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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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We must avoid the mistake of a hypothecated health tax – unless the tax takes income and capital into account.

Mistakes are all part of medicine. We make small mistakes all the time, and the pressures of work are part of this lack of perfection. Medical students have always helped out on teaching hospital wards, and it is fake news to suggest this is new. What is new is if their work is unsupervised, and if patients have no choice to opt out. There are some people who will take 17 stabs at a vein, and some patients will have PTSD as a result… Choice is part of Liberal philosophy, as is a progressive tax system whereby inequalities are reduced, and the tax system enhances choices. Hypothecated taxation could well be regressive rather than progressive, it could increase post-code rationing, and unless it is applied allied with an identity card, and fees are related to wealth as well as income, it may come to be regarded as grossly “unfair”. The German two tier insurance system would be better, as it is only a small percentage of high earners who get the extras, and these are not related to medical outcomes: rather to choice, comfort and convenience.. Pithed Politicians have an invidious choice: they have to choose what is less divisive, less regressive, and less unequal. Whatever they choose will be “unfair” to some, but they need to avoid the mistake of introducing a new system and of it being unsupervised. Even Iran has studied this more openly than the UK. 

In a deserts based system where co-payments are related to means, infrequent attenders who kept healthy and looked after their own needs would pay more, but less frequently.. Impoverished frequent attenders would pay less, but more often. There could be a rewards system for reducing attendance, and there could be increasing fees for multiple attendees/families. There could be tax exempt savings (Health ISAs) to encourage thrift, with tax relief on health related savings accounts.

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How to give the NHS extra billions it needs –

The PM and health secretary should be bold and support the emerging political appetite for a levy to fund social care

Another winter, another NHS crisis. With operations cancelled and ambulances queueing outside hospitals, the prime minister has already been forced to apologise to patients. Last week 68 consultants in charge of accident and emergency departments warned that people were dying “prematurely” in corridors because beds are full. Medical students are being asked to fill the staffing gaps. This is not just “shroud-waving” by health professionals or scaremongering by opposition MPs, but the result of a genuine demographic change.

The NHS crisis is really a social care crisis, created by an ageing population and exacerbated by government cuts. Although health service budgets have been ring-fenced since 2010, there has been a £6 billion reduction in spending on social care and an entirely related 50 per cent rise in the numbers of elderly people stuck in hospital because there is nowhere for them to go in the community.

Over the past decade, 929 care homes have closed and more than 30,000 places have been lost because providers can no longer afford to operate on the money they receive from the state. On average, local authorities pay £486 per week for residential care, while the typical private user is charged £700. At least one council pays a shocking £2.31 an hour to providers. Care blackspots have developed in poor areas where there are not enough wealthier “self-funders” to cross-subsidise the places paid for by the government. This is a market that is being broken by its state users at a time when the Conservative Party is calling for a more responsible capitalism.

Jeremy Hunt, the health secretary, has persuaded the prime minister to add “social care” to his job title, but the money to pay for this essential service remains at the Ministry for Housing, Communities and Local Government, which is absurd. If the rebranding is to be more than a change to the headed paper, then the budget must also be transferred to Mr Hunt. The NHS, rather than councils, should then be put in charge of commissioning social care. In Greater Manchester, where this has already happened, the service has improved dramatically while money has been saved. Delayed discharges have almost halved and A&E visits are stable, with GPs visiting care homes to reduce the number of ambulances called. The partnership has approved a pay rise for care workers to avert a recruitment crisis, but is still running a surplus.

It costs about £250 a day for someone to be on a hospital ward and £100 for a domiciliary care package, so there is a motive for the NHS to help elderly people to go home. If local authorities are funding social care, they have a perverse incentive to transfer the cost to hospitals.

Whatever happens, the Treasury will have to find more money. Care homes should be paid the true cost of the service they provide, rather than having to rely on private self-funders to top up the public sector contribution through what is in effect a stealth tax on those who are unlucky enough to need expensive residential care.

Most importantly, the government needs to address the complete unpredictability of the cost for families. Although half of us will end up spending less than £20,000 on our care, one in ten will have care costs of more than £100,000. The Tories like to say that they support those who “work hard and do the right thing” but old age is quite literally a condition lottery in which those with cancer have their treatment funded by the NHS while those with Alzheimer’s have to pay for the cost of their care.

In her first conference speech as prime minister, Theresa May argued: “The state exists to provide what individual people, communities and markets cannot.” It’s hard to think of a more perfect example than social care. The only fair solution is to pool the risk between as great a number of people as possible so that everybody loses something but nobody loses everything.

