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Medicine Interview Preparation

Table of Contents

4 Pillars of Medicine Ethics 1

Hot Topics 3

BAME (Black, Asian and minority ethnic) Staff Patients: 3

State of the NHS 4

Accident and Emergency Waiting Times 6

GP Services and Primary Care 7

Organ Donation 8

Abortion 9

Euthanasia and Assisted Dying 11

Ageing Population 13

Vaccinations 14

AI in medicine 16

The Francis Reports 17

Bawa-Garba Case 18

Shropshire Maternity Scandal 19

Antibiotic Resistance 20

Mental Health and the NHS 21

Public Health 22

Charlie Gard Case 24

HIV and PrEP 26

Brexit and The NHS 27

Junior Doctor Contracts 28

Medicinal Cannabis 29

Medical Licensing Assessment 30

4 Pillars of Medicine Ethics

1. Beneficence – doing whats in the best interest of the patient. Does it resolve the patient's medical problem? Is it proportionate to the scale of the medical problem? Is it compatible with the patients living circumstances? Is this option and its outcomes in line with the patient’s expectation of treatment?

Abortions – how does beneficence factor here?

Charlie Gard – MDDS only 16 people have this disease, he was on life support and the treatment offered had a 10% chance of working. His parents appealed to keep him on life support so they could take him to the US for treatment. It was denied by the Supreme Court as it was seen as additional and prolonged suffering. His life support was turned off at 11 months old.

1. Non-Maleficence – do no harm. If a treatment does more harm than good, it should not be considered.  In contrast, non-maleficence is a constant in clinical practice. For example, if you see a patient collapse in a corridor you have a duty to provide (or seek) medical attention to prevent injury.

2. Autonomy – a patient has the ultimate decision-making responsibility for their own treatment. A medical practitioner cannot impose treatment on a patient.

Charlie Gard – he was too young to make any decisions, parents made decisions on his behalf, were they prioritising whats best for him?

1. Justice – weighing up if something is ethical or not and if its compatible with the law, patient rights and if its fair / balanced. It ensures that no one is unfairly disadvantaged when it comes to access healthcare. Justice is one reason why the NHS has certain entitlements, such as free prescriptions for lower income individuals. It could be argued that prioritising cancer patients limited the ability of other patients to access healthcare however by seeing the cancer patients and referring them to oncology departments and centres it can be argued that spaces are freed up. Could also be argues that spending lots of money on chemotherapy to treat a small number of people takes away from others healthcare and cheaper healthcare, such as increase in statins for those at risk of CHD.

Example Ethical Dilemma

Imagine that a patient has appendicitis, and the surgeons believe that surgery is necessary. Technically, making an incision into the patient’s skin is causing “harm” to the patient; however, this is done with good intent as removing the inflamed appendix eliminates the risk of progression to rupture and peritonitis.

Surgery would be offered to the patient based on their clinical need and they will have the right to make an informed decision. The four principles would, therefore, support performing this surgery.

Medical Ethics Concept – Consequentialism

Ideology that states that the morals, of an action is dependant purely on its consequences. If your action has overall benefit, then it doesn’t matter about the action itself. “Ends justify the means”.

Example:

Your patient has a terminal illness and is not likely to survive the operation she is about to undertake. Just as she is about to be anaesthetised, she asks you: “Doctor, will I be okay?” A consequentialist ideology supports that lying in this circumstance is acceptable, even though lying itself is not a moral action.

Medical Ethics Concept – Utilitarianism

The best action is that one that brings about the best increase in utility (benefit). The ideas that the best choice is made for the most amount of people. Utility is generally considered on a broad scale, often taking into consideration wider society and not just the patient in question. It’s a form of consequentialism.

Example:

You have a sum of money to either fund a very expensive treatment for one patient with a rare disease or five patients with a very common and easy-to-treat disease. Utilitarian ethics dictates that treating the five patients is morally superior as a greater overall benefit is achieved.

Medical Ethics Concepts – Deontology

‘Duty Based Ethics.’  This ideology states that the correct course of action is dependent on what your duties and obligations are. It means that the morality of an action is based on whether you followed the rules, rather than what the consequence of following them was.

Example:

If your terminally ill patient asks if they’ll be ok after a surgery, they’re unlikely to survive, a deontological approach would suggest you don’t lie to comfort them. That’s because according to this concept, lying isn’t morally acceptable because it’s our obligation not to lie – no matter the consequences.

Hot Topics

BAME (Black, Asian and minority ethnic) Staff Patients:

• Unequal representation amongst board members 19.7% of the workforce is made up from BAME groups but just 8.4% of board members are from BAME background.

• Recruitment problems – lack of diverse representation at senior level produces barriers for BAME staff, particularly during the recruitment process. Which applicants are 1.46x likely to be appointed from shortlisting opposed to BAME applicants.

• BAME Staff are 1.22x likelier than their white colleagues to enter a formal disciplinary process. The GMC’s report found doctors from diverse groups didn’t always receive effective, timely or honest feedback.

• BAME staff are 2x as likely to experience discrimination (2019-2020).

• The NHS People Plan has action points to increase BAME representation across the workforce, including at senior level – this should make the NHS more reflective of the patient population that it serves. Structural racism and unconscious biases still need to be addressed in order for equality to be truly achieved.

• NHS is striving ti engage further with staff and staff networks so BAME staff can be heard and share their lived experiences.

BAME Patients:

• During childbirth black women are 5x more likely to die than a white woman. Women of mixed ethnicity are also 3x more likely to die and asian women 2x as likely.

• COVID19 also disproportionately affected the BAME community, 95% of doctors that died were from BAME community. This can be explained by health conditions, age and socio-demographic factors.

• Formal disciplinary processes are more common amongst BAME groups in comparison to their white counterparts, which could be a reason behind fear of raising COVID-19 related concerns or asking for safer alternatives.

• NHS now considering offering rehabilitation and recovering for BAME colleagues in addition to various existing sources.

State of the NHS

Ambulances

Ambulances have different categories for the severity of a call / patient – it can be sorted into 1 of the 4 categories: (90% of ambulances should arrive in…)

1. Immediate response to life threatening condition (15mins, average - 7) – cardiac arrest

2. A serious condition (40mins, average - 18) – stroke or chest pain

3. An urgent problem (2hours) – uncomplicated diabetic issue

4. A non-urgent problem (4hours) – transportation to a hospital ward

April/May 2022 – average wait time for category 2 = 40 minutes, over 2x the aim for average time.

Category 3 – average is 2h 9minutes, only 50% arrive by then (not reaching the aim of 90%).

