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Referendums, health, and the ‘will of the people’ – our last one may lead to 50 years of decline.
Will we eventually have a referendum on abolishing the NHS (in its 4 dispensations) or not? What would allow us to have the honest debate about its sustainability and its depoliticisation? The play Nye fails to mention the worries that Aneurin Bevan had about these issues, and his fears that a paternal state would discourage citizen autonomy. I did not find it a sycophantic 3 hours but rather an insight into the past and the creation fo a wonderful institution (at the time). What became evident was that the very issues for which ir was founded are coming back – in spades. Increasoing neonatatal and infant death rates, lower life expectancies, and an increasing health divide. The people voted to be poorer – motivated by pride and the media led society. As the dinosaurs in the 90% voting over 60s die off, the youth that remain behind, and failed to vote, will realise their forebears mistakes. Huffington Post: Jacob Rees–Mogg Says It Could Take 50 Years To Reap The Benefits of Brexit – so why didnt he say this during the debate? The people I find hard to forgive are the politicians who changed sides or who failed to think this through for themselves.
Matthew Paris in the Times 11th May 2024: Referendums leave us at the mercy of the mob – As Catalonia and Quebec show, the ‘will of the people’ is a shifting, nebulous concept that shouldn’t be decided so crudely
….What, then, of the “will of the people”? Is it what a majority may at any given moment say they want? Should we adjust it for the intensity with which they want it and the instability of their wants? How? Do we take our reading at a particular moment — like a pulse taken just after running up the stairs — or should we repeat the question at intervals over a long time, take the average and do the same for our measure of the intensity of the wishes?…..
…Referendums have their place. There are small decisions (a park or a leisure centre? Bell-tower chimes on or off in the small hours?) and huge decisions on questions of settled conscience (abortion? Gay marriage?) where heat-of-the-moment plebiscites are less risk. But our internet age is dangerously susceptible to mob hysteria and the illusion that useful opinions can be formed fast and on little information.
Among a population, opinion often moves in waves, sometimes rough. An advancing breaker can knock you over. Duck beneath it, however, and it passes harmlessly above. An undervalued quality in political leadership is the courage to duck.
In the Times letters 14th May 2024: Referendums and the ‘will of the people’
Sir, Matthew Parris makes a powerful case against the use of referendums to decide on complex and far-reaching issues (“Referendums leave us at mercy of the mob”, May 11). But there is another argument against them: too often referendums become about something completely different from the ostensible question on the ballot form. There is no doubt that the EU referendum came to be seen by millions of disadvantaged and less well-off voters as an opportunity to poke a stick in the eye of an establishment that they saw — not without good reason — as telling them what they ought to do. The problem was that this entirely legitimate reaction led to a decision with huge consequences for the whole population, and in all probability their children and grandchildren, with which we will all, whichever way we voted, have to live for a generation or more.
Sir Leigh Lewis
Watford
Sir, Matthew Parris writes that after the Brexit referendum it was common for voters to complain “they hadn’t felt they knew enough”. He omits to mention that a special leaflet — a hard, factual response to the public’s demand for more information on Brexit — was delivered to every home in the country. It did not hold back in emphasising the benefits to Britain of remaining in the EU.
Gerald Heath
Box, Wilts
Sir, Matthew Parris writes with his customary insight. The unfiltered “will of the people” would doubtless herald the restoration of the death penalty, the return of hard labour in gaols, the reinstation of flogging, the enaction of a colour bar, and the erosion of gay rights. This is why the late Lord Carrington believed that parliamentary democracy saved the electorate from itself.
Dr Millan Sachania
Chertsey, Surrey
Sir, Matthew Parris does not mention the sophisticated way in which referendums are conducted in Switzerland. Referendums are a whole way of life there at three levels: federal, canton and commune. The Swiss system is highly democratic and leads to peace, stability and prosperity.
Peter Ford
London SW2
Sir, Matthew Parris makes a convincing case that the “will of the people” is an elusive concept. It is invoked by politicians to justify a path but, as he states, support for going down an independence route (using Scotland as an example) is variable. As he implies, a referendum is too simplistic. It produces a result, yes, but would all Scottish voters who wanted independence then want to join the EU? Referendums by their very nature are divisive and are not a panacea. As Parris says, they are best left for small decisions, because big ones can be affected by a mob mentality.
David Rimmer
Hertford Heath, Herts Sir, Referendums applied to representative democracies are inevitably flawed. But, however flawed, such governance based on the rights of the individuals has proven the best of compromises. Might it be better though to prescribe the rules for referendums so that they do not resort to a simple majority of “for” and “against” but also offer more nuance, such as “don’t know” and “not interested”?
Bruce Williams
Galmpton, Devon
HMG – population change and trends in life expectancy
Midwifery: As with all failing systems, the poorest people experience the steepest decline….
Having a baby: Its a lottery and the chances of poor care in maternity are getting worse as the experience doctors and midwives retire. Who would want to be an obstetrician in a world with too few and without “no fault compensation” and adequate litigation protection? BBC News – Birth Trauma Inquiry: Report finds care is postcode lottery – BBC News. As with all failing systems, the poorest people experience the steepest decline. Any society that does nothing about neonates and infant deaths, and maternal deaths when there are so few children born, is failing badly. We have rationed the care of young people, and neonatal and infant deaths are rising.
Geraldine Scott reports in the Times 13th April 2024: Birth trauma inquiry: Good pregnancy care exception not the rule – MPs and NHS chiefs have backed a plan to improve maternity care in NHS hospitals after mothers claimed they were mistreated
New mothers risk suffering lifelong injuries as hospitals cover up endemic failures in Britain’s maternity system, according to a landmark inquiry which found good care for pregnant women “is the exception rather than the rule”.
The country’s first parliamentary inquiry into birth trauma has found there was “shockingly poor quality” in maternity services, resulting in care lacking compassion and a system where “poor care is all too frequently tolerated as normal”.
