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Consulting professionals and managers about the NHS.

This site aims to bring out the truth about the state of the NHS. We reveal the views of current and retired NHS professionals, doctors, nurses and managers in particular. This has never happened in a public domain before. We also report stories of interest in order to provide a context. Find out more..

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“Cruel Rationing”

….Of course, officially, rationing does not occur. The Health services are all part of a post code lottery, and only when the media points out the inequity of this, and that our political leaders have access to, and choice of, the best, in London, or can afford to go privately, will we start to get the honest debate needed. The irony of the recent adverts for a post code lottery is not lost on doctors and nurses.

In a letter to the Islington Tribune, “Cruel Rationing” is decried 4th  May 2018

WE all know the NHS and social care are in crisis due to Tory underfunding and privatisation. Without democratic consultation, Islington, Camden, Haringey, Barnet and Enfield have been classified as a Sustainability Transformation Plan (STP) pilot scheme.

The STP means longer waiting times – six months or more for vital operations like hip/knee replacements or varicose veins. Patients with any money, government assumes, will resort to private health firms rather than bear increasing pain.

NHS England wants to save £900m on NHS treatment and almost £250m on social care. There is also rationing of access to hospital beds for the “frail and elderly”, disabled people and pensioners, as George Durack’s case recently high­lighted.

So a “trusted assessor”, who need not have medical qualifications, can decide when one of these “second-class citizens” is to be discharged from hospital. GPs have been told to limit their hospital referrals, and only one third of children who need mental health support will get it by next year.

Accountable care organisations are being established – on the American privatised model of care. Parliament has had no say on these new developments and a judicial review has been lodged against this.

We’ll know its result by the end of May (www.crowdjustice.com/case/jr4nhs).

In its 70th year the NHS (and social care) are under renewed attack. All local patients should consider joining a local defend NHS campaign group, like Islington Keep Our NHS Public, against this cruel Tory rationing.

JAN POLLOCK
Hornsey Lane, N6

Rationing of of ibrutinib by NHS England (NHSE) for some patients with relapsed chronic lymphocytic leukaemia (CLL) contrary to guidance from NICE

 

LEUKAEMIA DRUG – Letters to the Editor The Times 18th May 2018Sir, Your report “Cancer patients denied effective drug ‘to cut costs’ ” (May 12, and letters, May 15 & 16) highlighted the denial of funding of ibrutinib by NHS England (NHSE) for some patients with relapsed chronic lymphocytic leukaemia (CLL) contrary to guidance from the National Institute for Health and Care Excellence (Nice) that ibrutinib was an option for all patients relapsing after chemoimmunotherapy. NHSE has further limited access to ibrutinib by restricting funding to patients relapsing within three years. This decision by NHSE therefore removes the ability of highly trained experts to treat all patients appropriately within Nice guidelines. Indeed, these restrictions force consultants to reuse chemotherapy for some patients with CLL when it may be clinically inappropriate, bringing considerable additional risks to the patient. The NHSE decision, in direct contrast to the Nice process, is a closed process with no input from patients or CLL experts. In our opinion the NHSE funding position makes no sense as it will result in poorer outcomes for patients and higher costs for the NHS. The decision by NHSE not to support ibrutinib in some patients with relapsed CLL must be reversed.

Professor Peter Hillmen, University of Leeds; Professor Anna Schuh, University of Oxford; Dr George Follows, Addenbrooke’s Hospital, Cambridge; Dr Adrian Bloor, Christie Hospital, Manchester; Dr Claire Dearden, Royal Marsden Hospital, London; Dr Christopher Fox, Nottingham University Hospitals; Dr Piers Patten, King’s College Hospital, London; Dr Helen McCarthy, Royal Bournemouth Hospital; Dr Renata Walewska, Royal Bournemouth Hospital; Dr Niamh Appleby, John Radcliffe Hospital, Oxford; Dr Ben Kennedy, University Hospitals of Leicester; Dr Guy Pratt, Queen Elizabeth Hospital, Birmingham; Dr Andrea Pepper, Brighton and Sussex Medical School; Dr Ingo Ringshausen, University of Cambridge. Sent on behalf of the UKCLL Forum

In the absence of diagnosticians, do we want paramedics, or nurses to run Primary Care?