This extended waiting time is caused by an increase in calls (up 20% from 2021 April), Post-2010 cuts to community services have resulted in greater pressure on the emergency services as people previously treated in the community are entering the health system later and therefore with more acute issues. Shortage of paramedics, 1000 paramedics left in 2018 for a better work-life balance. A&E waiting times have increases – emergency departments have become overcrowded, and this slows down ambulance crews as they have to wait with their patient until space in the department becomes available.

Backlog

The backlog of the NHS effects the ambulance services.

The decision to suspend much elective treatment during the COVID19 pandemic meant that the number of people on the waiting ist fell slightly. However as of September 2020 there was a steep climb in the number of people on NHS waiting lists.

Consultant Led Elective Care

May 2022, 7 million people on waiting lists for consultant led elective care. This is more than double than in May 2015.

2.75 million people are waiting more than 18 weeks for treatment.

Almost 390,000 people are waiting more than a year for treatment, this is 375x the figure for pre-pandemic in July 2019.

BMA is also converted about the ‘hidden backlog.’ This refers to people who in normal times would have presented themselves for treatment but chose not to or had referrals cancelled. Less people presenting themselves means more acute cases which has an effect on emergency services.

Cancer waiting times

August 2022, the aim of 90% of patients being referred from a GP to a consultant is 2 weeks and 90% of patients should be received g treatment following a GP referral, was not met. It was 75% of cancer patients being reffed to a consultant within target time and 62% starting treatment.

Care

A recent Skills for care study found that the number of available posits in the care sector increased un 2021/2022, while the number of applications for those roles decreased by 3%, leading to 165,000 posts going vacant (10.7% of all available posts).

Causes of Care Staff Shortage

2019,2020,2021 the rise in pat for the average care worker did not increase relative to the national living wage. The government provided pay rises for carers in 2021/2022 but still did not match the rate of inflation. The average wage for carers in 2022 (hourly) was less than that of retail assistants. The relatively low salaries explains why it's hard to retain and attract staff so it's difficult to fill posts.

Brexit

Brexit has an impact on immigrant regulations. In January 2021, it because impossible for someone in the EU to gain work in the UK in the care sector. This lead to rise in vacancies in the sector which had previously relied on EU workers to provide labour. From February 2022, care workers were added onto a shortage occupation list. This means that, as long as the role pays more than £20,480 per year, care workers can be recruited from the EU. Combined with a boost to international recruitment more generally, there is an increasing trend of care workers coming to the UK to find work.

Universities

There’s been a raise in the number of Medical School students in the last few years, and also progress towards the governments 2019 plan to recruit more than 50,000 by 2024/2025.

A June 2022 analysis by the Health Foundation found that there is a current shortage of 4,200 fully qualified GPs in England. This is projected to increase to 8,800 by 2030. This shortage has meant difficulties in patients seeing their GP in a timely manner and has therefore likely had an impact on the number of patients presenting to emergency wards.

Accident and Emergency Waiting Times

Rising A&E attendances

17% rise from 2010-2011, its assumed that COVID19 exacerbated this as well as an ageing population and rise in more acute cases.

Fewer Hospital Beds

‘Exit block’ occurs when theres a delay in admitting patients to the ward from A&E due to a lack of beds. The problem if exit blocking leads to delays in diagnosis and treatment, which can in turn cause harm to patients. The total number of NHS hospital beds in England has more than halved over the past 30 years, from around 299,000 in 1987/88 to 141,000 in 2019/20, while the number of patients treated has increased significantly.

Unnecessary A&E Attendances

Excess amount of people attending As they don’t know where to go for treatment or cant get an appointment with the GP.

Delayed Discharge

It can be difficult to discharge patients from hospital as they may need additional home support or a place in a nursing home. A patient who no longer has a medical condition requiring hospital treatment but who cannot be discharged from hospital is described as a delayed discharge or “bed blocking”, which in turn may cause a backlog to A&E due to bed shortages.

Staff shortages

Staffing issues caused by increase in workload for the remaining workers, a greater number of sick days and loss of workers sue to transfers, resignations and the burnout rate increasing for remaining staff.

Four Hour Target

Some other measures are also used alongside the four hour target to gauge the quality of service provided in A&E such as:

The number of re-attendances within 7days of their first attendance.

The waiting time to see a clinician.

The Care Quality Commission (CQC) rating of core hospital services.

Patient satisfaction surveys, such as the 2018 national survey of patients who have used urgent and emergency care.

Other Solutions

The creation of new emergency areas by assembling GPs, A&E staff, urgent care teams and pharmacists. Would help reduce the burden on hospitals and allow for patients to have greater access to healthcare system.

GP Services and Primary Care

Issues

• GP shortages – 15.3% of spots were vacant in 2018.

• Increasing demand – life expectancies rise and population expands.

• Recruitment Issues – in 2019 the aim was to hire 5000 new GP’s by 2020, this target was not met and just over 3,500 were hired.

• Practices are closing – 2019 99 GP practices were closed, that effected 350,000 people. In the past 5 years, 1.3 million patients have had to change their GP because of practice closures. Research suggests 40% of GPs are planning on leaving the profession by 2023.

• Unsafe patient levels – 1/10 GPs are seeing over 60 patients a day, double the number considered safe and some GPs work up to 11 hours a dat with patient consultations taking up 8 hours of that time.

• Long waiting times – 1/3 patients have to wait over a week for a GP appointment.

• Unnecessary appointments waste time – the average member of the public sees the GP 6 times a year. Some of these don’t require a Gp and could be sorted by other medical professions.

• Low public satisfaction – 2019 study reveals that public satisfaction is lower than it has ever been before.

Solutions

• Medical Schools are trying to correct misconceptions about GPs and encouraging more students to think about the role.

• The NHS has a £10million scheme to incentive Foundation Year doctors to become GP’s.

• As of 2017, there is a scheme where new qualified GP’s can receive a one off £20,000 payment in certain areas that need more GPs. Since then, the harder to recruit jobs have doubles in hire rate.

• Online consultations help reduce pressure on GP’s.

• Funding for 20,000 more staff including pharmacists, paramedics and physiotherapist to help GP practices work together as a local primary care network.

Organ Donation

Organ donation is the act of giving an organ to someone who’s in need of a transplant. People are able to donate organs such as a kidney whilst they are alive, but most organ donations come from people who have died.

Challenges

• The demand for organs is larger than the supply – 7,000 people waiting on the UK transplant list and 470 patients died in 2020/2021 before they could receive a transplant.

• Only a small number of deaths can allow for organ donation (such as brain injury) as those from circulator deaths where the organs are deprived of O2 cant be used.

• The BAME community typically experience longer waiting times for organ transplants, as theres less BAME donors than white donors. In 2020 40% of BAME families agrees to support organ donation whereas 69% of white families agreed. This was due to many BAME families having different religious believes or not having discussed donation with relatives.