The government and the NHS have committed to producing a comprehensive strategy for maternity services after the inquiry’s report, released on Monday, found that women were “treated as an inconvenience” and errors were covered up by hospitals who “frustrated parents’ efforts to find answers”.
Victoria Atkins, the health secretary, said that the experiences uncovered in the report were “harrowing”. Amanda Pritchard, the chief executive of NHS England, said the treatment of the women in the report was “not good enough”.
The report comes after a parliamentary inquiry launched by the Conservative MP Theo Clarke, who thought she was going to die when giving birth to her daughter, Arabella, in 2022. Those who gave evidence overwhelmingly spoke of the“distress at being neglected, ignored or belittled at a time when women were at their most vulnerable”, she found.
The number of women who die during pregnancy or soon after has risen to its highest level in 20 years, figures released this year show, while British infants are more likely to die before their first birthday than in most other developed countries.
The report details how new mothers had been left in blood-soaked sheets for hours, berated by midwives, or in one case been dismissed as an “anxious mother” when her baby then later died from complications that she was warning about. Several had stories of being left to lie in their own blood, urine or excrement, or even berated by midwives for having soiled themselves.
Clarke said the “horrific” testimony “has shone a light on how we must do so much better when it comes to maternity services”.
Clarke, along with Rosie Duffield, a Labour MP, took evidence from women and professionals over a number of months before releasing the report, which calls for, among other things, a new maternity commissioner who will report to the prime minister.
They heard evidence of women being treated like a “slab of meat” with their concerns ignored, sometimes resulting in the death of their babies. Clarke said: “We have listened to mums carefully and applaud their bravery in coming forward, sometimes with horrific testimony of how the system failed them and the mental, physical and economic cost of that failure. The raft of recommendations we make, especially the appointment of a maternity commissioner, are all designed to end the postcode lottery on maternity services.”
The Birth Trauma Association charity says an estimated 20,000 women a year develop post-natal post traumatic stress disorder, and that as many as 200,000 women may also feel traumatised by childbirth and develop some of the symptoms of PTSD.
Women told the inquiry that their lives had been ruined by their experience of birth, including those whose babies were stillborn or who were born with brain injuries as a result of oxygen deprivation. Some women had lifelong bowel incontinence after severe tears went undiagnosed.
In almost all cases it was reported that the outcome was due to mistakes made during labour and birth.
Earlier this month it was reported that Amy Stead, 27, from Wrexham, had been awarded more than £500,000 in damages for injuries she suffered during childbirth, which left her with a stoma bag and PTSD.
About 65 per cent of the NHS’s budget to cover clinical negligence claims — which totalled £69.3 billion in 2022-23 — related to maternity and neonatal liabilities. Pritchard said: “The experiences outlined by women in this report are simply not good enough and not what the NHS wants or expects for patients.”
She pledged to work with hospitals to “create and nurture a culture where women are listened to, their choices respected and care is personalised, equitable and safe”.
Both Pritchard and Atkins backed the call for an overarching strategy to improve care, with next steps expected to be announced in the coming months.
She pledged to work with hospitals to “create and nurture a culture where women are listened to, their choices respected and care is personalised, equitable and safe”.
Both Pritchard and Atkins backed the call for an overarching strategy to improve care, with next steps expected to be announced in the coming months. Clarke’s report comes after investigations into Shrewsbury and Telford Hospital NHS Trust, where it was found failures had contributed to the deaths of 201 babies and nine mothers over 20 years, plus other scandals at Morecambe Bay and East Kent. The report is backed by Donna Ockenden, the senior midwife asked by the government and NHS England to investigate serious maternity scandals and who is carrying out the largest maternity review in the UK at Nottingham University Hospitals NHS Trust.
She said that Clarke’s inquiry “highlights the extent of the problem we know exists across maternity services in the UK” and added she had given the government a “clear blueprint and roadmap” for maternity services but “progress has been far too slow”.
Atkins added: “I am hugely grateful to Theo Clarke for her carefully considered report and all those brave women who came forward to share their harrowing experiences.”
‘They left me there for ten days until I became gravely ill again’
A mother of twins has told how she was treated like a “birthing vessel” and a “slab of meat” by Britain’s maternity system which left her unable to work and reliant on benefits (Geraldine Scott writes).
Rachael McGrath, from Cheshire, believed she was bleeding to death when she was taken to hospital with an abrupted placenta.
Her twins were born requiring resuscitation and survived, but “impersonal” care and being met with what she felt was sarcasm or hostility when asking for help left her traumatised and unable to leave her children with anyone else through fear something could happen to them.
McGrath, 49, is now the chairwoman of the Birth Trauma Association and gave evidence to an inquiry launched by the Conservative MP Theo Clarke, who thought she was going to die when giving birth to her daughter in 2022.
McGrath told the inquiry how she went into renal failure after her twins were delivered by caesarean section, and five days after the birth, the scar from the surgery completely disintegrated.
“Nobody treated the fact that my insides were now on the outside,” she said. “They stuck a sanitary towel over my abdomen and left me there for ten days until eventually I became gravely ill again.”
Because of failures in her care she won damages, but said it had cost her “my physical and psychological health”.
She told The Times: “I couldn’t work for years, so I was on benefits. It just perpetuates the cycle instead of just investing money in the NHS and maternity and giving people good services.”
In her evidence McGrath said her care was “so impersonal”. She said: “I would have somebody holding a blood pressure cuff taking my blood pressure and on their phone giggling and texting with the other hand.
“I was in for such a long time and some of the staff would come and get in my room and talk about other patients unkindly and talk about other staff members unkindly.”
McGrath is one of more than 1,000 people who gave evidence to Clarke’s inquiry looking into how, over the course of years, maternity services have failed expectant mothers both before and after giving birth.
The report found “a maternity system where poor care is all too frequently tolerated as normal, and women are treated as an inconvenience”.
Felicity Benyon, from Mansfield, told Clarke’s inquiry that she had her healthy bladder removed during an emergency caesarean section and was wrongly told that the placenta percreta had enveloped the bladder, and that she would have lost it anyway. It was a urologist who blew the whistle and told her that the mistake had been covered up.