If there’s to be a National 10 year shortage of diagnosticians, and in their absence, do we want paramedics, or nurses to run Primary Care? The only way to provide GPs in Fife is to pay them more than elsewhere, along with removal costs and other inducements. This takes GPs away from other areas. Robbing Peter tot pay Paul is what Wales and the North East did in recruitment last year, but now other areas of the country are copying. The reduction ad absurdum situation leads to inflation in GP pay as competition for rare resources continues.

Image result for robbing peter to pay paul cartoon

Fife today reports 18th May 2018: Pressure mounting as NHS Fife told ‘We must fix this GP crisis’

Fife-wide campaign and petition is mounting pressure on health bosses to reinstate the three Out-Of-Hours emergency care services closed suddenly six weeks ago. Public meetings have taken place in Glenrothes, Dunfermline and St Andrews this week all demanding a guarantee that the midnight to 8am Primary Care Emergency Service (PCES) in those towns be reinstated at the end of the three month closure. And while individuals are fighting for local services, an orchestrated Fife-wide campaign is now coming together, with a petition set to be presented to Michael Kellet, director of Fife Health and Social care Partnership ahead of a crucial meeting of health bosses later this month. The partnership was forced to close the three services leaving just Victoria Hospital in Kirkcaldy to deal with out-of-hours care for Fifers, because of the lack of GPs and fears over patient safety.
The Scottish Government has admitted that Fife faces “significant issues … with GP recruitment and retention” as it failed to give its confidence to the three closed out-of-hour services reopening when reviewed in June.The admission of challenges facing NHS Fife to recruit GPs came in response to a question by Claire Baker, MSP for Mid Scotland and Fife.

Fife curently has 11 of its 55 GP practices attempting to recrute staff, and of the 150 registered GPs, just 68 regularly cover PCES. “We have known for some time that Fife is facing a crisis in recruiting and retaining GPs so if there are well known difficulties with practices struggling to recruit GPs for during the day, it is unsurprising that finding cover at night is even harder,” said the MSP.

“Whilst the lack of consultation and the suddenness of these closures is concerning and raises legitimate criticisms of Fife Health and Social Care, the Scottish Government must accept its own responsibility.”At a public meeting held in St Andrews, Dr Gerry Smyth told the audience that the decision to close the service between midnight-8am at St Andrews’ hospital was “unnecessary because the staffing difficulties arose in central and west Fife”.He added that he felt “the decisions that have been made were ill-considered, unnecessary and unsafe.”He also said that he and three of his colleagues had offered to do out-of-hours work at St Andrews, but were turned down.

Dr Seonaid McCallum, associate medical director at the Fife Health & Social Care Partnership, which made the decision to close the service, said that the GPs had only offered to provide the service in north east Fife and had rejected to cover the whole of Fife, and that had been the reason their offer had been rejected.Speaking about the emergency decision to close the service, Ms McCallum said: “One of our doctors had to stop working for us – that’s what pushed us.”At the conclusion of the meeting, MP Stephen Gethins called for the service to be reopened before a planned consultation on the takes place.The Integrated Joint Board is to meet on May 22 to decide whether to postpone a public consultation regarding a wider reshaping of the current primary care service.

 

The end of outsourcing now that it puts patients at risk? NHSreality doubts there will be any change.

The If you are a regular reader of health service news, you may not have made the connection with the demise of Carillion and your particular part of the UK Health Service. The different trusts have made their low paid staff become employees of Carillion. The savings in pensions as well as pay are then compounded by asking the service provider to cut costs by 35%. Result, instead of the Health Services going bust, Carillion does.

Chris Smyth reports 17th May 2018 in The Times: NHS outsourcing ‘put patients at risk

Patients were put at risk of cancer and other serious harm because of a botched £330 million NHS outsourcing deal, the spending watchdog has found.

An attempt at cost-cutting has led to more than two years of chaos in back-office services for GPs, opticians and dentists, the National Audit Office said.

Dozens of women were wrongly told that they no longer needed cervical cancer screening and incompetent staff may have been allowed to carry on practising, the report concludes.