Opt-In System

• Doctors can only use a person’s organs after death if that person signed up to an organ donation register during there life.

• Many potential donors either don’t register or are unaware of the system.

• England pre-opt out system (2019) – research showed 80% of people supported organ donation but only 38% had opted in.

Opt-Out System

• With an opt-out system if that person has not registered a decision to become an organ donor they are considered to have no objection to being an organ donor after death.

• This is known as presumed consent.

• Those who oppose an opt-out system argue that deemed/presumed consent is less valid, because people could be unaware that they are automatically signed up to donate their organs.

• An opt-out system was adopted by England, Scotland and Wales in order to increase the number of possible donors. It’s expected only those with strong views about organ donation will opt-out.

• Wales has the highest consent rate after switching to an opt-out system (77%)

• In spring 2020, England also adopted a soft opt-out system, in which people over the age of 18 are automatically added to the Organ Donor Register and must actively withdraw if they want to opt out of it. Families are still consulted before any organ donation goes ahead.

Abortion

Abortion is defined as the medical process of ending a human precinct so it doesn’t culminate in the birth of a baby. A pregnancy can be terminated through surgical procedures or through medication.

• 1967 Abortion Act – Abortion is legal in England, Wales and Scotland up to 24 weeks. After this 24 week period there are 4 other main reasons why the pregnancy would be terminated. An abortion can only be legally carried out if 2 doctors agree that continuation of the woman’s pregnancy will negatively impact her physical or mental health or that of exiting children or family.

An abortion after 24 weeks is legal if the woman’s life is at risk due to the pregnancy, the child will be born with a severe disability or theres a risk of physical or mental injury to the woman.

Surgical Abortion

• Before 14 weeks 0 vacuum or suction aspiration can be used.

• After 14 weeks, dilation and evacuation can be used.

Medical Abortion

• Before 10 weeks – mifepristone is taken which inhibits progesterone and this must be taken at the clinic. 24-48 hours after the second pill misoprostol is taken either at home or in the clinic. This induces contractions in the womb to pass the pregnancy.

Medical Abortion at Home

• In August 2018, women in England were allowed to take the 2^nd pill at home to prevent miscarrying on the way home which was a common, painful and traumatic experience.

• This has been well received by gynaecologists as it proves the distress and embarrassment of pain and bleeding on their journey home from taking their 2^nd pill.

• Others argue that this pushed women to experience the trauma of miscarriage without medical supervision.

Legal Debate

• Centred around when life begins. Some believe abortion at any point of the pregnancy is murder whilst others argue that abortion is acceptable at any point during the pregnancy as the child’s unborn, therefore not considered alive.

Abortion in Northern Island

• Until October2019 abortion was illegal in Northern Ireland, unless the woman’s life was at risk or would cause serious physical or mental effects to the woman.

• Abortion was not legal for rape, incest or fatal foetal anomalies.

• In May 2018 66.4% of voters voted for abortion to be legal so was decriminalise in October 2019.

Ethics – Pro-Life

• Human life begins the point of contraception, therefore abortion is tantamount to murders as its the destruction of human life.

• Instead of carrying out an abortion and taking an innocent human life, the Chile can be adopted if the parents aren’t able to look after them.

• Some woman may be pregnancy as a result of rape or incest. The unborn chid is innocent and shouldn’t be pushed for this crime through abortion.

• An abortion can cause mental and physical distress for the woman.

• All children have great potential and a woman couldn’t decisions to abort a foetus that may have been extremely important to the society or world.

• Aborting a foetus with a disability further alienates them – determines their value of life being less than a foetus or child without an abnormality.

Ethics – Pro-Choice

• Almost all abortions are carried out in the first three months of the pregnancy, at which time the foetus cannot exist independently outside of the mother’s womb. Therefore it cannot be regarded as a living organism, and abortion is arguably not murder.

• Fertilised eggs which are used for in vitro fertilisation (IVF) are often thrown away or destroyed if not implanted and some would argue that these fertilised eggs are human lives – but destroying them is not considered as murder.

• In the case of rape or incest, forcing a woman to have the child is likely to be more psychologically damaging to her than having an abortion.

• Keeping abortion legal will prevent deaths and complications from unsafe backstreet abortions that are carried out in secrecy.

• An abortion may be necessary to save the woman’s life in certain cases and thus this option should be taken where necessary, rather than risking the mother’s life.

Euthanasia and Assisted Dying

Euthanasia refers to ending a patients life who is suffering from an incurable and/or painful disease or is in an irreversible coma. It’s sometimes known as ‘mercy killing.’

Active euthanasia - When the acting person deliberately intervenes to end someone’s life. For example – a Doctor injecting a patient who has terminal cancer with an overdose of muscle relaxants.

Passive euthanasia - Where a person causes death by withholding or withdrawing treatment that is necessary to maintain life. For example – withholding antibiotics from someone who has bacterial pneumonia

Voluntary – euthanasia carried out at the request of the person who died.

Involuntary – when the patient who dies wants to live but is killed anyway (normally called manslaughter or murder).

Assisted suicide – the physician is he one who intentionally gives the patient the means to take lethal medication themselves.

Assisted dying – when a patient who is terminally ill or dying asks for help to die.

Euthanasia in The UK

• Both euthanasia and assisted suicide are illegal in the UK. Euthanasia is punishable by life in prison and assisted suicide, 14 years under the 1961 Suicide Act.

• 2015 – a bill was brought forward that aimed to let terminally I’ll patients in the last 6 months to be prescribed medicine to administer themselves. The House of Commons rejected the bill.

• 2018 – Legal permission no longer needed to withdraw treatment from patients in permanent vegetative state.

• 2019 – Paul Lamb, who lives with chorionic pain following a car crash, reneged a bid for the right to die after losing a Supreme Court Case in 2014.

• September 2019. 80-year-old Mavis Eccleston was cleared of murder and manslaughter after getting her husband the prescription medication he needed to overdose. Mr Eccleston was a cancer patient, and his wife Mavis was respecting his wishes, according to daughter Joy. Not wanting to live without her husband, Mavis also took an overdose and recovered in hospital after being found unconscious.

• September 2021. Members of the British Medical Association (BMA) voted to adopt a neutral stance on assisted dying, with 49% in favour, 48% opposed and 3% abstaining. Before this, the BMA had opposed assisting dying, so the new stance could potentially pave the way towards a future change in the law.

Euthanasia is currently legal in other countries such as parts of Australia, Netherlands, Canada and NZ.

Arguments for Euthanasia

• Autonomy – patients should be able to decide for themselves when to end their life at a point where medical treatment is no longer able to prolong their life or provide adequate symptom control.