A “failure to listen to women when they said something was wrong” was a thread running throughout the testimony.
“Often they were told they were being over-anxious”, the report said, with one woman being recorded as an “anxious mother” in her notes but actually suffering from spontaneous hemoperitoneum, a rare and often fatal complication of pregnancy whereby tissue had torn behind her uterus.
If she had been given a scan, as is recommended, it would have identified that her baby was experiencing growth restriction and action taken. Instead, her baby died during labour.
One woman told the inquiry: “I was concerned that my baby was looking ‘yellow’ and asked the midwife. She told me I was being overly anxious and he was fine. She wrote in my notes that I was an overly anxious mother and my baby was not jaundiced. My husband intervened and a doctor confirmed my baby was jaundiced and he was treated. The next day the page written by the midwife had been torn out.”
Another described how her severe physical symptoms from birth trauma, including fatigue and tremors, were wrongly diagnosed as psychological, leading her to receive eight sessions of electroconvulsive therapy, which involves sending an electrical current through the brain.
A woman who suffered bowel problems after a traumatic birth and took her hospital to a tribunal for neglect after problems during labour was told by a doctor “why don’t I just a stick an anal plug in and get on with my day”.
One woman carrying twins went into premature labour at 19 weeks and lost her first baby.
“I was told by one of the consultants to stop my crying, calm down and try to save the other baby. His words were: ‘This baby was dead a long time anyway so you should stop stressing over it and let’s try to save the other one’,” she said. The second baby also died.
Amanda Pritchard, the chief executive of NHS England, said the experiences in the report were “simply not good enough”. She said improvements had been made but added: “We know there is more that can be done to prevent and improve support for birth trauma, which is why we are committed to working with the Department of Health and Social Care on a cross-government strategy to build on the NHS three-year delivery plan for maternity and neonatal services, so that we can continue to make care safer and more personalised for women and babies.”
• Midwives’ ‘toxic’ working conditions putting babies’ lives at risk, report finds • ‘The NHS was designed by men for men. My role is to reset that’
• New mothers being driven to suicide, senior midwife warns
• Poor NHS care ‘adds to rising number of women dying in childbirth’
• One in four mothers ‘scared and alone’ while giving birth
NHSreality on the degradation of midwifery and the need for consultant care for all pregnant women.
NHSreality on “No fault compensation”
The Times letters 14th May: Maternity lottery
Sir, Further to your report “Birth trauma report calls for tsar to end postcode maternity lottery” (May 13), the all-party parliamentary group on birth trauma recommends, inter alia, better continuity of care and the digitisation of the mother’s health records. Both were recommended by the National Maternity Review in 2016 but NHS England has yet to implement them. The review also recommended a “rapid resolution and redress” scheme for investigating and compensating birth injury based on a no-blame system as in Sweden, which has better outcomes than we do. This system has been associated with a steady reduction in birth injuries there while such injuries now cost the NHS more than £1 billion a year in compensation. The Swedish experience is that it has also led to an improvement in culture in the teams providing care, which is a significant problem here. The health select committee endorsed the recommendation but the Department of Health has not so far supported it.
Sir Cyril Chantler
Vice-chair, National Maternity Review 2015-16; London SE1
Listen to Mums: Ending the Postcode Lottery on Perinatal Care
Health Secretary pledges new national maternity care plan after birth trauma report – The Health Secretary has accepted calls for a national strategy to improve maternity services
Health and Social Care Secretary speech at birth trauma APPG
Battleing for a GP slot. GPs (but not other staff) need to be allowed to use time as a diagnostic tool, and to live with uncertainty. No fault compensation is needed in a degraded and declining system..
The two letters below tell us a lot about the health services in the richer shires. Purley and Bournemouth are relatively affluent compared to Wales and the North East. The services there are even worse than those described here, and there are fewer private options. These tow patients need better communication, speedier access, better diagnosticians and quicker treatment options. The English Health Service can no longer provide. They need to see the National Theatre’s “Nye” and reflect that the very conditions that Mr Bevan was irate about are now returning. The play is excellent in that it reflects the idealism and politicas of the creation fo a much improved service. It does fail to cover Bevan’s worries about a paternal state, and the sustainability of a system that has not been copied by any other country in the world. The letters also omit so much: were the persons first in contact / reading the forms diagnosticians, nurses, receptionists or physician assistants? Like many other sapects of a declining system, the staff need the protection of “no fault compensation” if they are to take appropriate rather than inappropriate risks. Its the culture thats wrong… GPs (but not other staff) need to be able to use time as a diagnostic tool, and to live with uncertainty.
The Telegraph letters Saturday 11th May 2024:
Our local GP practice , like that of James Woods (Letters May 10th) has switched to an online request system. This was sold as an efficient way of prioritising appointments for those in most need – so when my 85 year old mother was suffering from a red, swollen and painfuil leg, with a discharging would, i trusted she would be near the top of the list.
After I completed a labyrinthine form on her behalf, submitted a photo, we waited seven hours to be notified that we wpould be contacted for a telephone appoitment. This took place 2 hours later.; we were informed that “It doesn’t look infected”, but told to “get back in touch” if it worsened. An appointment wsas made for my mother to see the practice nursing team three days later.
Within six hours \i was completing the same form again, adding that my mother now felt worse and reiterating concerns about a probable infection. This time we were contacted withion a few hours and given a face to face appointment at which antibiotics were immediately issued.
As the GO can nevertheless argue tyhat my mother was gien a same day appointment for her condition, it seems to me that the online request system is more to the benefit of surgeries than their patients.
Andrew Davis, Purley, Surrey.
Sir, Chris Thomas asks if he is lucky in having a good local hospital Trust. Many of us would say so. I know someone who has been suffering from acute hip and leg pain – not just for months but for years. They can no longer walk, and barely sleep.
