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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..


There are many more doctors in the rest of Europe, compared to Wales

NHSreality has long pointed out the deficit in provision of medical school places, the gender bias which means there is less continuity of care, and that graduate entry to medical school would help to correct this. There are still many applicants who are disappointed, mainly undergraduate men, and all should now be given the chance to qualify as a doctor. Doctors do prefer to live in areas with good schooling, and this also needs addressing…. especially in Wales.

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David Williamson in Walesonline December 11th reports: The shocking figures which show how many more doctors the rest of Europe has compared to Wales  There are almost twice as many doctors per person in Austria than Wales.

Shocking figures have revealed how poorly staffed the Welsh NHS has become compared to the rest of Europe.

Wales has fewer GPs than other European countries – including impoverished former Soviet states in Eastern Europe.

There are just 2.8 doctors per 1,000 people in the UK, compared with 3.9 in Spain, 4.3 in Norway and 5.1 in Austria, according to the OECD.

The OECD research shows that the former Communist states of Estonia and Latvia have better provision of doctors per 1,000 people, at 3.4 and 3.2, respectively.

Plaid Cymru says the figure in Wales is just 2.75 per 1,000 people.

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Dr David Bailey, who chairs the BMA’s Welsh Council said more GPs were needed.

He said more training places for young doctors were vital.

He: “Those who train in Wales are more likely to stay here in the longer term.

“We have repeatedly called for an increase in the number of doctors trained in Wales as part of the solution to tackling recruitment challenges.

“The bottom line is that we need more doctors in order to offer patients a safe standard of care.”

An “exit interview”? Lord Kerslake was ‘asked to resign’ as NHS trust chairman two days before he quit

Laura Hughes in the Telegraph reports 11th December: Lord Kerslake was “asked to resign” as NHS trust chairman two days before he quit.

At last we have an “exit interview” – but by the press. Kerslake gets the NHSreality hero spot for 2017. He fails to use the R word but by implication he says we need to know what is unimportant, and needs exclusion and rationing. Niall Dickson What is unarguable is that demand is growing beyond our capacity to meet it  (chief executive of NHS Confederation).

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ord Kerslake was asked to consider resigning two days before he quit as the boss of a major NHS hospital trust, it has been reported.

The former head of the civil service resigned as chairman of King’s College Hospital NHS Foundation Trust in London on Sunday, saying the health service could not continue “staggering along” under the current funding levels.

However, it has since emerged that he is said to have been asked him to “consider his position” over poor financial performance at the Trust.

Dido Harding, the new chair of regulator NHS Improvement, is understood to have spoken to Lord Kerslake on Friday, according to Sky News.

In his statement, Lord Kerslake said: “He said a “proper review”, potentially on a cross-party basis, was required to address the future of the NHS – and how to pay for it.

Asked on BBC Radio 4’s Today if he believed the public could be forced to contribute more through an extra levy, he said: “I think we are into a proper debate with the public, I think in fact that’s the key issue. 

“We now need a debate with the public to say ‘what’s most important to you?’ I think most people would put the quality of their health and care right at the top and I hope that would be reflected in the response to any such exercise.”

Questioned on whether it was time tell the public that the NHS needed raise more money and it may have to be achieved through taxation, he replied: “I think that’s a big part of it, of course efficiencies have to be made, of course investment has to be there to improve productivity .

“But fundamentally we have to choose, do we want to match the best in healthcare against Western healthcare or not.”

NHS Improvement branded the trust’s financial performance “unacceptable” but Lord Kerslake insisted that savings had been made.

On Monday the watchdog placed the trust into financial special measures, saying its financial performance was the worst in the NHS.

NHS Improvement said King’s board had earlier this year agreed a budget deficit with it of £38 million for 2017/18, but last week forecast it would hit £92 million – an increase of £54 million.

Lord Kerslake earlier told the BBC there was “not enough understanding of the scale of the challenge that both King’s and the NHS is currently facing”.