• When assisted dying is illegal, there will be people who try to end their lives alone and may not be able to carry  it out properly, leading to increased suffering. Legalising assisted dying would prevent such deaths, similar to how legalising abortion prevented deaths from botched backstreet abortions (despite many people still objecting to abortion on moral or religious grounds).

• Some Doctors argue that the legislation would provide a clearer legal framework for end-of-life care. There is a concern that current decisions about end-of-life care can hinge on the doctrine of double effect, whereby it is legal to give a patient treatment that may shorten their life if the Doctor’s main goal is to relieve their pain.

• The current UK law, as it stands, means that patients who want to end their lives have to travel abroad to do so. In 2018, 43 people from the UK died at Dignitas and Life Circle (two facilities in Switzerland). It is likely not how they would have chosen to die (usually at home surrounded by loved ones) if the law allowed.

• No matter how excellent our palliative care services may be, there will always be some patients for whom their illness causes intolerable suffering. To help those patients end their lives would be the compassionate thing to do to end their suffering.

Arguments against euthanasia

• Many argue that the legislation would “turn Doctors into executioners”. This is at odds with the principle of non-maleficence which means do no harm. However, this principle could also be used to argue for the other side – that Doctors are causing more harm by prolonging suffering.

• Another concern is that the legislation could be used to justify assisted dying in vulnerable groups, such as those with disabilities and mental illnesses. The legislation sends out a message that, where a life falls short of certain conditions, it is not worth preserving.

• Although autonomy is a pillar of medical ethics, patients still do not have a right to demand treatment and Doctors can refuse treatments they believe not to be in the patient’s best interests. The drugs prescribed to end life could be seen as a ‘treatment’ like any other.

• It could be argued that the potential negative consequences of this legislation – the premature ending of lives – outweigh the small number of people this would benefit.

Ageing Population

There are currently 3.2 million people over the age of 80 living in the UK and this number is expected to reach 8 million by 2050. By this point, 25% of the UK population will be over 65.

Although longer life expectancy is a positive effect of good healthcare and is often seen in HICs (such as UK and Germany), an ageing population also increases the burden on healthcare systems.

Impact of an Ageing Population

• Increasing number of chromic conditions associated with ageing such as hearty disease, arthritis, type 2 diabetes and Alzheimer’s.

• As of 2021, 1 in 6 people over the age of 80 had dementia and 70% of people in care homes suffered from dementia or severe memory problems. The cost of support with daily activities, such as washing, dressing and cooking can be high and often needs to be partly funded by the patient. People with dementia typically spend £100,000 on their own care.

• Cuts in social care spending have led to an increase in A&E admissions among people aged 65 and over, placing increased demand on already under pressure services. Inadequate social care can leave elderly people vulnerable to infections, falls and dehydration, which would otherwise be avoidable. If an elderly person is admitted to A&E after a fall, it can sometimes take days or weeks for them to be discharged, which is described as bed blocking.’

Certain area sin the UK are more likely to be effected than others, such as coastal or rural areas.

Healthy Life Expectancy

• Average life expectancy for men is 79.9 years and 83.6 for women, however HLE is only 63.1 for men and 63.6 for women.

• HLE is an estimate of years that a person will live in very good or good health, therefore with people living longer it means more people are spending an increased amount of time in a state of not being in good or very good health.

• The government has an ambition to increase people’s HLE by five years by 2035. To achieve this, there needs to be increased public health education and support around alcohol and smoking, better nutrition, and improved physical health and fitness. This would reduce the risk factors that contribute to conditions such as heart disease and dementia. There also needs to be improved support for people living with disabilities and long-term conditions.

Vaccinations

They work by giving small amounts of weakened or dead pathogen. When a vaccine is given it stimulates a response form the immune system, so if that person is exposed to the same pathogen again, the body will recognise it by producing AB’s rapidly and reduces the chance of developing symptoms.

Vaccines are useful as they help make Herd Immunity. This is when enough people are immune to a particular infection through vaccination that those who aren’t or cant be vaccinated can be protected. They also help with Mass protection and prevent 2-3 million deaths per year.

Free NHS Vaccines

• Those 65+ can receive flu vaccines on the NHS and primary school children can receive the vaccine in form of a nasal spray.

• Most vaccines provide long-term immunity however flu vaccines are more short term and the virus can mutate meaning the strains in last years vaccines may not circulate in next years vaccines.

COVID19 Vaccine

• The first person to get Pfizer / BioNTech COVID19 vaccine in the UK received it on Dec8th. By December 31^st 2020 it was expected that 4 million others would also receive this vaccine but less than 800,000 were given the vaccine.

• Both vaccines are designed to be given as 2 injections, 21 days apart, but the government instead decided to give the 1^st dose to as many people as possible then use a booster 12 weeks after.

• A booster program started in September 2021, offering booster jabs to people who had their 2^nd dose over 6 months ago.

Anti-Vaccination Groups

• These groups claim that vaccines are unnatural and toxic. This dates back to the 1880’s about the smallpox vaccine.

• Anti vaccination social media posts had an increase of 7.7 million followers from the UK and US during the pandemic. Investigations discovered than hundreds of NHS staff followed these pages that compared COVID19 vaccines to poison.

Wakefield and the MMR Scandal

• 1998 a controversial paper linking the MMR vaccine to autism was published by Andrew Wakefield and 12 others. The paper go widespread despite the fact the sample size was small. It later emerged that the team behind the paper engages in ethical misconduct.

• The papers claims have been proved false but this still led to a drop in the MMR vaccine uptake.

Measles Increase

• In 2017 the WHO declared the UK as measles free but in 2019, the UK lost this status. It’s thought this could be traced back to 1998 and 2004 where there was a fall in MMR vaccines and this age group (now in university is where the highest reports of measles is coming from.)

Why are vaccinations falling?

• 2/5 Parents have been exposed to negative messages about vaccines online.

• Also  it’s been generations since the mumps and measles were endemic in the UK, perhaps many parents have forgotten how serious the illness was and therefore do not feel an urgency to vaccinate their child.

• Timing and availability of appointments for vaccinations.

How does the NHS plan to tackle this?

• The long term plan includes various measures that will be used to increase the uptake of both MMR doses.

• This includes improving local coordination and support to improve immunisation conversation in low uptake areas.

• Addition of an MMR check for children aged 10 and 11 with GPs, and trying to ‘catch up’ young adults who missed the MMR vaccinations as children.

AI in medicine

AI systems are being designed to accurately diagnose diseases from medical scans and microscope slides, such as cancers and use in IVF to determine how likely a pregnancy is to be successful. Virtual nursing could also be implemented.

Robotic Surgery

• Robots have been developed which are able to carry out routine operations. Recent research has shown that these surgeries can have up to a five-fold reduction in surgical complications. This, partnered with the decrease in staff required and time saved, could be a promising investment for the future.