Finally, two months ago, after constant struggles to get help, they were given a daate for the local musculoskeletal clinic – in September. The appointment is a telephone one. The accompanying instruction reads: “Do not attend”.
Lillian Hilse, Bournemouth, Dorset.
A professorial view on the economic oportunity – for business. This runs against the trend.
The only problem is that no government, including ours, can afford all the technological advances equally. The fact is that the value of our economy (stockmarket value) has diminished by 37.5% since 2007. The decline has been accellerated by Brexit. See “Why the stockmarket is disappearing- Large companies such as ByteDance, OpenAI and Stripe are staying private” in the Economist 18th April 2024 and 18th Jan 2024 “A golden age for stockmarkets is drawing to a close” – Share prices may be surging, but even AI is unlikely to drive a repeat of the past decade’s performance. Leaving the EU and the EFTA area cannot be helping.
Times letters 6th May 2024: Economic medicine
Sir, The OECD figures suggesting that next year the UK economy will be the worst performing in the G7 (report, May 2) strengthen the case for an ambitious industrial strategy to boost sectors that could act as engines for economic growth.
Medical technology is an example. Despite being half the size of biopharmaceuticals in terms of jobs, med tech contributes £13.5 billion to the UK economy annually, against biopharma’s £15 billion. Its annual growth rate between 2016 and 2020 was 19 per cent — far higher than biopharma’s 3 per cent. But the med tech sector’s vitality has been in spite, not because, of government policy. Regulatory uncertainty, scarce funding, and ineffective NHS procurement processes make it difficult for med tech inventions to develop into viable businesses.
We have no shortage of talented people in this country, and we boast some of the best universities in the world, so bringing academic expertise together with industry should be an easy win. But countless good ideas go to waste. Imperial College London is investigating how to improve the competitiveness of the UK economy. A central theme is the need for more flexible regulatory environments that can align with key markets such as the EU and US. With the right strategy and investment, we have an opportunity to generate economic growth and cement the UK as a world leader in technology and innovation.
Professor James Moore Jr
Bagrit & RAEng chair in medical device design, Imperial College London
Exit Interview: MP resigns from Tory party over NHS “stretched close to breaking point”
If the medical profession are going to shape Labours 10 year NHS plans, which doctors will they ask? The BMA and most of my froends are divided. There is however a 70% , and increasing, majority in favour of rationing: not having everything for everyone for ever everywhere for free. This means excluding some treatments. The debate on reducing social security support and sick pay is a similar one. The ethics are around the choice between a paternal state and autonomous, resilient self sufficient individuals and societies. Jacqui Wise for the BMJ reports 4th May 2024: MP resigns from Tory party over NHS “stretched close to breaking point”
Dan Poulter, a consultant psychiatrist and former health minister, has resigned from the Conservative Party over the state of the NHS and accused the government of putting political ideology before pragmatism over doctors’ pay. In a shock resignation on 28 April the MP for Central Suffolk and North Ipswich for 14 years said he would sit as a Labour MP until the general election and then would stand down.
Poulter said he had made his decision after spending more than 20 night shifts over the past year working as a mental health doctor in a busy accident and emergency (A&E) department. He told BBC Television’s Sunday with Laura Kuenssberg programme, “I found it increasingly difficult to look my NHS colleagues in the eye, my patients in the eye, and my constituents in the eye with good conscience.”1
In an article for the Observer newspaper Poulter said, “Throughout the small hours, my clinical colleagues and I cared for many patients suffering from serious psychosis who would routinely be waiting several days, rather than hours, in a windowless room in A&E for a mental health bed.”2 He added, “The chaos of today’s fragmented patchwork of community addiction services—making A&E the default location for people to get treatment and help—has added pressure to an already overstretched service. The mental toll of a service stretched close to breaking point is not confined to patients and their families. It also weighs heavily on my NHS colleagues, who are unable to deliver the right care in a system that simply no longer works for our patients.” Poulter said he believed that the Conservative Party no longer valued public services. “It is abundantly clear to me that the Labour Party alone has the will and the trust to restore and reform the NHS.”
Poulter, who served as a health minister under the UK’s coalition government from 2012 to 2015, said he was deeply concerned about the failure of the government to implement vital reforms to mental health law and to the 1983 Mental Health Act, many of which were contained in the 2018 independent review of the act by the psychiatrist Simon Wessely.3
Writing in the Observer, Poulter said that in particular he was “dismayed by the failure to address racial disparities in the use of mental health laws and to reform aspects of mental health law relating to the care of people with learning disability and autism.” He added that community services have been hollowed out, leaving the system poorly equipped to prevent crisis admissions and deliver the transformative care in the community that patients with mental ill health needed.
He also accused the government of failing to tackle NHS staff’s longstanding concerns over pay at a time of a cost-of-living crisis and increasing staff recruitment and retention challenges. “Political ideology has been put before pragmatism and meeting the needs of patients—who are the real losers from the strikes,” he said.
In January Poulter spoke about the parlous state of the NHS at the launch of the BMJ Commission on the Future of the NHS (bmj.com/nhs-commission).45 The commission identified years of constrained funding, workforce shortages, and high demand among an ageing population as some of the key pressure points on the health service and called on the government to declare a national health and care emergency.
Commenting on Poulter’s decision, Nigel Crisp, an independent member of the House of Lords and lead author of the commission’s first report, said, “The Conservative Party has changed massively in recent years and left many good people behind, Dan included.” He told The BMJ, “I am not surprised he feels so strongly about the state of the NHS. An incoming government should declare a national health and care emergency and get the country mobilised behind it.”
2014: A first debate in West Wales BMA – on rationing – wins a majority in favour
TAKING STOCK Rammya Mathew: We can’t miss the backdrop as the UK becomes sicker
The absense of truth seeking behaviour in all 4 dispensations.
Medical continuing education is not complete without many more post mortems.