The prime minister is nervous of championing reform after her disastrous manifesto pledge, dubbed the “dementia tax”. But the problem with the policy drawn up by Nick Timothy was that it raised the prospect of higher charges while failing to pool the risk. That was why Mr Hunt emailed No 10 as soon as he saw the plan (the day before the manifesto launch) to warn it was a “disaster”. With the health secretary now in charge of the green paper, due out this summer, the government will surely return to the idea of a cap on care costs, with anything above the agreed level funded by the state. Indeed, Sir Andrew Dilnot, whose commission first proposed such a scheme in 2011, has been appointed to an expert panel advising on the future of social care.

It will then be a political decision how to pay for the change. One option is to take the money out of people’s estates after they die, but this looks dangerously like the Labour plan condemned by Tories as a “death tax”. The government could raise some of the cash by means-testing pensioner benefits such as the winter fuel allowance and ending the pension triple lock but this has been ruled out by the power-sharing agreement with the DUP.

Mr Hunt is among a growing number of Tories attracted to the idea of a hypothecated health and social care levy as a way of making tax rises more palatable to the public. Last week Nick Boles, the former planning minister, proposed turning national insurance into a ring-fenced health tax. Oliver Letwin is a fan of the plan and Lord Macpherson of Earl’s Court, the former permanent secretary to the Treasury, which traditionally opposes hypothecation, has been won round to the idea.

Sarah Wollaston, the Conservative chairwoman of the health select committee, believes national insurance should also be extended to those beyond retirement age, who are presently exempt, in order to increase the money raised for health and social care. There could be a higher rate for older workers, as in Japan, which has an additional levy paid by those over 40.

Although sources say Mr Hunt is not “wedded” to the idea, he is “open to all the options”, including a dedicated tax, because he knows more money needs to be found. There would be widespread support for it on the Labour and Liberal Democrat benches.

With the number of people over 85 set to double by 2039, social care is now a much more pressing spending priority than reducing university tuition fees. There is no time for another royal commission, nor is there any need for one. A political consensus is emerging about what has to be done. It just needs courage and leadership to see it through. With nothing to lose after his reshuffle showdown, Mr Hunt is willing to be brave. The only question is whether the prime minister has the authority to back him up.

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Medical students are asked to help out in crisis-hit hospitals

Medical students have been asked to help out in overstretched hospital wards to deal with the winter backlog. The request came as leaders of Britain’s 220,000 doctors warned of a crisis in the NHS, which they said would get…

The NHS is already in crisis – Brexit could finish it off – New Statesman

Hypothecated taxation and the NHS – CentreForum (2014)

Hypothecated taxation is not the answer, and Brexit may “finish off” the UK Health services.

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

LibDems suggest hypothecated taxation – without examining the ideology

Hypothecated taxation? A separate NHS tax would rein in spending

The NHS can no longer provide everything to everyone, and we should “Look abroad for serious solutions to the NHS crisis”.

Inequity in Health Care Financing in Iran: Progressive or Regressive Mechanism?

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

Laura Kuensberg comments for the BBC News 11th Jan 2018: Time for an answer on the NHS?

Pithed Politicians?

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The NHS can no longer provide everything to everyone, and we should “Look abroad for serious solutions to the NHS crisis”.

NHSreality suggests major change, with overt rationing, and a system of payments for services related to means. Initially this will lead to many people opting out of the UKs four health services, until standards rise. Eventually, if the standards get good enough, with little difference between private care outcomes and state care outcomes, even the rich will opt for the state care, as it will be cheaper. This is in effect another form of taxation, but it could be offset by the reduction, and eventual removal of inheritance tax IHT). IHT is a double tax, which discourages savings, and encourages perverse behaviours. If we are moving to an era where “user pays” for, say roads, then the same should apply to health. People with poor lifestyles will pay more, until their assets have gone. People who are healthy will pay less. Everyone, of whatever age and means should pay something, but the poorest could have a rebate in their next social security. A scale of payments related to tax code could be a good starter, but eventually the system would need tweaking to allow for wealth as well as income.

Rob Wilson in the Telegraph 12th January:  The NHS can no longer provide everything to everyone (for ever, for free).

The National Health Service challenge facing the Prime Minister is not an easy one. From a weak political position, Theresa May must work out how to help the NHS and see it through its immediate difficulties without entering a Dutch auction of promises to increase funding – an auction no Conservative government can ever win against Labour.

Yet if she does not act, things could turn very ugly indeed, with doctors blaming her Government for the deaths of patients.

Something hugely damaging, akin to the political aftermath of the Grenfell fire, could befall the PM and Jeremy Hunt, her Health Secretary.