• Many NHS hospitals now use robotic technology in certain operations (knee and hip replacements and postage cancer surgery).

Earlier Diagnosis

• A great deal of diagnosis is about recognising patterns. For example, radiologists will look at X-ray images to spot potential disease. However, if we spot subtler patterns earlier, perhaps the disease could be diagnosed at an earlier stage.

Data Collection

• The NHS is still very reliant on paper files and most of its IT systems are not based on open standards which limits the exchange of data

• If the NHS wants to use accurate AI algorithms, there needs to be an improvement in how data is collected and stored and in the quality of the data, as these algorithms are reliant on the data they are fed.and information across the NHS.

Pro’s vs Con’s

• The pubic is wary about how their data is used, especially the levels of personal information required. The NHS will need to improve its IT systems and collect the right type of data in the right format to harness the full potential of AI.

• AI could however support the improvement of the health and wellbeing hap by redacting which individuals or groups of individuals are at risk of illness and would allow the NHS to target treatment towards them.

The Francis Reports

Robert Francis QC is a Barrister specialising in medical law, including clinical negligence claims. With this expertise, he led a public inquiry into the poor care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. The investigation looked into why organisations responsible for regulating and managing the trust did not spot problems before they were brought to light by the campaign group ’Cure the NHS.’

Healthcare Commission Report

An estimate of 400-1,200 excess deaths caused between 2005-2008, with recurring problems being:

• Calls going unanswered

• Patients left lying in own urine or excrement

• Food and drinks left out of patients reach

• Patient falls being concealed from relatives

• Too few consultants and nurses

• Poor communication between staff and patients relatives

Findings of Francis Reports

• 1^st Francis Report (2010), stated that there was severe understaffing of nurses and the ratio of registered nurses:healthcare assistance dropped as low as 4:6 in some areas.

• 2^nd Francis Report (2013), looked at how the set-up of the health and social care system in England can help or hinder nurses and other staff to deliver good care. It focused on the culture of the NHS and its impact on the ability of staff to raise concerns.

The report made recommendations to eradicate the blame culture and bullying and help improve the recruitment, training and standards of registered nurses.

Responses

• GMC – in 2013 amendments were made to the education and safety in the practice environment and information sharing.

• Government – took action for improving patient care increasing openness and changes to regulations in hospitals in late 2013.

• NICE was asked by the Department of Health and NHS England to create guidelines on staffing capacity to ensure safety in the NHS.

Bawa-Garba Case

On 18th January 2011, six-year-old Jack Adcock had been feeling unwell – he was having difficulty breathing, as well as vomiting and diarrhoea. Jack had Down’s Syndrome and a known heart condition, and required long-term medication.

He was admitted to the Children’s Assessment Unit (CAU) at Leicester Royal Infirmary following his GP’s referral. Jack’s condition deteriorated that day and he passed away.

He was seen and assessed by Junior Doctor Hadiza Bawa-Garba, a paediatric registrar in year six of her speciality training (ST6). Generally, being an ST6 junior Doctor means being one or two years from sitting the final examinations to reach the level of a consultant.

Dr Bawa-Garba was taken to High Court and on 4th November 2015 was found guilty of manslaughter on the grounds of gross negligence.

Timeline of Events

• The X-ray results were available from 12.30pm but didn’t get seen until 2.5 hours late at 3pm. Antibiotics were then prescribed at 4pm. These 3.hours could have been vital in saving Jacks life.

• A blood test was taken showing high levels of CRP, however this was 5hours late due to failings in the computer system.

• Dr Bawa-Garba stopped Jacks heart medication but did not document this and his medicine was administered by his mother at 7pm, unaware of this change.

• Jack suffered a cardiac arrest at 8pm but Dr Bawa-Garba mistook him for another patients with a DNAR, resuscitation continues after this mistake was identified.

The Legal Battle

• Dr Bawa-Garba underwent a 12 month suspension and the GMC applied to have her permanently struck off the medical registers but this was deemed disproportionate.

• Crowdfunding in 2018 for Dr Bawa-Garba occurred meaning her legal battle continued and her 12 month suspension was reinstated as she won her appeal, rather than a permanent suspension.

• February 2020. Due to lack of patient contact since 2015, Dr Bawa-Garba has returned to work with a lower grade than previously employed at and must work with close supervision and several imposed conditions.

• July 2021. The Medical Practitioners Tribunal Service ruled that Dr Bawa-Garba is now fit to practise without restrictions.

Shropshire Maternity Scandal

In November 2019, a report from an interim inquiry into failings at the Royal Shrewsbury and Princess Royal Hospital in Telford was leaked to the press.

The inquiry was investigating the deaths and injuries of babies at the two hospitals dating from 1979 to present, with the majority of cases having occurred since the year 2000.

Midwife Donna Ockendon led the review, with more than 1,800 cases examined after families were invited to contact the inquiry. The review was expanded from an initial 23 families, and the Royal Shrewsbury and Princess Telford Hospitals were placed into special measures.

The pregnancy was meant to be flagged as high-risk and the mother, Rhiannon, should have never been on the unit in the first place. Compounding this, midwives failed to monitor their daughter Kate’s condition.

The family first secured an inquest into Kate’s death, and once this had been ruled avoidable, they challenged the NHS on how they investigated it. The resulting review found systemic failings of the former head of midwifery and midwives who altered notes retrospectively.

Findings of the Report

• An interim report examining 250 cases found that at least 42 babies and three mothers may have died avoidably. It also found that more than 50 newborns may have sustained avoidable brain damage.

• The review examined over 1,800 cases. Not all cases involved death or serious harm, but many involved significant errors.

• The report revealed that concerns over injuries to babies were highlighted in 2017 to regulators.

Malpractice was noted as bereaved families were not treated with kindness or respect, with instances of staff referring to babies as ‘it; and one baby’s body was left to decompose for weeks after a post-mortem.

The Trust was ordered to repay £1 million that was given by NHS Resolution for good maternity care. Two months after the payment in September 2018, maternity services were rated inadequate by the Care Quality Commission (CQC) and were placed in special measures. Weekly status reports were required from the hospital bosses due to the concerns.

In June 2020, West Mercia Police began a criminal investigation into the deaths of babies at Shrewsbury and Telford Trust, to see whether there was evidence to support a criminal case against either the Trust or individuals involved. The case is ongoing.

In August 2020, it emerged that new areas of concern had been identified at the Royal Shrewsbury and Telford’s Princess Royal Hospitals. The CQC Chief Inspector of Hospitals, Ted Baker, has said that failing leadership is perpetuating poor care. The trust was rated inadequate on every measure.