Matt Dathan reports in the Times 2nd May 2024: Grieving families let down by ‘unacceptable delays’ in coroners’ courts – Chief coroner blames underfunding as number of cases waiting more than a year for a verdict rises 25 per cent to a record high
Thousands of bereaved families are being let down by “an unacceptable level of avoidable delay” in coroners’ courts across the country, the chief coroner has admitted. The number of cases waiting more than a year for a coroner’s verdict has increased by more than a quarter to a record high of 6,149, according to new figures.
Judge Thomas Teague, the chief coroner of England and Wales, said the delays were not only preventing families from complying with their loved one’s beliefs and last wishes but also compounding families’ grief. Th
e registration of a death cannot be completed until the coroner’s investigation concludes and it can also delay burial and cremations, affecting the grieving process, he added. Teague attributed the unnecessary delays to “chronic underfunding” of coroners’ services, a shortage of pathologists and the “residual effects” of the Covid-19 pandemic. Writing in his annual report for 2023, the chief coroner called on the government to take urgent action to “address the fundamental problem of resourcing”.
The report was published last week but has since been removed from the Ministry of Justice (MoJ) website after being published “in error” and was not supposed to be in the public domain until after the local elections due to purdah rules which bar certain civil service announcements that may affect voting behaviour in the run-up to polling day.
The report will be republished on the MoJ website later this month, government sources said. Labour blamed government inaction for betraying bereaved families.
Emily Thornberry, the shadow attorney-general, said: “All across the justice system we are seeing these same pressures and backlogs, and as the chief coroner says, it is ordinary families who are being let down as a result. We cannot go on with a government that just sticks its head in the sand, and pretends these problems do not exist.”
Under the 2009 Coroners and Justice Act, coroners’ offices across England and Wales are required to complete inquests within six months of the date on which a death is reported to them, or “as soon as reasonably practicable” afterwards. To monitor compliance, they must report to the chief coroner all investigations that have not been completed within a year. In the report, obtained by The Times in full before it was removed, Teague reported that as of April 2023, 6,149 cases had been outstanding for more than 12 months. This is up by more than a quarter on the previous year when 4,812 cases had taken more than a year and four times higher than the figure for April 2017 (1,508).
In 2017 there was only one coroner area in England and Wales — the City of Manchester — reporting more than 100 cases waiting over a year. However, in the latest annual report the number of areas reporting outstanding cases of more than 12 months rose to 18 from 14 in 2022. While 29 areas saw their number of cases outstanding for over 12 months fall in 2023, 52 saw their number increase, and in 24 areas, their total rose by at least half.
Writing in his 2023 annual report, Teague described 2023 as a “difficult year” for the coroner service as many areas were “still struggling to eradicate the backlogs that built up during the Covid-19 pandemic”.
Changes to medical practice that have led to greater numbers of natural deaths being reported to coroners have also caused delays. Teague said the financial crisis had also “severely affected the ability of many local authorities and police services to resource the coroner service appropriately”. He wrote: “Under-funding of the service remains a serious and pervasive problem. “Although delays can never be completely eradicated because of the need for coroners to wait for external investigations and processes to conclude, I must report that there is currently an unacceptable level of avoidable delay within the coroner service.”
Addressing the impact that the delays can have on bereaved families, Teague wrote: “Coroner cases should be conducted without delay — the posthumous duty of the family to the deceased includes ensuring that the body is disposed of with dignity and in accordance with the deceased person’s beliefs, that the death is registered, and that the estate is dealt with as the deceased person would have wanted.
“Where a death has been reported to a coroner, the family cannot arrange for their loved one to be buried or cremated until the coroner has released the body. “The registration of the death is also delayed until the coroner’s investigation concludes. There is therefore a tension between the coroner’s duty to investigate and the family’s need to fulfil their obligations to their loved one. “This tension is particularly acute where the deceased person held religious beliefs that are incompatible with delayed burial.”
He added: “Delays within the coroner service not only prevent some families from complying with their loved one’s beliefs, but also compound families’ grief and impact on the reliability of the evidence available to coronial investigations. Avoiding unnecessary delay must therefore be a key priority for the coroner service.”
A government spokesman said: “We are taking decisive action to ease the burden on grieving families and reduce any delays they may face when laying loved ones to rest. This includes changing the law to make it easier to establish if a death is from natural causes without the need for a post-mortem, reviewing pathologists’ fees and investing billions to help local services recover from the impact of the pandemic. We will respond in full to the report in due course.”
NHSreality posts on “post mortems”, the absense of truth seeking behaviour, and the restrained Coroners.
Ministry of Justice – GOV.UK (Where the report will be released this May.
RAAC and collapsing Hospitals. An allegory for the all 4 “NHS” dispensations
It is interesting that since the original RAAC reports in 2023 it seems that we knew about the timebomb in our school and hospitals and other public buldings since 1993, and our politicians and administrators at high levels in government were unwilling to tell us the “hard truths” – as usual. We could replace these hospitals wityh open spaces, parks and parking places for the next generation of hospitals. (In plastic and cardboard) . Our collapsing ceilings in multiple buildings are an allegory we should all take seriously. It will have to be bottom up if the conservatives stay in office! If you dont provide caring environments for your staff, and indeed, you dont care, you cannot expect them to stay in the UK. Its a world market in medical jobs. “Nobody cares how much you know antil they know how much you care”. The staff will no longer be gagged.
6th July 2023: Inverclyde Royal Hospital inspection raises ‘poor conditions’ concerns | The Herald
23rd September 2023: BBC News: More than half NHS Scotland buildings not inspected for Raac
14th December 2023 Dennis Campbell in the Guardian: Hospitals ‘falling to bits’ as NHS in England faces record £12bn repair bill – Government needs to find more than £2bn for urgent maintenance to prevent catastrophic failure, report shows
Meaningless targets – even plastic and cardboard missen hut hospitals may not be within our means.