Mrs May cannot allow this to happen; so what can be done to alleviate the immediate pressure? Philip Hammond, the Chancellor, provided an additional £350 million in the Budget for winter pressures, so there is money available.

As always in the NHS, questions exist as to whether it is reaching…

Laura Donelly in the Telegraph 13th Jan : NHS crisis fuelled by closure of 1000 nursing homes, housing 30000 pensioners. (or 30,000 beds).

Laura Donelly and Henry Bodkin report 3rd Jan: Come and collect your elderly, hospital trusts say … – The Telegraph

The Telegraph Leader 12th Jan: Look abroad for serious solutions to the NHS crisis.

The NHS is not working. Official figures released this week show the worst A&E performance in England for 14 years. Norovirus cases rose by almost a third. Flu cases threaten an epidemic. The Government insists that the NHS has been better prepared “than ever” for winter – and, if that is technically true, the fact that it is still doing so badly indicates that the health service’s problems are bigger than one  funding round can fix.

The Left insists that all that’s needed is more money, and some on the Right have embraced the idea of a hypothecated tax – perhaps replacing national insurance with national health insurance – that pays specifically for health and social care. But that amounts to a rebranding exercise to justify an inevitable tax hike, asking voters to pay more for a system that remains unreformed. The long‑-term problem is that while the NHS was created for a smaller, younger…

Janet Daily on 6th January opined in the Telegraph: If the health service is to stay nationalised, here’s what we need to do.

If ministers are too cowardly to part-privatise the health service, they’re going to have to get creative

The seasonal crisis in the NHS – if indeed it is a crisis; there has been some dispute over the semantics – is a direct consequence of government-run health care. By that I mean pretty much every government, of whatever political orientation, which presides over the running of the health service.

It was a Labour health secretary, Alan Milburn, who drew my attention to this when he told me, with considerable pride, that the NHS was the most efficient system for administering medical care in the world. What he meant by this was that it was financially efficient: that is, the least wasteful procurement and delivery mechanism for universal medical treatment yet devised.

He was probably right about that, as are all the subsequent government apologists for the effectiveness of the prevailing…

Letters in the Telegraph 14th January:

SIR – Janet Daley provides an accurate assessment of the current predicament of the NHS.

This organisation, managed by the state for decades, with highly unionised staff, has become unable to adapt to the rapidly changing demands of the population.

Its leaders are so distant from the shop floor that they cannot respond effectively. The staff cannot accept change. Meanwhile, the management structure has grown and grown.

It is time for a major change. The nation deserves an efficient, modern health service.

Geoffrey Shaw
Theydon Bois, Essex

When a crisis is the predictable outcome of poor policy making. It will take 10 years to begin to recover, and 20 years to recover completely from the politicians’ cowardice.

Perhaps the politicians (who go privately) think we the people deserve this. The falling standards, lengthening waits and lack of social safety net are now becoming evident. NHSreality started warning over 5 years ago, and even then it was 5 years too late….. It will take 10 years to begin to recover, and 20 years to recover completely from the politicians’ cowardice. … & The captains will NOT go down with the ship…

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Mary McCartney in the BMJ opines: When a crisis is the predictable outcome of poor policy making (BMJ 2018;360:k90 )

When is a crisis not a crisis? The “crisis” may be felt differently in the UK’s four NHSs, but these services are being pushed beyond reasonable capacity. I’ve little doubt that the coping mechanisms—corridor care, ambulance stacking, and a month’s worth of cancelled operations and outpatient appointments—are harmful. And these will contribute to burnout, sick leave, resignation, early retirement, and the cycle of even more rota gaps.

This is not a sudden explosive “crisis” but the predictable, and predicted, result of multifactorial choices over long periods that have made a mockery of evidence based decision making. This is winter: it’s a foreseeable annual event.

Yes, the NHS needs more money. But that money’s wasted if it’s spent on initiatives that don’t work and are driven by party politics, not patients. And it’s been spent on such initiatives repeatedly and avoidably. England has had the internal market and vast monetary waste from administering the legal framework,1 such that Virgin sued the NHS in 2017 in a dispute over tendering.2 This money should have been spent on direct patient care.

In Scotland a quarter of delayed discharges have been due to a lack of residential care beds.3 England has 43% fewer general and acute hospital beds than 30 years ago and fewer beds per head of population than any comparable country.4 People can’t get into hospital, but neither can they safely leave.

In 2013, management consultancies were telling us that technology would save us,5 when it couldn’t; and the government said that telehealth could save the NHS £1.2bn a year,6 before a randomised controlled trial found that it wasn’t cost effective.7 This was all money that could have paid for beds, hospital nursing, and community care.