Antibiotic Resistance

Due to random mutations in their DNA, bacteria can develop resistance to antibiotics, reducing their effectiveness. The survival of bacteria in a patient’s body allows the resistant genes to be passed to the next generation, leading to a rapidly reproducing colony and infection.

According to a recent government-backed report, annual deaths due to multiple drug resistance could reach 10 million by 2050 if the inappropriate use of antibiotics continues.

• Drug resistance has become so widespread that it is now often customary for Doctors to prescribe multiple antibiotics to combat a single infection.

• The number of drug-resistance bloodstream infections increased by 35% from 2013 to 2017.

What causes AB resistance?

• Lack of education – 40% of patients believe AB’s.

• Virus mutations – livestock being dosed with AB’s so eating dairy and meat products contributes to multiple drug resistances.

• Not finishing a treatment with AB’s.

• Pressure for GP’s to prescribe AB’s (48% GP’s prescribed AB’s to remedy coughs and bronchitis but AB’s have no effect on the common cold.)

Solutions

• GPs have been encouraged to prescribe more sparingly.

• New guidance for medical professionals on prescribing antibiotics appropriately.

• A push to reduce infections that are contracted from surgery.

• Farmers are restricted in which antibiotics can be given to livestock.

• Clinical Commissioning Groups have reduced the number of antibiotic prescriptions and the use of broad-spectrum antibiotics.

• Public Health England has continued to push the education of infection-preventing public

• hygiene, such as hand-washing.

• They aim for a 15% drop in AB use by 2024 in humans and a father drop in AB use in cattle.

Push for new drugs

• One of these dugs, teixobactin was discovered to be effective against bacteria infections. However its still years away from being tested on humans and might not even be effective.

New therapies

• Combination therapy may work to help fight antibiotic-resistant bacteria by using two or more drugs together in order to increase the effectiveness of both drugs against bacteria that are resistant to normal antibiotics. Drugs working together in this way may even be effective against colistin-resistant bacteria.

A Boost to Research

• £32million was donated to research centres to enable earlier diagnosis and treatments with the appropriate antibiotic and dose.

In England the total AB consumption declined by 9% from 2014-2018

Mental Health and the NHS

Studies show that almost 1 in 3 people experience mental health issues at some stage in their life. In 2017 alone, 1.4 million people were referred to NHS mental health therapy services.

Impact of COVID19

• COVID19 exacerbated the growth in number of mental health issues, and wellbeing was significant lower compared to pre-pandemic.

Perinatal Mental Health

• 1 in 5 women experience perinatal mental health issues, most commonly depression and anxiety. In February 2018, the NHS pledged £23 million to improve perinatal mental health services. This helped 30,000 women receive specialist care from doctors, murdered, therapists, physiologists and psychiatrists.

Mental Health and Eating Disorders

• Its estimated £30 million goes into funding eating disorder services each year.

• In February 2019, NHS England announced that patients with diabulimia, in which patients with diabetes restrict their insulin intake to lose weight, will have access to therapy for social media and body image. This was part of a pilot scheme, fitting in with the NHS Long Term Plan to change mental health treatment with a focus on children and young people.

• Claire Murdoch (National Director for Mental Health) claimed that NHS England was on track to achieve their goal of treating 95% of all children and young people diagnosed with an eating disorder within one week for urgent cases and four weeks for routine cases by 2020/21. However, a report from the Nuffield Trust revealed that as of December 2020 the percentage of children and young people requiring urgent treatment receiving that treatment within one week had fallen to 70.5%

Access to Services

• Many patients struggle to get beds in a mental health hospital near their home. 6,000 patients were sent out of their local area (405 rise in 2 years).

• In April 2019, NHS England reported that new and expectant mothers would have access to healthcare across England following a rollout of specialist mental health services. This would be the first time that each of the 44 local NHS areas have specialist services.

NHS Staff and Mental Health

• £15 million was deemed to be put into mental health services for all medical staff, specifically nurses, therapists and paramedics.

• This was done through creating a national support service for critical care staff who are most vulnerable to severe trauma. Funding nationwide assessment services ensuring staff receive rapid access to mental health services. Developing wellbeing and physiological training.

Improving NHS Mental Health Services

• The Five Year Forward View for Mental Health, published in 2016, secured an additional £1 billion in funding for mental health. In 2019, the NHS Long Term Plan made a renewed commitment that mental health services will grow faster than the overall NHS budget, with a ring-fenced investment worth at least £2.3 billion a year for mental health services by 2023/24.

Public Health

In developed countries, most of the deaths are caused by NC diseases, particularly cardiovascular diseases (these cause over ¼ of the deaths in the UK). There’s evidence that smoking, alcohol and obesity increase the risk of developing NC diseases.

Wether a government implements a certain health policy depends on the benefits gained by preventing ill health or deaths against the human cost of infringing personal freedoms.

Public Health Measures – Sugar Tax

• Introduced in 2018. Drinks wit over 8g per 100ml have to pay 24p per litre of tax and drinks with 5-8g of sugar per 100ml have to pay 18p per litre.

• For aged to make £1.37 billion from 2020-2024, and the money has said to be put into sports and breakfast clubs.

• The sugar tax has been helpful in raising awareness and manufacturers have started to decrease the amount of sugar in their drinks. Over 50% of manufactures altered their recipe.

• A study show that purchase of the drinks has stayed the same, but the amount of sugar in the drinks fell by 10%.

• This has helped to combat childhood obesity – before sugar tax there was a 47% rise in children with T2 diabetes in the last 5 years.

Public Health Measure – Local Council Trials

• In 2017 a plan was published to reduce childhood obesity and reduce it significantly over the next 10 years.

• In 2019, 5 local councils were given £100,000 over the course of 3 years to help address childhood obesity and health inequalities.

• These 5 councils included Birmingham and Blackburn.

• These councils partnered with mosques to decrease the proportion of asian kids who were obese and restaurants to introduce healthier menus.

Public Health Measure – Opportunities to Exercise

• In 2019 it was made mandatory for primary school children to do 1 hour of sport / physical activity per day.

• £2.5 million went into PE teacher training to enable school to open facilities on weekends and holidays.

• £2 million was put in to create 400 new after school sports clubs in disadvantages areas.

. Public Health Measure – Fat Tax

• Obesity costs the government more than any other lifestyle factor.

• Fat tax was aimed to reduce consumption and encourage people to pick healthier foods.

• The cost of implementing the tax may be better spent on improving treatments that don’t infringe on society’s freedom.

• Price manipulation is seen as a form of control. Not only does it drive people to a certain decision, but it implies that people are not responsible for their actions.

• Denying autonomy may be a step backwards for a developed society such as the UK.

• It’s most likely to effect lower income families – this corresponds to the less socio-economic groups having higher obesity rate.

Public Health Measures – COVID19 Reaction

• A Better Health Campaign was announced the help people lose weight as nearly 8% of the critically ill patients were morbidly obese, compared to 2.9% of the population who is morbidly obese.

• Banning unhealthy food commercials past 9pm.

• Ending the ‘buy one get one free’ for foods high in fat and sugar.

• Increase in discounted healthier foods, especially in areas of lower income.

• Expansion of weight management services from the NHS so more people can get support when they need to lose weight.

Charlie Gard Case

Born 4^th August 2016, a month later he was diagnosed with MDDS. He was 1/16 known cases of RRM2B-related MDDS.

He suffered severe progressive muscle weakness meaning he couldn’t move his arms or legs and couldn’t open his eyes. It was impossible to tell if he was in pain or whether he was asleep or awake.

Treatment

• Nucleoside Bypass Therapy was the recommended route of treatment, however it was untested on animals and humans with RRM2B related MDDS and has been used on cases less advanced than Charlie’s.

• The patient must ingest compounds needed to develop new DNA strands which their body could not otherwise produce. There was no evidence to suggesting that the treatment would be able to cross the blood-brain barrier and resolve Charlie’s brain damage.

Legal Battle

• Charlie’s parents accepted Dr Hirano’s offer of experimental treatment and raised the £1.3M travel and treatment costs through crowd-funding campaigns. They believed, as did their supporters, that it was their parental right and responsibility to give their child any and all life-saving treatment they could. They made an appeal to stop his life support being switched off, so they could take Charlie to the US. The appeal was denied when it was taken to the Supreme Court, and their appeals were further denied at the European Court of Human Rights.

• It was concluded that Charlie was probably being exposed to continued pain, suffering and distress, with no proven form of treatment to help.

Alfie Evans Case Study

Alfie suffered from a degenerative neurological condition and was admitted to hospital in 2016 after suffering seizures. His parents wanted to fly Alfie to Rome for further treatment, but Alder Hey Children’s Hospital described the decision as ‘futile, unkind and inhumane.’

At 23 months old, the court ruled for his life support to be removed.

Impact on the NHS and UK Law

The Royal College of Paediatrics and Child Health (RCPCH) believes that such cases are “traumatic and distressing”, and this could lead to difficulties in recruitment and retention of vital NHS staff.

Charlie Gard’s parents are advocating for a change in the law in order to prevent other parents from going through a similar court case. They want judges to ask whether the parents’ choice of treatment would cause significant harm, and if not, they should be allowed to test their options.

Ethical Dilemmas

• Autonomy – a competent patient may refuse it. In Guards case, his agents acted on behalf of him due to his age.

• Distributive Justice – The National Institute for Health and Care Excellence (NICE) recommends treatment at £30,000 or less per Quality-Adjusted Life Year (QALY). NBT was fairly inexpensive but the cost of ongoing intensive care was estimated at £150,000. Overall the Quality Adjusted Life Years would have been 1.5 and the overall treatment cost was over 3x this recommended limit.

• Treatment may not be best for the patient – the success rate of the NBT was low and the amount of trauma Charlie would experience was too high in relation to the success rate. Also the success in the procedure did not guarantee a success in the QOL of Charlie.

HIV and PrEP

PrEP (pre-exposure prophylaxis) is a drug taken by HIV-negative people before sexual contact, usually with an HIV-positive personPrEP is not needed if an HIV-negative person has sexual contact with an HIV-positive partner, providing they are taking HIV medication and have an undetectable viral load. If viral load is undetectable, HIV cannot be transmitted.

• It can be taken as 1 tablet per day regularly or 2 tablets can be taken 2-24 hours before having sex, followed by 2 other tablets 24 and 48 hours after sex.

When taken correctly and daily its over 99% effective at stoping HIV. This reduces to 96% for those who take four tablets a week, and 76% for those who take two tablets a week. PrEP should be taken by an HIV-negative person who has an HIV-positive partner with a detectable viral load and sex without a condom is anticipated.

Is PrEP widely available?

• Sexual health clinics in Scotland and Wales provide the pills to anyone at risk of HIV for free.

• In England, PrEP was initially made available to 10,000 people as part of a 2 year trial. This trial ended in July 2020 and the drug was rolled out to England officially that year.

Advantages

• PrEP is effective at helping HIV-negative people to maintain their HIV-negative status, especially those who have an HIV-positive partner or have multiple partners whose HIV status is unknown.

• It has no side effects for the vast majority of people.

• It’s widely available in England, Scotland and Wales.

• Allows people to have sex without using condoms without the risk of getting infected with HIV when one person is HIV-positive.

Disadvantages

• It can have serious side effects on kidney function and bone health, making it unsuitable for some people who have existing bone or kidney conditions.

• Regular bone and kidney tests are needed for people who take PrEP regularly.

• Real world adherence isn’t perfect – it wont be as effective as stated.

• It may lead to a greater rate of other sexually transmitted infections (STIs) due to misconceptions that it protects against STIs as well as HIV.

• It may promote drug-resistant HIV if people take PrEP without knowing they are HIV-positive or become HIV-positive when they are on a break from taking PrEP.

Brexit and The NHS

The UK officially left the EU on 31st January 2020, with a transition period until 31st December 2020. Brexit negotiations were agreed on 24th December 2020, with effects on healthcare and scientific research unfolding as the transition period concluded.

One of the ways that the Leave campaign swayed the public’s opinion was by claiming (incorrectly) that leaving the EU would free up £350m per week to be spent on the NHS. The cross-party campaign couldn’t dictate how any funds were to be spent, nor had they quoted an accurate figure. Nevertheless, some people voted to leave because they took the claim at face value.

In 2018, the government promised a £20 billion increase to the NHS budget per year for the next five years, starting in 2019/20. They said it would be partly paid for through the ‘Brexit dividend’. However, there is no guaranteed extra money from leaving the EU, as it is expected that costs associated with leaving will outweigh those that are being saved.

In 2019, the Conservative manifesto stated an increase in the NHS budget by £33.9 billion by 2023/24 and an immediate injection of £6.2 billion. Stricter immigration laws, such as the new ‘settled status’ for EU citizens, may slow the UK’s population growth, and Leave campaigners in the referendum argued that the fewer people who are eligible to access NHS services, the greater the government spend per capita.

Staffing Crisis

• Harsher immigration laws were implemented.

• Value of the sterling and UK salaries decreased.

• 5,000 nurses and midwives from EU countries left the NHS from 2017-2019, with many identifying Brexit as the reason.

• In 2017 – there was a shortage of over 40,000 nurses.

• Now the NHS is quite dependant on international nurses.