Rachel Davies in 12th September 2023 in The Evening Standard: RAAC hospitals: Full list of NHS buildings with unsafe …
Alice Thompson changed her mind on assisted dying. So can our MPs,
Its time to think that the naysayers might be ina minority, and they might be wrong. It has noticably taken many votes and much discussion to get to this point in new legislation on dying choices. The comparison with other countries is valid: in some up to 67% die at home. The charitable funding of hospice care is part of the problem… not because it is charity money (We have to ration care) but because it is unequal and unfair depending on where you live. In richer areas the opportunity to look after more people at home is reduced because of the nindset that inpatient hospice care is better and expected. Unfortunately this is true for individuals but not for the population. There is an added issue in that in my area, and many others, several charities compete for funds and fundraisers leading to reduced efficiency of those funds in totality. It might be that if more money was given from government to those hospices that increased the proportion cared for at home, the expectations would change. The choices around assisted dying are hard, and harder as we get nearer our end. But they must be OUR choices, and we should not be forced overseas to make them.
The Times letters 2nd May 2024: End-of-life care
Sir, The campaign for assisted dying is a missed opportunity to talk about fixing our social care and palliative care systems so that proper end-of-life care with appropriate pain relief is available for all. It is to be hoped that others follow Alice Thomson’s lead (Comment, May 1) and change their minds.
Canon Dr Chris Sugden
Oxford
Alice Thompson April 30th: Why I changed my mind over assisted dying – My father’s dementia was dreadful to watch but right-to-die laws in Canada and the Netherlands are a slippery slop …. (• Don’t assume we will get assisted dying right)
…..Our children used to roll their eyes at our right-to-die conversations, insisting that they wanted both their parents and pets to be kept alive as long as possible. But whenever my husband and I read about people being charged with attempted murder for helping a loved one to end their excruciating pain, we agreed the system was barbaric. Only this week the former mayor of Winchester was in court for putting a pillow over his nonagenarian mother’s head to end her suffering. Neither of us wanted to die in a Swiss clinic far from home……
A majority in Britain now want assisted dying. (80% in the Times on line poll) An Ipsos Mori poll last year found 65 per cent in favour. Many of those I respect most, from Dame Esther Rantzen, who has terminal cancer, to Jonathan Dimbleby, whose brother died with motor neurone disease, to my fellow columnist Matthew Parris, want a new legal right-to-die.
A recent House of Lords bill set out how a law might work. It proposed that terminally ill adults certified as being mentally competent by two doctors could apply to a High Court family judge to end their lives. However, a debate in parliament this week showed the difficulties of defining such terms.
I don’t think Britain is full of granny killers nor do I want the terminally ill to have to starve themselves to death, but I don’t trust our politicians to get this legislation right — or future parliaments to hold the line. What would start as a choice could become an expectation.
Sir Keir Starmer has made changing the law a priority for a Labour government, promising a free vote. But this moral conundrum is already turning into another part of the culture war with activists on both sides becoming increasingly shrill and uncompromising. I worry that we will lose sight of the need to be compassionate and humane.
Increasingly, I would prefer us to prepare for better deaths. Only 3 per cent want to die in hospital, yet more than 50 per cent do, with only 17 per cent ending their days at home where they can be surrounded by family and friends. Hospices are another alternative. In Spain, two thirds of adults die in their own beds, often aided by pain relief. This is achievable with better social care.
My husband disagrees. The sooner assisted dying becomes law the better, he says. He wouldn’t want to be kept alive with multiple complex conditions and sees little joy in eking out his final days to postpone death rather than extend any meaningful life. Both of us want to promote individual choice, but I don’t want to hasten anyone else’s death.
Letters |May 3rd 2024: Assisted dying and improving end-of-life care
Sir, Alice Thomson emphasises some of the complex and deeply personal issues around assisted dying against a background of an ageing population, worries around loneliness, being a burden, chronic illness, the cost of care and other matters that may put pressure on individuals (“Why I changed my mind over assisted dying”, May 1). Despite an increasing number of people seeking assisted dying once it has been established, these individuals remain a tiny proportion of those who die each year.
Thomson points out that more than 50 per cent of people with an end-of-life condition die in hospital even though only 3 per cent of people state that to be their preferred place of death. Good end-of-life care should be provided by the hospice service, with an emphasis on quality of life. However, a recent all-party parliamentary group report on end-of-life care found that the integrated care boards that supply health funding locally were “not fit for purpose”, which was echoed in a parliamentary debate last week.
We need excellent — and properly funded — end-of-life care across the country for 24-hour care by all hospices, not just some. Skilled palliative care is the chosen path for most of us but we must get assisted dying right for the few who choose it.
Professor Stephen Spiro
Vice-chair of trustees, St Luke’s Hospice, Kenton, Harrow
Sir, Alice Thomson is to be applauded for her courage in changing her mind, given the ever-widening selection criteria in the Netherlands and Canada. Clinical experience indicates that many patients also change their minds, after an initial request of “Please help me to die”, if they are given the opportunity and the time to discuss their fears of dying. Patients who have assisted suicide no longer have the chance for a change of mind.
Dr David Jeffrey
Former palliative care doctor; senior lecturer, Three Counties Medical School, Worcester University
Sir, I am a retired NHS surgeon and a Swiss citizen. I have always believed in assisted suicide the Swiss way. The Swiss law on assisted suicide was passed in 1942 and enacted the next year: the country “got it right” from the start and the law has not changed since. The only change has been that individual cantons can (and have) chosen to impose on hospitals the duty to allow it to take place in hospital. In the canton of Vaud (where I grew up and trained) this is done by Dignitas or Exit, not the team caring for the patient. The process has been working well there for nigh on 80 years now.
Michael Dusmet
Ret’d thoracic surgeon, Richmond upon Thames, Surrey
Sir, Alice Thomson emphasises the downsides of assisted dying in societies that have it: expansion from terminal illness to someone with depression, the possible inclusion of children, and much else. But it need not be like this. Proper rules, carefully supervised, can control assisted suicide. There will be controversies and even mistakes. But we should not let the perfect get in the way of the good.