Austerity has meant English councils cutting adult social care by 11% in real terms.8 The privatised, opaque process of carrying out medical assessments of eligibility for benefits has had a “substantial disadvantage” for the people it should have helped,9 while being associated with worsening mental health.10 This is avoidable harm done to patients and picked up by primary care, all while the provider turns a profit.

The origins of the current winter “crisis” have their roots in multiple places, all accumulating harm. Yet several campaigns aim to change behaviour by advising alternatives to visiting a hospital or GP.

These campaigns are untested and may not work—but they may harm. Patients, induced into guilt about “taking up resources,” may delay consultations and incur avoidable, expensive complications. Shifting problems we’ve failed to tackle onto the shoulders of ill people is unfair. This is a systemic problem that needs systemic change. If we can’t get the essentials of the NHS right we’re failing everyone, including the staff.

We’ve had our fill of short termism and party political policy making. We need to plan for the long term, seek cross party agreements, prioritise the basics, and have an “evidence desk” using expertise and systematic reviews, over which we can debate policy, disallow conflicts of interest, and stop wasteful nonsense in its tracks.

GP out-of-hours services struggle to fill shifts amid “intense” winter pressure –  2018; 360 doi: https://doi.org/10.1136/bmj.k97 (Published 08 January 2018)   (BMJ 2018;360:k97 )

Providers of out-of-hours GP services are struggling to fill gaps in their rotas in the face of “intense” pressure this winter, despite a £10m (€11.2m; $13.6m) cash injection to help cover indemnity fees that was intended to ensure full coverage.1

Simon Abrams, chair of Urgent Health UK, a federation of social enterprises that provide out-of-hours GP services, told The BMJ, “My colleagues generally have found it more difficult this year to recruit doctors to shifts. Pressure on health services has been intense this winter, especially over the bank holidays.”

Abrams believed that previous extra funding from government for winter pressure, such as the £335m announced in November,2 had been too focused on hospitals. “In the wider strategy, there hasn’t been that recognition of …

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A dire shortage of specialist cancer nurses in Oxford reflects a staffing crisis across the NHS that can only be rectified with better long-term planning

NHSreality warned you it was going to get worse, and sure enough it is. It may be that the current crisis is forcing the oncologists to make decisions that they have ducked to now. Patients can often be led into making the right decision, and rarely is it to have toxic therapies that prolong their lives for only a few weeks. The letter from Dr Burt needs to be read and re-read. People are the most valuable resource in the UKs four health services, and we have just not trained enough.

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The Times leader 10th Jan 2018: Care Critical – A dire shortage of specialist cancer nurses in Oxford reflects a staffing crisis across the NHS that can only be rectified with better long-term planning

If anywhere in Britain can offer first-rate cancer treatment, Oxford should be on the list. It has some of the world’s best teaching hospitals, a good record of health service management overall, and every inducement for doctors and nurses considering where to live and work. Yet these inducements seem to be failing. Largely for want of specialist nurses, cancer care in Oxford faces severe rationing that could shorten the life expectancy of terminally ill patients and hurt the chances of recovery for the newly diagnosed.

Emails seen by The Times, written by a senior Oxford oncologist, describe a 40 per cent nursing shortfall that he considers “unsustainable in the short, medium and long term”. They set out a plan to delay the start of chemotherapy for new patients and stretch out fewer cycles over longer periods for those already undergoing treatment.

It is not the drugs that are in short supply, but the staff to administer them. If this were an isolated case the blame could be laid squarely at the door of local NHS managers. In reality the problem is more complex and widespread. Because of falling morale, falling real wages, the scrapping of nurse training bursaries and the impact of Brexit, a general nursing shortage is threatening the quality of care across the NHS. Andrew Weaver, the Oxford oncologist, has issued an appeal for constructive suggestions to fix his staffing crisis. On the national level similar appeals have produced a ten-year NHS “workforce strategy” and an undertaking to train 10,000 more nurses a year, starting in September. This is the right approach, with one glaring shortcoming. It should have been adopted a decade ago.

It takes three years to train a nurse and at least two more for him or her to specialise in cancer care. The work involves delivering lifesaving but also potentially lethal drugs and cannot safely be delegated to non-specialists. Faced with staff shortages, NHS trusts have historically muddled through or sought emergency funding to hire from agencies, overseas or both.

Muddling through is not an option for patients in urgent need of chemotherapy. Emergency funding is in short supply, and hiring from agencies is rightly frowned upon as an inefficient use of public money. Hiring from overseas has been complicated by Brexit.

