrays being an example). The problem for GPs is that they do not now generally have direct access to the recommended investigations so have little choice but to refer on. If a referral is genuinely inappropriate, then it shouldn't result in further investigations. The patient should be referred back to the GP. What actually tends to happen is that the 'specialist' moans about inappropriate referrals and then investigates them anyway. It is a bit rich to moan about dubious/inappropriate referrals whilst at the same time ordering inappropriate investigations.

The problem is that the general public expect a Gold Standard service, and at the same time clinicians are trying to avoid getting sued. The service however, is (at best) resourced for a Bronze Standard service, and is therefore coming apart at the seams. Resourcing isn't just about annual budgets either. It is much deeper than that including number of doctors and nurses being trained, specialist training programmes etc. etc. If you were to set about solving it now, it would probably take 15 years to see the results. The short term view taken by politicians, and the fact that the public don't vote for political parties (in the UK anyway) that want to raise taxes, means that they all try to solve the problem with 'efficiency savings' which doesn't work. It's way beyond that.

Excellent post, thank you.

Re my highlight, surely this is what people want to hear?  I would vote for vision, investment and a long-term plan: but we are getting squillions pissed against the wall by our politicians to reduce waiting lists etc.  That is reactive and not strategic.

Politicians can be honest too about the reality of a bronze standard service, because it is still probably good enough.