Paul Larsmon
Burbage, Wilts
Sir, The crux of Alice Thomson’s article is in her last sentence: “I don’t want to hasten anyone else’s death.” But what if the person concerned wants to hasten their own death? It is morally wrong and patronising to deny that person their wish.
Rachel Wildblood
London SE21
Update letters 6th May: Help at the end
Sir, Further to Alice Thomson’s article (“Why I changed my mind over assisted dying”, May 1), I believe the hastening of death for the terminally ill has been around for a long time. My mother, who was in a care home in her nineties, became constantly dehydrated. She was hydrated several times and eventually those in her care decided on denial of food and drink, and she soon passed away. Several years later my sister, who had cancer, asked her doctor “to make her comfortable”. Morphine was administered and she died that night. Both were helped to die.
Bernard Jackson
Harrow, Middx
Sir, I have never really understood the slippery slope argument referred to in Alice Thomson’s article. It seems to boil down to this: we cannot afford to do what is right today because it may lead us to do what is wrong tomorrow. Applied generally, this argument would inhibit us from doing pretty much anything at all.
Richard Oerton
Cannington, Somerset
If the NHS workforce includes the politicians, then yes, its future depends on their honesty and altruism!!
There are many stakeholders in the 4 health services. The workforce is certainly the greates tasset, but they dont feel they are. The patients have to want to use the services: they dont. The politicians have to use it themselves, and they dont. The King and the royal family dont either. Yes, if the workforce leaves the services will fail, but it is in the hands of the politicians to change the systems to ones that are sustainable, fair, transparent and honest in that everyone knows what is NOT available. The new NICE guidelines on Storke for example, mention levels and frequency of physiotherapy that are not possible given for a decade given current capacity, and only informed and affluent families can afford what is recommended. It looks as if IT strategies will be different as “Palantir gets £480m data contract” from NHS ENgland. In Mental Health inpatient care is often miles away from patient’s homes. Remember that “Its the complexity stupid” (BMJ Leader – Kamran Abassi) and that unintended outcomes of changes always need to be expected and anticipated. The unintended consequences of breaking up the NHS into 4 dispensations being one of them. The miners of Tredegar no longer have the same life chances as the bankers of London. Notes from one dispensation to another are not automatic downloads, and in England GPs dread the arrival of a person from Wales as the notes have to be entered manually.
And why is it that letters are still sent out for appointments rather than offering e-mail or test options, and why are the 4 dispensations the last users of Fax in the country?
The future of the NHS depends on its workforce BMJ 2024;384:e079474 : M Dixon-Woods mary.dixon-woods@thisinstitute.cam.ac.uk
Achieving a high quality, sustainable NHS is currently challenged by major workforce problems. Staff are the most significant element of NHS expenditure1 and its most important asset in providing care for NHS patients, but stewardship of the workforce is not optimised at policy or service level. Based on knowledge of the field, the literature, and listening to patients and staff, we identify three key interlinked areas in which action is urgently needed: configuring the workforce, improving conditions and working environments, and enhancing career and training pathways. We propose what might be done to tackle the current challenges, emphasising that workforce stewardship needs to be highly intentional about diversity, inclusion, and equity and needs to be done collaboratively with staff, patients, and the public.
Configuring the workforce for the future of the NHS
Staff shortages
The future of the NHS depends on having the right numbers of staff in the right roles, at the right times, and in the right locations. At present, the NHS simply does not have enough staff to deliver on its goals and commitments: it has fewer doctors, nurses, and managers than peer countries. By June 2023, there were over 125 500 vacancies in hospital and community health services in England.2 Over 1 in 10 nursing posts were unfilled, with mental health and community nursing especially affected.2 Although the overall number of doctors in hospital and community services has increased to 134 000, representing an additional 39 000 medical staff since 2010,2 the NHS is currently short of nearly 11 000 doctors (a 7.2% vacancy rate). The vacancy rate in clinical professional roles is compounded by difficulties in recruiting and retaining high quality staff in other roles, including administrative, managerial, scientific, and technical staff, as well as estates and ancillary staff. These groups make up nearly half of the workforce and are essential to the NHS but receive much less recognition than their clinical counterparts. Despite the essential nature of their work, some are disparaged in policy and media discourses as somehow not “frontline.”..
Remeber “Its the complexity stupid” Why hospital capacity is more complex than bed capacity(BMJ Leader – Kamran Abassi) BMJ 2024;385:q883….. and Video
Its easy and somewhat commonplace to liken healthcare to a widget factory, to boil it down to inputs and outputs; to capacity, productivity, and efficiency. I was reminded of this at last week’s international quality and safety forum, jointly hosted by BMJ and the Institute for Healthcare Improvement. The event was held at the ExCel, London’s homage to the austere corridor world of Blake’s 7—and the site of a Nightingale hospital at the height of the covid pandemic. The Nightingale hospital was assembled in rapid time and added to hospital bed capacity.
But that extra bed capacity went unused, because hospital capacity isn’t just about beds. It also requires, for example, trained staff and appropriate equipment. Counting the number of beds alone, it turns out, isn’t especially useful in determining hospital capacity, particularly in intensive care. Kevin Fong and colleagues, in a sobering piece that should be widely shared with anybody sceptical of the pandemic’s impact on health services (doi:10.1136/bmj-2023-075613), describe hospital capacity as a “complex property of a complex sociotechnical system.”1
The same magical thinking—that bed capacity somehow conjures the staff, equipment, and expertise to accompany it—is the logical hole in political plans to use the private sector to reduce waiting lists (doi:10.1136/bmj.q858).2 Beyond ideological objections, plans to engage the private sector are bedevilled by data gaps across a broad range of metrics, from workforce to patient outcomes (doi:10.1136/bmj-2024-079261).3
Critics attacked the NHS when the pandemic was most severe for crying wolf over being overstretched because the bed count exceeded bed usage. Yet the service was overstretched, care was compromised, and staff reported mental health symptoms at a rate of 47%, similar to that among Afghan war veterans. Despite the extraordinary efforts of staff, on the background of a depleted health service coming into the pandemic (doi:10.1136/bmj.q760),4 intensive care capacity was exceeded, with knock-on effects on routine services and care.