In the year after the EU referendum the number of nurses from the European Economic Area (EEA) registering to work in Britain fell by 32 per cent. Some of the decrease was accounted for by nurses failing new and necessary language tests, but the fall was still significant. It has been compounded by a sharp increase in the number of EEA nurses opting to leave in the same period.

In absolute terms an exodus of British nurses from the profession is even more troubling. In 2015, for the first time, more left the national register of the Nursing and Midwifery Council than joined it. Last year the net loss was nearly 5,000. The Royal College of Nursing has spoken of a “perfect storm” of factors leading to a record 40,000 nursing vacancies nationwide. Prominent among these is a vicious circle of increasing workloads deterring new recruits.

Macmillan Cancer Support recently listed the consequences of a “historic lack of long-term planning”. One is that a majority of doctors and nurses are no longer confident that the NHS gives cancer patients even adequate care. Where this care is prompt, personalised and comprehensive it can still be second to none. Where it is not, outcomes and survival rates lag behind those of other advanced countries. Having fought to stay on at the Department of Health, Jeremy Hunt will want to do better. A good first step would be a more ambitious expansion of nurse training and a reinstatement of bursaries for specialist training where it is most needed. Starting with cancer.

Top hospital cuts cancer care due to lack of staff

Patients dying in corridors and on makeshift wards, A&E chiefs warn – Chris Smyth 12th Jan

A seminal letter on this subject 9th Jan 2018:

Sir, Oncologists need to take a long hard look at what they are trying to achieve. Response rates in second and third-line chemotherapy are very poor and inevitably interfere with quality of life. There is an obsession with including patients in clinical trials, which are costly and are often used for career progression rather than cancer progression. The hardest thing for an oncologist to learn is not how to treat patients but when to treat them. Many need to learn that no treatment is often the best treatment. It takes guts to tell a cancer patient that no further active anti-cancer treatment is now right for them. The best oncologists do that.

Oncology can surely not moan about staff shortages when literally dozens of consultants and senior nurses sit down for hours on end to discuss routine cancer cases, the management usually being obvious. Multidisciplinary team-working (or medicine by committee) is the biggest waste of NHS resources bar none.
Dr Paul Burt

Retired clinical oncologist, Stockport

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Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

Brexiy buyers remorse may be increasing, as the message in health is clear. There is going to be less rather than more. The Guardian on 13th October published “Labour flags up Brexit poll suggesting public regrets decision”, and no wonder when rather than saving £350m we are losing more than twice than much, annually in the devaluation of the £ and the cost of imports.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts.. As the health services collapse, mainly due to lack of long term planning, and a political and media collusion of denial, some of the predictions in NHSreality are becoming true. The only thing that is National is the opportunity to buy better, faster private care…. We need more youngsters to man our service industry country, and if we don’t stay in the EU we may need to take the example of a town in Japan. (The Economist Jan 9th: A small town in Japan doubles its fertility rate).

The first part of the safety net is the GPs, and the second is the Hospitals and all their staff. 80% of health contacts are seen by GPs, but lives are saved mainly in the second net.. Rationing needs to happen at all levels and the letter from Dr Burt (below) should be read with care. NHSreality has asked for GPs to work alongside Oncologists and this alone would save millions.

Subsidising parenthood appears to work wonders

An unofficial two tier National system. (Where moneyed people go privately)

Covert and post code rationing.

A disengaged medical workforce.

A management wriggling on the inability hook: to make the books balance.

An English language which obfuscates the truth.

A collusion of denial between politicians and the media.

A system where even those fearful conditions, such as cancer, are not properly and fairly covered by the state safety net.  (Bring back fear instead of “In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear“)

Carolyn Wickware in Pulse reports 30th October 2017: GP leaders prepare for explosive vote on practices leaving the NHS

Sarah Marsh in the Guardian 11th Jan 2018: NHS winter crisis: hospital ‘felt like something out of a war zone’ – Husband of a patient and locum doctor share moving experiences of severe pressures on national health service

Kat Lay has reported on Cancer services, especially in Oxford, in the Times recently. Jan 11th: Hospice loses beds in NHS staff crisis and in the letters 12th Jan:

Cuts to cancer care owing to staff shortages

Sir, For the past three years we have been urging the government to tackle cancer workforce shortages in the NHS. It is totally unacceptable that these shortages could now lead to delays in patients getting treatment. This latest episode at the Churchill Hospital in Oxford (report, Jan 10), where chemotherapy may be delayed owing to a lack of specialist nursing staff, adds to a growing list, which includes cases where lung cancers were left undiagnosed because of a lack of radiologists. Immediate action needs to be taken by the government to deal with this, otherwise problems like the one at Oxford will become more widespread and more severe.