The outsourcing company Capita and NHS England are still bickering about the deal, leading to failures including a backlog of half a million patient registrations, the NAO warns.

“Trying to slash costs by more than a third at the same time as implementing a raft of modernisation measures . . . potentially put patients at risk of serious harm,” Meg Hillier, chairwoman of the public accounts committee, said.

 

You have been warned…. No genetic secrets will remain ….

We already ration infertility treatment, in most commissioning groups, and we also restrict the use of pre-embryonic blastocyst selection to avoid inherited disease to one child in most commissioning groups. This is despite the cost (long term) of looking after an individual with HD or CF. The result is that affluent families pay for the embryo selection, but poorer families are faced with either having one child, or taking the risk and having more. If the state wishes to construct a data base of risk, and the potential is there, we will have to let rationing become as overt for everything as it is for infertility.

Image result for infertility cartoon

The Economist has pointed out in 2003 (jan 23rd) No hiding place – The protection of privacy will be a huge problem for the internet society and now more recently. In Science and Technology May 5th “No hiding place” (Genomes and Privacy) reports: Police have used genealogy to make an arrest in a murder case – The did so by tracing the suspect via distant relatives’ DNA

….If a serial killer really has been caught using these methods, everyone will rightly applaud. But the power of forensic genomics that this case displays poses concerns for those going about their lawful business, too. It bears on the question of genetic privacy—namely, how much right people have to keep their genes to themselves—by showing that no man or woman is a genetic island. Information about one individual can reveal information about others—and not just who is related to whom.

With decreasing degrees of certainty, according to the degree of consanguinity, it can divulge a relative’s susceptibilities to certain diseases, for example, or information about paternity, that the relative in question might or might not want to know, and might or might not want to become public. Who should be allowed to see such information, and who might have a right to see it, are questions that need asking.

They are beginning to be asked. In 2017 the Court of Appeal in England ruled that doctors treating people with Huntington’s chorea, an inherited fatal disease of the central nervous system the definitive diagnosis of which is a particular abnormal DNA sequence, have a duty to disclose that diagnosis to the patient’s children. The children of a parent who has Huntington’s have a 50% chance of inheriting the illness. In this case, a father had declined to disclose his newly diagnosed disease to his pregnant daughter. She was, herself, subsequently diagnosed with Huntington’s. She then sued the hospital, on the basis that it was her right to know of her risk. Had she known, she told the court, she would have terminated her pregnancy.

That is an extreme case. But intermediate ones exist. For example, certain variants of a gene called BRCA are associated with breast cancer. None, though, is 100% predictive. If someone discovers that he or she is carrying such a variant, should that bring an obligation to inform relatives, so that they, too, may be tested? Or does that risk spreading panic to no good end?

It may turn out that such worries are transient. As the cost of genetic sequencing falls, the tendency of people to discover their own genetic information, rather than learning about it second-hand, will increase. That, though, may bring about a different problem, of genetic snooping, in which people obtain the sequences of others without their consent, from things like discarded coffee cups. At that point genetic privacy really will be a thing of the past…..

Image result for infertility cartoon

I may never witness another quality service in primary care. Over 1000 or 4% leave GP in two years… predictably.

The result of long term rationing of medical school places, too many part time doctors, and poor manpower planning, have led to the current situation. My life expectancy at 68 is some 10-15 years, so I may never witness another quality service in primary care. The solutions lie in longer term planning, graduate entry to medical schools, and a virtual medical school whereby potential doctors live and work in communities rather than cities. Even then we would need adverse selection as a policy to address the dominance of large city suburban schools.Image result for retiring GPs cartoon

Nick Bostock reports in GPonline 15th May 2018: GP Workforce falls 4% in two years as shortage continues to grow.

…Excluding registrars, retainers and locums, figures published by NHS Digital on Wednesday reveal a total full-time equivalent workforce of 27,773 in March 2018, a 1,260 fall compared with March 2016. This represents a 4.3% drop in just two years.

Numbers of GPs in partnership roles continue to drop sharply, the latest data reveal. In March 2018 there were 22,593 GP partners, down 6% compared with March 2016 – showing that 1,563 partners were lost to general practice over this 24-month period alone….

and Katie Osborne of  Pulse 10th May reveals that, during this period, only “Just 85 GPs recruited from overseas”.