Stockpiling Medicines

• In anticipation of Brexit negotiation deals, the UK built a stockpile of drugs and medical supplied hat were used up during COVID19 pandemic. Rebuilding stockpiles were an issue during the post-transition period, where border disruption and delays occurred.

Scientific Research

• The UK previously received €1.28 billion each year from Horizon 2020, which is the EU’s science and innovation funding programme. However, the EU-UK trade deal stated that the UK can apply for top-tier membership of the forthcoming EU Horizon research initiative, but it will not be given access to funding for new technology projects. 

• 1 in 3 papers are co-authored with EU scientists, these links could potentially be lost.

• 2,300 EU academics resigned form British Universities.

Student Fees

• Brexit is set to cause two significant changes for students from the EU/EEA. Previously, EU/EEA students applying to study at UK universities were eligible for the same loans and grants as home students. EU/EEA nationals who started their studies before the end of the transition period will remain eligible for the student loans and grants for the duration of their course, even if it ends after the end of the transition period.

• EU students will also be subject to higher international tuitions fees and the reverse is the same for British pupils.

Junior Doctor Contracts

It’s the contract of employment for all NHS Junior Doctors, outlining pay scales and other details. The government trued to update the contract in 2016, with changes such as:

• Overhauling the system of pay and hours for Junior Drs / Protecting junior doctors from any unfair consequences from whistleblowing / Designating a member of staff for each hospital to ensure that Junior Doctors are working rotas that are manageable and safe for patients.

After graduation, Doctors complete a 2-year foundation programme and then progress to further specialist training. This post-graduate training period, which can take anywhere from five to ten or more years to complete, is the period in which a Doctor can be described as a Junior Doctor. After completion of their training, they can apply for the role of GP or consultant. The Junior Doctor contract therefore affects a wide variety of Doctors and specialists in the early stages of their career.

Controversy

The controversy around the Junior Doctor contract began in 2013 when the Department of Health shared its proposals. It said that the updates would make pay fairer and wanted to spread emergency and elective services across seven days a week – but Junior Doctors felt the contract was risking patient safety and was unfair to them. 

The Old Junior Dr Contract

• In the old contract, Junior Doctors were paid a standard rate for shifts where the hours fell between 7am and 7pm on Mondays to Fridays. If a FY1 Doctor worked these standard hours, they would have earned a basic salary of £22,862. This basic salary would go up as the Doctor progressed through their training and their time served increased.

• JD’s are also required to do on-call shifts outside of social El hours, which could add an addition 40-50% to their basic salary (banding).

Proposed Pay Changes

• Proposed change was that their basic salary increased but there was a reduction in supplements for on-call shifts meaning their salary effectively fell.

Other Concerns

• The old contract stated that if a Doctor trained in one specialty, such as emergency medicine, and later decided to retrain in another, such as general practice, the salary gained through their emergency medicine experience would be protected. This reflects additional experience. With the proposed contract changes, these two Doctors would be paid the same, which could discourage Doctors from changing specialties.

Junior Doctor Strikes

• In November 2015, 98% of Junior Doctors voted to reject the contract, and in favour of industrial action. This led to four Junior Doctor strikes between January and March the following year. Each of the four strikes lasted 24-48 hours on 12 January; 10 February; 9-10 March; and 26-27 April.

• 8 in 10 JDs didn’t show up on the first strike.

• September Strikes were called off over patient safety concerns.

• 2021/22 and this year as the pay rise JD’s and other healthcare professionals are receiving are not increasing at the same rate that inflation is increasing, causing many to struggle.

Updates

The JD contract was updated in 2018 but the BMA still had issues surrounding out of hours pay and less than full time training.

Medicinal Cannabis

From November 2018 specialist Doctors in England, Wales and Scotland can prescribe cannabis-derived medicine in exceptional circumstances. It was the first change to the law on medicinal cannabis, which had been in place since 1971.

Patients not Getting Medicinal Cannabis

Englands Chief Medical Officer has called for scientific trials to check safety.

In 2019, the NHS only provided 18 prescriptions for cannabis-related medications.

Billy Caldwell

1. In 2017 Billy was prescribed cannabis oil by his GP. This was the first prescription of cannabis oil in the UK – but the GP received a letter from the Home Office saying he must not renew the prescription or would face serious consequences. That’s because the oil contains low amounts of THC, which is illegal in the UK.

2. His mother travelled to Toronto to pick up medicinal cannabis and this was confiscated.

3. Billy wasn’t weaned off the medication, and he suffered seizures. He was admitted to hospital, where Doctors struggled to keep the seizures under control.

4. There was a huge public outcry and the Home Office decided that Billy would be allowed the cannabis oil as a special measure.

5. A hospital trust was given a special license to administer doses to Billy, which meant a daily four-hour round-trip for the family. His mother described it as being under hospital arrest.

6. Billy was later getting a prescription from a private paediatric neurologist in London, but this meant flying to England every few weeks to collect more oil.

7. In 2019, Billy was ultimately awarded a lifelong medicinal cannabis prescription on the NHS, in a decision that could pave the way for more patients to receive the treatment in the future.

Alfie Dingley

• His condition improved when he was prescribed cannabis in Amsterdam, and it was predicted that his seizures would fall from 3,000 a year to just 20 on this medication. His family eventually moved there because they couldn’t get the medication in the UK.

• His mother became the first person to be granted a special license to import medicinal cannabis back to the UK. Alfie has since become tolerant to his medication and needs a new strain – but his mother said it would take months to get access to this.

Medical Licensing Assessment

The MLA has 2 parts, an applied knowledge test that’s computer bases and a clinical and professional assessment. The aim of the MLA is to provide standardised means of assessing all UK Doctors, which in turn will help to ensure patient safety. It’s a pass / fail assessment.

When will this come into effect

It will affect anyone graduating in the year 2024-25 onwards. UK medical students graduating in this academic year need to pass the MLA before joining the medical registrar.

Currently, medical graduates shut their final written and clinical exams at their Medical School and if they pass, they can apply for provisional registration on the GMC Medical Register. This then allows then to apply for Foundational Training.

Revalidation

Every five years, licensed Doctors must demonstrate that they are up to date with medical procedures and fit to practice. This is known as ‘revalidation’ and ensures that the Doctor can continue to hold their license to practice. They need to use supporting information to demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice

Good Medical Practice by the General Medical Council (GMC) is the core ethical guidance for doctors. It sets out the principles and professional values on which good practice is founded.

All NHS staff, including Doctors, are expected to have annual appraisals as part of their revalidation. Each Doctor needs to maintain a portfolio of supporting information which demonstrates that they are continuing to meet the attributes set out in the framework. The main purpose of revalidation for doctors is to check that their practices, skills and behaviour are in line with the GMC’s standards, as well as to reflect on their performance, using this to improve their skills or develop their practice.hiv