An additional 150,000 people are expected to have cancer diagnosed annually by 2035. We need more staff, with the right training and support, in the NHS to deal with the increasing number of cancer patients who need to be diagnosed and treated. We estimate that the projected 2022 consultant oncology workforce could be roughly half the size that it may need to be to deliver the best care, with a shortage of between 1,281 and 2,067 staff. Health Education England recently published its first-ever plan to deal with the staff shortages in cancer care, but this relies heavily on stretched local areas taking action and making difficult spending decisions, and will not change the situation overnight.

We have a national ambition to achieve world-class cancer outcomes for all patients. We will not get close to achieving this — and to offering patients the best chance of long-term survival — without tackling crippling workforce shortages.
Sir Harpal Kumar

CEO, Cancer Research UK

Sir, Oncologists need to take a long hard look at what they are trying to achieve. Response rates in second and third-line chemotherapy are very poor and inevitably interfere with quality of life. There is an obsession with including patients in clinical trials, which are costly and are often used for career progression rather than cancer progression. The hardest thing for an oncologist to learn is not how to treat patients but when to treat them. Many need to learn that no treatment is often the best treatment. It takes guts to tell a cancer patient that no further active anti-cancer treatment is now right for them. The best oncologists do that.

Oncology can surely not moan about staff shortages when literally dozens of consultants and senior nurses sit down for hours on end to discuss routine cancer cases, the management usually being obvious. Multidisciplinary team-working (or medicine by committee) is the biggest waste of NHS resources bar none.
Dr Paul Burt

Retired clinical oncologist, Stockport

Sir, Cancer care at the Churchill Hospital is likely to be compromised as a result of the shortage of trained oncology nurses. The reasons are multifactorial; one that is quoted by the management of the hospital is the high cost of housing in Oxford. Training more specialist nurses takes five years, whereas the introduction of an Oxford weighting to nurses’ salaries on a par with the existing London weighting could be introduced immediately. London is not the only city with housing costs well above the national average. No doubt new money would have to be found to do this but it would go some way to help nurse recruitment in high-cost areas.
Griffith Fellows

Retired urologist, Churchill Hospital, Oxford

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.

Bringing back fear, and suffering. A return to 19th century inequalities.. How quickly politicians destroyed what was the best safety net in the world?

 

 

 

 

Our state-run healthcare model makes winter crises inevitable: the healthcare crisis seen from abroad, and publicised in the City.

Even the Americans have failed to appreciate that there is no NHS any longer, and no wonder when the City Am newspaper continues to ignore that there are at least 4 jurisdictions. The different sets of rules mean different outcomes. Seen from the Cato institute in Washington, Ryan Bourne opines in an article today. He was probably prompted to write by Ed Morrisey in “Hot Air” on 5th January: Great Moments in single payer: Britain cancels 5000 surgeries. With extremist views from America, the civil unrest that NHSreality has warned about becomes more likely. It is helpful to government that dead patients don’t vote, but in the end the model has to fail. We need to look elsewhere, and not to the USA. Canada, NZ and Australia all have sustainable models with good results, and the German and Dutch models from Europe are realistic and pragmatic. In the shires we know the truth..

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Ryan Bourne for City am 9th January reports: Our state-run healthcare model makes winter crises inevitable.

The Daily Mirror claimed “our NHS is dying”.

The Sun reported on “third world A&E”. The Daily Mail saw the “A&E crisis worst for 10 years”, while the Daily Express lamented “hospitals just can’t cope”.

No, these were not last week’s newspaper headlines, as Britain’s ailing health service cancelled thousands of operations, and large queues developed at accident and emergency again.

In fact, they appeared on Facebook as a “memory” from this same date in 2015.

Can a healthcare system in perennial crisis like this really be the “envy of the world” as politicians claim? Each year we hear the same old cliches.

Those with blind faith in the abilities of the NHS point to other major countries spending more on healthcare. The issue is merely “underfunding”, they claim.

For those who acknowledge that healthcare outcomes here are worse than in other countries, technocratic tweaks are suggested, or cop-outs advocated. The most popular is the creation of a cross-party commission which will supposedly come up with all the answers.

For all the talk of the need for an “honest conversation about the NHS”, people do not really want to hear the basic economic problems associated with a taxpayer-funded, state-run, socialised healthcare system. And if the scope of any commission makes such a model sacrosanct, what is the point?

Basic economics tells us that if you set the price of something at zero at the point of use, demand for it will always vastly exceed supply.

The implicit “price fixing” of an NHS delivered “free” to users will mean that there is always a “shortage” of healthcare. Absent prices, the only way of allocating such care will be queuing and rationing.