“We face some here and now issues. I am deeply concerned about the position generally, actually, in London where most of the hospitals are struggling.

“But there is also a big issue about social care as well which got no additional funding in the Budget.

“And I think, deep down, what we need is a proper review, a cross-party review, I don’t mind what it’s called, that looks at what kind of NHS do we want, how much is it going to cost and then how are we going to pay for it.

“Unless we do that we are just going to carry on staggering along, kicking the can down the road and not really addressing the fundamental issue.”

The crossbench peer, who has carried out some work for Labour, insisted that his decision to speak out was motivated by a “deep passion for the NHS” and was “nothing to do with party politics”.

An NHS Improvement spokeswoman said the financial performance at King’s was “the worst in the NHS and continues to deteriorate”.

The trust has now been put into financial special measures regime, with a new interim chairman appointed.

Jim Mackey, the outgoing chief executive of NHS Improvement, singled out King’s as a hospital that had “let down” the NHS by allowing costs to run out of control.

“King’s hasn’t hit a single number that they’ve put to us in the two years I’ve been involved,” he told Health Service Journal, in an interview carried out before Lord Kerslake’s resignation but published since.

NHS leaders have expressed disappointment about a £1.6bn funding boost promised for next  year.

Simon Stevens, head of the NHS has said waiting lists are unlikely to be met, after asking for £4bn.

Mr Mackey said: “If I was … the chancellor or prime minister and you put that kind of money in and all you get is all this negativity, I’d be really pissed off.”

Shadow health secretary Jonathan Ashworth said: “This is embarrassing for the Government and is evidence from a heavily respected figure on the frontline that the Budget utterly failed to deliver for the NHS and that seven years of underfunding is impacting on patients in unacceptable ways.”

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Patients hit by shortage of drugs as prices soar – Mental illness and cancer sufferers forced to wait. Citizens should never be asked to purchase core drugs outright..

In the third world it is usual to be asked to purchase your drugs. When you go to the pharmacy you have no idea whether you re being sold a counterfeit or a placebo capsule with chalk inside. The very idea that in a first world country common drugs should be unavailable is anathema. Politicians and administrators should be ashamed of their rules and statutes that have allowed unscrupulous businessmen to take advantage. But it is not the businessmen’s fault. Their lives are addressed at financial opportunity, and the state gave them one. Now we must tighten up the legislation, and if pharmaceutical companies are not interested in producing cheap generics we will need a National Pharmaceutical Company…. Prescription charges encourage autonomy, but citizens should never be asked to purchase core drugs outright.. So what is non-core will need to be defined…

Billy Kember reports December 7th in The Times: Patients hit by shortage of drugs as prices soar – Mental illness and cancer sufferers forced to wait

In it’s leader on the same day the Times opines: Drug Money – A flawed pricing system is putting lifesaving drugs beyond the reach of the taxpayer

It has become a cliché to say that the National Health Service will always need more cash than the Treasury can afford. Jeremy Hunt, the health secretary, said so recently. Insofar as the NHS is having to minister to an ageing population and pay for more and more exotic and expensive treatments, it is true that whatever money is made available for healthcare will never be enough.

All the more reason for the NHS to bear down on spending where it can. And yet, as we report today, the cost of many drugs used to treat several serious conditions is anything but under control. Recent figures suggest that in the six months to September, the health service paid out an extra £180 million to obtain medicines to combat prostate cancer, breast cancer and severe mental illness among other conditions.

The excess spending was caused by shortages of the necessary drugs. Under agreed rules, these shortages triggered price increases designed to ensure continued supply, but the increase spiralled out of control. In the most extreme cases they have been in the order of 4,000 per cent. One product that not long ago cost the taxpayer £1.62 a unit now costs £65. Such inflation in the price of a potentially lifesaving medicine is, to put it mildly, unfortunate. What shifts the situation from merely expensive to deeply problematic is that some suspect the shortages responsible for the price rises may have been deliberately caused by wholesalers in expectation of surplus profits. Pharmacists are mystified by a continuing difficulty in securing supplies of standard medicines manufactured by a variety of large companies. What is more troubling is that pharmacists say once the price has risen, these drugs sometimes magically become available.