It isn’t hard, therefore, to understand the lasting damage to patient care and staff welfare. A third of UK doctors are considering leaving in the next 12 months to work abroad (doi:10.1136/bmj.q856).5 Around four million people in the UK are out of work, and around the same number are living with a work limiting health condition (doi:10.1136/bmj.q734).6 When relations between health and employment (and employment and health) have rarely seemed so critical, a decision by the NHS to review its practitioner support service and close it to new referrals seemed extraordinarily insensitive. The decision was overturned within 24 hours after a public outcry (doi:10.1136/bmj.q874).7
This undermining of healthcare staff is now a system failure within the NHS and government. What the public needs is a healthy, satisfied workforce, in the best possible shape to meet the population’s health and wellbeing needs (doi:10.1136/bmj-2024-079474); a workforce that can fill the gaps in our knowledge and practice on the primary prevention and complications of the growing burden of atrial fibrillation (doi:10.1136/bmj-2023-077209 doi:10.1136/bmj.q826), implement the new advances in the diagnosis and management of type 1 diabetes (doi:10.1136/bmj-2023-075681), narrow the gender health gap (doi:10.1136/bmj.q787), and find solutions to the perplexing challenge of social care (doi:10.1136/bmj.q783), even in Northern Ireland, where, despite an integrated health and social care system, community and social care remain deprived of resources (doi:10.1136/bmj.q704).891011121314
Healthcare isn’t a widget factory. It’s a complex sociotechnical system, growing more complex by the day with the impact of new technologies such as machine learning on medical science and clinical practice (doi:10.1136/bmj-2023-07806316 doi:10.1136/bmj.q749 doi:10.1136/bmj.q721).151617 Inputs and outputs matter. As do capacity, productivity, and efficiency. When you’re struggling to make sense of medicine and healthcare, remember: it’s the complexity, stupid (https://en.wikipedia.org/wiki/It%27s_the_economy,_stupid).18
Ignoring a 2013 report has led to the crisis in Maternity, Neonatal, (and other) care as politicians fail to act because they cannot grasp the complexity of medicine. Since 2019 there have been 15 chairpersons of the health and social care committee!
You need to be in medicine for 20 years to become experienced. You need to have begun training 10 years previous to become really useful, How can politicians be tought the importance of long term planning, and of Primary Care in making the 4 health services the efficient filters that they use to be 20 years ago. Living with uncertainty is impossible without trust and continuity of care. Using time as a diagnostic tool is not recieved wekk in a litigous society, and will only come back if we have no fault compensation. Without these strengths GPs are deprofessionalised and we are heading for a private based and regresive (unequal and worsening) system. Ignoring a 2013 report has led to the crisis in Maternity, Neonatal, (and other) care as politicians fail to act because they cannot grasp the complexity of medicine. This follows for General Practice. They just dont seem to care! They even get rid of the best chair persons, Sarah Wollaston 2019, and ensure frequent change in what needs a long term perspective, from the Health and Social Care committee of the House of Commons. Since 2019 there have been 15 chairpersons of this committee!!!
Matthew Limb in the BMj: Government criticised over failure to implement patient safety recommendations Cite this as: BMJ 2024;384:q727 and on ITV News 22nd March: Government ‘failed’ to act on patient safety recommendations, post-Lucy Letby report finds
The government has failed to implement a number of recommendations over major patient safety issues, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress.
The recommendations on maternity care and leadership came from the 2013 report that followed a public inquiry into patient deaths at the Mid Staffordshire NHS Foundation Trust, as well as the 2015 report from the Morecambe Bay Investigation, which highlighted serious failings at the University Hospitals of Morecambe Bay NHS Foundation Trust leading to the deaths of mothers and babies.
The panel gave the government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good.
The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”.
“Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. The panel did recognise the impact the Covid-19 pandemic may have had on implementing recommendations. Professor Dame Jane Dacre, chair of the expert panel, said: “Nine or more years have passed since these recommendations were accepted by the government of the day.
“We are concerned about delays to take real action to implement them and rate overall progress by the government on this serious matter as requiring improvement.” The report added the aim of using “evidence-based scrutiny” is to “feed back to those making promises so that they can assess whether their commitments – or in this case, the implementation of recommendations the government has accepted – are on track to be met”.
Steve Brine, chairman of the Health and Social Committee, welcomed the report, which he said was “commissioned in the wake of the deep concern around the Letby case which gave rise to calls for another statutory inquiry”. Letby was convicted of murdering seven babies and attempting to murder six others, with two attempts on one of her victims, at the Countess of Chester Hospital’s neonatal unit between June 2015 and June 2016. Senior judge Lady Justice Thirlwall is leading the inquiry into how the nurse was able to carry out murder and how the hospital handled concerns about her.
Mr Brine added: “The Health and Social Care Committee has now launched its inquiry into leadership, performance and patient safety in the NHS. The work of the panel will provide valuable insights and an important foundation in support of our forthcoming public evidence sessions.”
Publication of the panel’s findings comes after NHS Whistleblowers, a group representing hundreds of current and former doctors, midwives and nurses, asked to contribute to the Lucy Letby inquiry.
They have instructed Hudgell Solicitors to represent them, arguing there is a need to look at problems across the entire health service, not just in one trust. A spokesperson for the Department of Health and Social Care said patient safety was “paramount”, adding that it had “made significant progress to improve care, including publishing the first NHS Patient Safety Strategy”. “We recently announced the first phase of Martha’s Rule which will give patients or family members in 100 NHS sites the right to a rapid review of their care if they are concerned their condition is worsening,” they said.
“We have also established an independent body to investigate and learn from serious patient safety incidents, and we have made progress in improving maternity services, reducing the stillbirth and neonatal death rate by 23% and 30% respectively since 2010.”
Current enquiries and reports from the Health and Social Care committee of the House of Commons.
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