Demand for healthcare is rising, exacerbating this problem.

As people get richer, they tend to want more healthcare (mainly preventative care). An aging population increases the “need” for healthcare too. Yet the demographics also mean that the main tax paid by working-age adults is shrinking relative to the retired population, where demand is highest.

So demand for healthcare is rising in a system where demand already exceeds supply by construction, and where it’s getting harder to raise tax revenue to fund new supply.

Add to this the “planning problem”. At this time of year, there tend to be spikes in demand for healthcare, due to cold weather. In an ordinary market, unforeseen surges in demand would raise prices, encouraging other providers to enter the market or to alter where they put resources to serve the waiting customer base.

In the NHS, unforeseen demand simply results in more queuing and rationing. Given that budgets are largely fixed by the political process, and resources are allocated to different parts of the service based on highly speculative demand estimates, deviations in demand can lead to acute shortages.

Of course, on the margin, having more resources can help. An NHS awash with cash would no doubt be under less pressure than it is today. But no reasonable amount of funding would solve these structural economic realities entirely.

There is a reason the NHS has these winter crises regularly, and other countries do not

In fact, the NHS model creates other problems. Since healthcare in the UK is provided free at the point of use, and providers rely on the government for funds, there is little pressure for harnessing technological innovations for improving efficiency.

ONS data showed this clearly last week. NHS productivity essentially flat-lined in the years from 1997 to 2010, when healthcare officials knew Labour intended to hugely increase funding. It has only seen significant improvement in the years since 2010, when its funding diet has been relatively lean.

This point is missed by those who think all our current problems stem from “underfunding”. That the NHS spends less than other countries on healthcare does not mean the NHS is more efficient, because efficiency is the outputs you get for given inputs, not just the inputs themselves.

And most other countries get better treatment and health outcomes per pound invested than we do.

We are therefore left with this quandary. All major western countries face healthcare spending pressures as populations age. But other systems allow individuals to spend more themselves and provide market-based incentives for innovation and adaptive provision.

In the UK, we have a socialised NHS rationing system that is delivering poor healthcare outcomes, in large part due to basic economic phenomena. Yet all political parties support the current model.

Absent a change in the political consensus, more money will eventually be thrown, no doubt providing a sticking plaster for a while. And then the sensationalist headlines headlines will reoccur next winter.

In the same paper Kate Andrews and Roz Davies asked 20th December: Is it time to overhaul the structure of the NHS?

Kate Andrews, news editor at the Institute of Economic Affairs, says YES.

You can keep the three letters if you wish, but it’s time for the NHS to be overhauled and replaced with a better, patient-centric system.

The NHS is not unique in providing universal access to healthcare; indeed, the majority of the developed world offers it. But while the NHS tends to rank in the bottom third internationally for health system performance, the social health insurance systems of Switzerland, Germany, and Belgium provide significantly better healthcare services through the use of market mechanisms.

The outlier study from the Commonwealth Fund, which grades the UK best overall for healthcare, still ranks it tenth (out of 11) in the “healthcare outcomes” category.

When the Guardian wrote up the study in 2014, it noted that “the only serious black mark against the NHS was its poor record on keeping people alive”.

This sacred cow isn’t worth protecting. It’s time for a system fit for 2018, which delivers more for British patients.

Read more: To save our treasured NHS, we must first acknowledge that it is failing

Roz Davies, principal director for communities and localities at the New Economics Foundation, says NO.

People from all backgrounds trust and value the 70-year treasure that is the NHS. Compared with the US privatised model, the NHS is cheaper, more efficient, more accessible and more equitable. It makes no economic or political sense to break up one of the best healthcare systems in the world.

But seven years of austerity, coupled with growing demands, have taken their toll. Simon Stevens, chief executive of NHS England, says the NHS can no longer do everything asked of it, and in financial terms, the current situation is “well short of what is currently needed”. It would be foolish to ignore his warning.

The NHS doesn’t just provide healthcare free at the point of contact. It is also a critical part of the local economy, employing people, purchasing supplies, supporting community groups, training students, and working in partnership with local authorities to improve lives in countless ways.

Investing in the NHS means investing in people and places all over the country. What can be more important than that?

Rachel Cunlliffe in the same paper 5th January 2018 opines: We cant save the NHS until we recognise it’s failing health.

The NHS has had to cancel 50,000 non-urgent operations to deal with the winter crisis. This is not normal.

The Prime Minister may be pretending everything is fine, but this is not acceptable.

The trouble is that, beyond the acknowledgement that there is a very serious problem with a health service that spasms in predictably cold seasonal conditions, the national conversation grinds to a halt.