Chris Smyth reports in the Times 16th May 2018: 1,000 GPs leave despite recruitment drive

More than 1,000 family doctors have been lost since ministers set out plans to hire 5,000 more, official figures show.

GPs are continuing to abandon the NHS as they become fed up with rising numbers of appointments, in what professional leaders called a “hammer blow” for patients. They warned that a spiral of decline risked making remaining GPs even more fed up, threatening the family doctor system with collapse.

Jeremy Hunt, the health secretary, promised in 2015 to recruit 5,000 extra doctors by 2020, warning that hospitals would be “overwhelmed” if the NHS did not improve at caring for the elderly locally. However, despite schemes to stop doctors retiring early and golden hellos to tempt them to parts of the country with shortages, numbers have continued to decline. Figures published yesterday showed that there were 34,435 GPs in March, excluding locums and trainees, down from 35,516 two and a half years ago.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “The stark truth is that we are losing GPs at an alarming rate at a time when we need thousands more to deliver the care our patients need, and keep our profession, and the wider NHS, sustainable. It is clear that substantial efforts to increase the GP workforce in England are falling short — and we need urgent action to address this.”

A Department of Health spokeswoman said: “We are committed to meeting our objective of recruiting an extra 5,000 GPs by 2020. This is an ambitious target and shows our commitment to growing a strong and sustainable general practice for the future. More than 3,000 GPs have entered training this year, 1,500 new medical school places are being made available by 2019 and NHS England plans to recruit an extra 2,000 overseas doctors in the next three years.”

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

Its going to cost you – approximately £450 per month or £5000 per year – and that’s for starters. Denial of need to ration will lead to nemesis..

Meltdown in South Pembrokeshire will extend across the Haven. What reassurance can the minister offer now?

Nick Bostock also reveals “How GPs fell out of love with partnerships”.

Image result for retiring GPs cartoon

Britain ranked last (out of 20 rich countries) by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.

The Times leader may 13th 2018: Cancer Catch-up

There is a mismatch between great British research and less impressive careSee the source image

In Baroness Jowell’s final speech to the House of Lords she drew attention to the fact that just 2 per cent of British cancer research funding is spent on brain tumours. She would no doubt be pleased that the government is increasing that amount by £65 million in her name. Her accomplishments on many fronts are themselves a memorial to a life well lived and the extra money will be a capstone on that memorial. It is not, however, a strategy for bearing down on the most stubbornly lethal cancers and driving up survival rates, and a strategy is what the country needs.

There is a stark divergence between the quality of cancer research in Britain, which is genuinely world-class, and the quality of treatment and outcomes, which continue to lag behind those in other developed countries. One of only two top-rated cancer research centres in Europe is in Cambridge. Cancer Research UK works with 13 centres in all and they are among the world’s most prolific publishers of peer-reviewed papers. By contrast a recent study ranked Britain on average 17th out of the 28 EU countries by five-year survival rates for nine common types of cancer.

This underachievement on cancer treatment is not new. Nor is it simply a result of limits on resources available to the NHS. It is largely a result of delays in diagnosis and treatment, and all-too-frequent failures to make new therapies available to those who need them. These failures may be explained by the need to save money, only to cost more in the long run.

With no operational proton beam therapy machines of its own, for example, the health service now pays for patients to have the treatment abroad or privately. Or leaves them to go without. A systematic effort to speed up diagnosis and treatment might not have saved Lady Jowell, but it would save thousands of others.

Part of the challenge is to boost uptake of screening programmes already available on the NHS. There are well-known risks attached to excessive cancer screening, including false positive results and unnecessary but debilitating treatment. These risks have been taken into account in setting current screening guidelines for breast, prostate and cervical cancer. Despite this, the number of women attending recommended breast cancer screenings fell last year to its lowest level in a decade, while 25 per cent of those booked to attend a cervical cancer screening did not.

When diagnosis is late the best treatment in the world may not be enough. Even when it is not, a simple lack of specialist staff and equipment may delay treatment. Of 20 rich countries in a recent King’s Fund study, Britain ranked last by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.

Prevailing in the battle against cancer requires choices. It will be galling for some if the government now allows brain cancer patients to take part in more than one clinical trial at a time, at Lady Jowell’s suggestion, while denying other cancer patients, such as those with leukaemia, access to drugs approved as clinically and cost-effective on the false basis that they are still experimental. Surviving cancer patients deserve a coherent strategy to bring British care up to standards taken for granted elsewhere in the developed world.

The English Health Services have finally been shamed into action by Ashya Prague’s parents. Proton beam centres ‘to treat 1,500 patients a year’….

Proton beam therapy arrives in the UK.

It was rational rationing: but it revealed the lack of Proton Beam therapy in the UK: a shame on the Health Services

Proton Beam Therapy – it’s covert rationing in all UK regional health services since 1990!

So, you did not think there was post code rationing of cancer care?

Sir Hughes-Hallet proposes “Healthforce” – an army of volunteers to “stop NHS sinking”. It might work in Wales, but rationing overtly still has to be part of the package.

See the source imageUpdate 16th May: Disparity between cancer care and research, and the post code lottery.

Sir, The problems identified in your leading article (May 15) on cancer survival rates in Britain are very real. We are a persistently poor performer relative to countries that we would like to see as our peers. But this is a complicated problem, and simple solutions will not work. Studies suggest that British patients are more reluctant than their counterparts on the Continent to go to their GP with symptoms, and GPs in turn are less likely to refer people for testing.

Although there would be advantages to spending more on cutting-edge drugs, the high cost could come only from other NHS treatments, and the evidence suggests that the overall effect would be relatively small compared with improving other aspects of prevention and care. This is not a problem unique to cancer: the NHS needs to improve outcomes across a wide range of conditions. It is very seductive to focus on particular diseases but experience in other countries suggests that strengthening the overall system will be more effective.
Nigel Edwards

CEO, Nuffield Trust

Sir, Your leading article succinctly describes how the UK lags behind most of Europe in terms of cancer survival rates. But it (perhaps inadvertently) creates the impression that the solution lies in narrowly focusing on improving cancer care.

This is doubtful. The NHS is a laggard in terms of health outcomes in general, not just cancer survival. It is also a laggard in terms of stroke survival, measures of avoidable premature deaths, mortality rates for respiratory diseases, and almost any indicator for which we have comparable data. It would be odd if cancer were the exception.

The health systems that achieve the best outcomes tend to be competitive, pluralistic systems with a mix of municipal, regional, private for-profit and private non-profit providers. Not wholly unlike the one sub-sector in which, as your leading article notes, the UK excels: medical research.
Dr Kristian Niemietz

Institute of Economic Affairs

Sir, Chronic lymphocytic leukaemia (CLL) is one of more than 130 types of blood cancer (reports, May 12, and letter, May 15). A recent report by the all-party parliamentary group on blood cancer found that unlike the treatment of solid tumour cancers, blood cancer is often not treatable using surgery or radiotherapy. This means that it is even more dependent on drugs being available.

People affected by CLL will often be monitored under “watch and wait” until their cancer reaches a certain stage, when they will undergo chemotherapy with all of its associated side-effects. Even then, many people will relapse. Approximately 200 people a year, whose CLL has relapsed, will be denied the drug — ibrutinib — that offers them a lifeline.

It is not acceptable that guidance by the National Institute for Health and Care Excellence (Nice) on the use of ibrutinib is being reinterpreted by NHS England, particularly if this is for anything other than what is in the best interests of people with CLL.
Henry Smith, MP

Chairman, all-party parliamentary group on blood cancer

Sir, Ibrutinib is an innovative treatment and alternative to conventional chemotherapy and can improve quality of life for patients. On January 25, 2017, Nice approved the use of ibrutinib for previously treated CLL patients. We are dismayed that ibrutinib will not be offered to these patients if they have relapsed more than three years after treatment. It is unclear how NHS England could implement such an arbitrary restriction without evidence or guidance from Nice.

NHS Wales and NHS Scotland have made no further restrictions to Nice’s guidance. This is creating a health equity issue. It is a cross-border postcode lottery, unfairly penalising English patients and their families.
Zack Pemberton-Whiteley

Leukaemia Care