The provision of pharmaceuticals is not like that of crops or coal or cod. There is no obvious variable involved in the mass production of drugs likely to create a sudden shortage and therefore a consequent spike in their cost.

Or maybe there is. A deal negotiated between the Department of Health and the pharmacist’s professional body allows for the price of hard-to-obtain drugs to be raised in extremis. This deal, which rejoices in the comically misleading name of a price concession agreement, is the mechanism that has enabled the recent increases even though they have signally failed to restore supply. Indeed, with pharmacists continuing to report unprecedented shortages, the system appears to encompass a poisonous cocktail of both irregularity and inefficiency.

The consequences are dire. Lives are at stake. Cancer patients are being turned away from their local chemist for want of deliveries. Breast cancer recurrence rates are in danger of increasing. Sufferers of epilepsy are at risk. Schizophrenics and victims of bipolar disorder forced to change their usual prescription are especially vulnerable to a switch in — or worse, an absence of — their usual medication.

The government has made great play of its commitment to mental health treatment. This commitment is fatally undermined when drugs are not affordable. The drug that has risen in price by 4,000 per cent is quetiapine, an anti-psychotic. If some in the supply chain are milking the system that is disgraceful but predictable. Ultimate responsibility for policing the system rests with the government, which must move swiftly to fix it.

Majorities in poor areas will always vote for the party that gives most handouts.. Payment for breast feeding is not well directed..

All education, and health care is divisive in some way. But the politicians role is to devise systems to equalise opportunities as much as possible. Even before breast feeding, the opportunity is potentially “lost” if a mother smokes, and bottle feeding compounds this loss. The next “loss” is lack of nursery placements, lack of meaningful grandparents, divorced parents, and then mitching from school, experimenting with drugs and smoking themselves. Finally underachievement in school meaning less rewarding and productive work, poorer housing, less money and a cycle of deprivation. Where else in this cycle should we “pay” to make a change? Payment not to smoke could result in purchase of more alcohol or drugs. The perverse outcomes of giving handouts to those unable to manage them have been well recorded.. Payments might work for selected groups, like those who have never had a smear (less than 10%), but in Wales, 80% do not breast feed, and when a handout goes to a majority we are on a slippery slope… And how would you confirm compliance? Will breast pumps count? Weighing a baby after feeding? In addition, majorities in poor areas will always vote for the party that gives most handouts.. 

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Chris Smyth reports in the Times 12th December: Health experts say mothers should be paid to breastfeed

Mothers should receive cash incentives as a reward for breastfeeding, experts said last night after a trial found that handing out shopping vouchers improved rates by about 20 per cent.

Public health workers said that a wider use of incentives could improve Britain’s rates, which are among the worst in the world with just 1 per cent of babies breastfed exclusively at six months.

They said that the vouchers made breastfeeding “more normal” in areas where women were embarrassed about it and argued that payments could help to kick-start a wider cultural change.

However, other doctors and midwives said that Morrisons and Asda supermarket vouchers were not the right solution.

Breastfeeding is known to protect babies from infection and has been linked to a lower long-term risk of conditions such as obesity, diabetes and heart disease.

Three quarters of mothers start breastfeeding but this tails off quickly, with fewer than half continuing when their babies are eight weeks old. The figures are worse in poorer areas, with fewer than a quarter of babies starting off breastfed in some places.

To counter this, a trial incentive scheme was set up in areas of Derbyshire and South Yorkshire with low breastfeeding rates.

Women were offered up to £200 in vouchers for supermarkets and the Love2Shop site, which could be redeemed at places ranging from Alton Towers and Champneys spas to New Look, Matalan and Pizza Express.

Over a year 32 per cent of the 5,000 women offered normal care were breastfeeding at eight weeks, compared with 38 per cent of the 5,000 that were offered vouchers.

Clare Relton, who led the study at the University of Sheffield, said she was delighted with the results. “Mothers reported that they felt rewarded for breastfeeding,” she said.

By the end of the trial the gap between the two groups had risen to nine percentage points, with 41 per cent of those offered vouchers breastfeeding, according to data published in the journal JAMA Pediatrics.

Shirley Cramer, of the Royal Society for Public Health, said that payments “could be just the nudge that some mothers need”.

However, Gill Walton, chief executive of the Royal College of Midwives, said: “The motive for breastfeeding cannot be rooted by offering financial reward. It has to be something that a mother wants to do in the interest of the health and wellbeing of her baby.”

The trial relied on women reporting whether they were still breastfeeding and researchers acknowledged that they could not be sure people were not lying to claim the vouchers. Andrew Whitelaw, of the University of Bristol, said that because of this the study was “not a justification for a general policy of economically rewarding mothers who report breastfeeding”.

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Despite the idea that there might and should be a plan, NHSreality is certain there is only a “void”.

Dennis Campbell in the Guardian reports 11th December 2017: Labour demands Commons vote on ‘secret’ plan for NHS – Party says ministers are trying to push through changes that could lead to greater privatisation and rationing of care

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Labour is demanding that MPs be allowed to debate and vote on “secret” plans for the NHS that they claim could lead to greater rationing of care and privatisation of health services.

The party says ministers are trying to push through the creation of “accountable care organisations” (ACOs) without proper parliamentary scrutiny.

Jonathan Ashworth, the shadow health secretary, has written to Andrea Leadsom, the leader of the House of Commons, urging her not to let “the biggest change to our NHS in a decade” go ahead without MPs’ involvement.

NHS England’s chief executive, Simon Stevens, and the government see ACOs as central to far-reaching modernisation plans that they hope will improve patient care, reduce pressure on hospitals and help the NHS stick to its budget.

ACOs involve NHS hospital, mental health, ambulance and community services trusts working much more closely with local councils, using new organisational structures, to improve the health of the population of a wide area. The first ACOs are due to become operational in April in eight areas of England and cover almost 7 million people.

Labour has seized on the fact that the Department of Health plans to amend 10 separate sets of parliamentary regulations that relate to the NHS in order to pave the way legally for the eight ACOs.

In his letter, Ashworth demands that Leadsom grant a debate on the plans before the amended regulations acquire legal force in February.

“Accountable care organisations are potentially the biggest change which will be made to our NHS for a decade. Yet the government have been reluctant to put details of the new arrangements into the public domain. It’s essential that the decision around whether to introduce ACOs into the NHS is taken in public, with a full debate and vote in parliament,” he writes.

A number of “big, unanswered questons” about ACOs remain, despite their imminent arrival in the NHS, he adds. They include how the new organisations will be accountable to the public, what the role of private sector health firms will be and how they will affect NHS staff.

Ashworth also says “the unacceptable secrecy in which these ACOs have been conceived and are being pushed forward is totally contrary to the NHS’s duty to be open, transparent and accountable in its decision-making. The manner in which the government are approaching ACOs, as with sustainability and transformation plans before them, fails that test.”

Stevens’s determination to introduce ACOs has aroused suspicion because they are based on how healthcare is organised in the United States. They came in there in the wake of Obamacare as an attempt to integrate providers of different sorts of healthcare in order to keep patients healthier and avoid them spending time in hospital unnecessarily.

A Commons early day motion (EDM) on ACOs also being tabled by Labour on Thursday, signed by its leader, Jeremy Corbyn, and other frontbenchers, notes that “concerns have been raised that ACOs will encourage and facilitate further private sector involvement in the NHS”.

In his letter Ashworth adds: “There is widespread suspicion that the government are forcing these new changes through in order to fit NHS services to the shrinking budgets imposed from Whitehall.” The EDM also notes “concerns that ACOs could be used as a vehicle for greater rationing”.

The King’s Fund, an influential health thinktank, denied that ACOs would open up NHS services to privatisation. “This is not about privatisation; it is about integration,” said Prof Chris Ham, its chief executive.

“There is a groundswell of support among local health and care leaders for the principle of looking beyond individual services and focusing instead on whatever will have the biggest impact in enabling people to live long, healthy and fulfilling lives,” added Ham.

However, he added: “ACOs will not in themselves address the desperate underfunding of the NHS and may divert more money into processes of reorganisation. Current procurement and competition regulations create the potential for ACOs to be opened up to global private providers within a fixed-term contract and with significant implications for patient services and staff.”

The Department of Health refused to say if MPs would be able to debate ACOs. “It is right that local NHS leaders and clinicians have the autonomy to decide the best solutions to improve care for the patients they know best – but significant local changes must always be subject to public consultation and due legal process.

“It is important to note that ACOs have nothing to do with funding – the NHS will always remain free at the point of use,” a spokesman said.

The Canadians shame us with their plans for end of life care..

The Assisted Dying bill was rejected by Parliament and by the profession. The BMA conference is full of older members as the younger ones are working, but if their opinions were canvassed, the UK would introduce similar legislation to Canada. The Canadians are shaming us and more in touch with their young people. Just as with Brexit, where the oldies votes have outweighed those of the young, assisted dying will not become UK law – for some time yet.

Trish Audette Longo reports in the Canadian National Observer 11th December:  Canadian Parliament makes plans for end of life care.

Canada has moved one step closer to creating new national guidelines for palliative care following the Senate’s passage of a private member’s bill this week.

The legislation was adopted more than a year after it was first introduced in the House of Commons by Sarnia-Lambton Conservative MP Marilyn Gladu in 2016.

“This is the best gift at Christmas time that Canadians could receive,” Gladu told National Observer Friday.

The bill, “An Act providing for the development of a framework on palliative care in Canada,” is expected to receive royal assent, or come into force, on Tuesday, Dec. 12. Gladu explained that the legislation incorporated recommendations made by an all-party committee report on palliative and end-of-life care.

The legislation requires the government to come up with a palliative care framework.

In an e-mail Friday, Thierry Bélair, a spokesman for Health Minister Ginette Petitpas Taylor, told National Observer: “The framework is expected to define palliative care, the training needs of, and other supports for, health care providers and other caregivers, as well as (find) ways to facilitate consistent access to palliative care in Canada.”

A final framework is also expected to “promote research” and “evaluate whether to re-establish a secretariat on palliative care and end-of-life care.”

Bélair noted health care falls primarily under provincial and territorial government jurisdiction, and the federal government is committed to working with them to improve palliative care access. “In addition, our government continues to support pan-Canadian initiatives that enhance quality palliative and end-of-life care, as well as a range of programs and services, such as family caregiver benefits and resources.”

Gladu said the federal health minister would need to meet with the provinces over the next half-year to develop a “plan to get consistent access to palliative care for all Canadians.”

“We have to define the services that the federal government is going to cover in palliative care, the levels of training for the different service providers and caregivers, the data collection,” Gladu said, adding the framework should be established within a year and the federal government would be making transfer payments for defined palliative care services.

End-of-life care can include acute, hospice, home, and crisis care, as well as counselling. Options are particularly difficult to access in rural, remote and northern areas, however, the Ontario MP noted.

Life would be better if we faced up to death…. important conversations are put off until too late

Suicide clinics a preserve of middle class A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

A Dignified Death

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

About time too – Doctors ponder ending ban on assisted dying

Why the Assisted Dying Bill should become law in England and Wales

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