The NHS is sacred. Criticising it in any way, even in an attempt to improve it, is therefore sacrilege.

And hence we have the absurd situation where health secretary Jeremy Hunt, who is not even responsible for how much money the NHS receives, is dragged before the cameras to personally apologise to individuals whose operations have been cancelled……..

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An absence of political courage means the Health Services are dying..

The author of this piece in the FT is not persona grata in the cabinet circles at present, but she has worked at the coal face and is honest. With apologies to the FT for reproducing the article, but I am sure the author would not be upset. Political courage is absent in our current distracted leaders, so no prospect of the real reform needed exists. Its. going to get worse.. Back to the “dark ages”?

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Sarah Wollaston in the Financial Times January 6th 2018: Only political courage can save Britain’s health service

It will take a cross-party approach and a willingness to put public interest first

There is nothing new about winter pressures in the National Health Service. What has changed
is that those pressures have become relentless, extending year round into the traditionally
quieter months and deepening in intensity over the winter. The current crisis is not simply
caused by the number of people turning up to A&E but because those who do are far more
unwell and many more need admission. With hospital bed occupancy running at unsustainably
high levels and a growing shortfall in community beds and workforce, the health and care
system can rapidly become overwhelmed. An upswing in norovirus and flu over the past
fortnight seems to have been the final straw. NHS England had little choice but to implement its
emergency plan to ease the acute pressure by cancelling routine surgery until the end of
January. Unless we address the underlying issues across both health and social care, this risks
becoming the norm every winter. The unsustainable pressures will also result in a collapse in
routine waiting times. Increasing life expectancy is one of the greatest successes of our age. But
as we live longer and with more complex conditions, health funding has lagged behind. There
has been an abject failure by successive governments to plan for the sheer scale of the long-
term demand and costs associated with demographic change � and for the change required
to properly integrate health and social care. The House of Lords select committee set up to
examine the sustainability of the NHS rapidly concluded that it could not do so without
including social care. The government needs to take note before repeating the mistakes of the
past. A green paper that looks solely at long-term funding for social care will miss the point that
these two systems cannot be considered in isolation. Neither should anyone underestimate the
challenge of delivering policy change in a hung Parliament, or by a government whose energy is
so consumed by Brexit. There is a way forward but it will take political courage from all parties
and a genuine willingness to put the public interest first. Before Christmas, 90 backbenchers
from both sides of the House of Commons wrote to the prime minister urging a cross-party
approach to the challenges and funding of the NHS, social care and public health. Select
committees could also play a role to help to build on existing work and set out the options for
the public. Nick Timothy, Theresa May�s former chief of staff, has advocated a Royal
Commission but we do not have the luxury of time to kick this critical issue into such long grass.

Many of the options have already been outlined by the Barker Commission and recent House of

Lords inquiry. The reality is that we will all need to be prepared to contribute more if we want
the NHS, launched in 1948, to remain a universal service, free at the point of delivery and
meeting our needs both now as well as in the future. This cannot, in my view, fall entirely on
working age employed adults. We also need to consider inter-generational fairness, wealth and
contributions from those who are self employed. As graduates struggle with student loans it
would be unfair to expect them also to shoulder the increasing costs of health and care for
those in retirement irrespective of their wealth. We could look at ideas for a hypothecated
health and care tax paid by those over 40 and with income from any source above a set
threshold. Some advocate introducing charging and top ups but these bring higher transaction
costs and widen health inequality. All options should be clearly set out alongside the
consequences of a failure to invest more in the NHS, care, public health and prevention. Since
2010, total health spending has risen by an average of just over one per cent per year. This is
far lower than the long term average increase of around four per cent and comes at a time of
extraordinary rise in demand and costs of drugs and technologies. Real terms cuts to social
care have added to the strains. It is time to stop viewing health as a bottomless pit but rather as
one of our greatest successes. Investment should be a source of national pride. I cannot think
of a better way for Mrs May to celebrate the 70th anniversary of the NHS than by helping to
make sure that it has a sustainable long term future.
The writer is the Conservative MP for Totnes, a former doctor and chair of the House of Commons health select committee
Alex Matthews-King for the Independent reports: Independent inquiry ‘only way’ to guarantee agreement on future NHS funding as May says 55,000 cancelled appointments are ‘part of the plan’

Winter crisis caused by short-term funding linked to political whims, says think tank

The Centre for Policy Studies suggests: Papers back CPS calls for an NHS Royal Commission – Maurice Saatchi’s latest paper on an NHS Royal Commission receives widespread support from the media and commentators.

BBC News around the regions: