In the BBC Radio 4 “moral Maze” 20th June 2018, the discussion is getting closer to the true concerns of health staff in the know. The protagonists are knowledgeable, and the programme is worth listening to, for all of us. Suggestions that “free at the point of use” is not a moral principle, notions of fairness, and togetherness, and a left wing GP who was not interested in looking at other systems. The differing views were well managed in the limited time, and Dr Niemitz repeatedly observed that other systems perform better, and that many of the phrases used by deniers are “shutting down the conversation”. Is there a mission for the NHS? If so does it need stating again, and reviewing in view of the pace of current advances in technology, the medicalisation of life, and the lack of autonomy in many communities in the UK?
In my own area democracy has been usurped. A new school is imposed using a language that not more than 10% of the residents support, and at the expense of other languages that would make the children more competitive in seeking jobs. The local hospital is threatened, and even if it was “saved” there would not be enough professionals to staff it. Money has been spent on cycle lanes that would better have been spent on duelling the main A40. There is no disincentive to make a claim on health, as opposed to dentistry and eyes. Social Care is means tested, so why not health care?
[PDF]Universal healthcare without the NHS – Institute of Economic Affairs by Dr Kristian Niemietz.
Patient care and safety are fundamental to the NHS, and scandals such as Gosport and the syringes are a reminder to politicians not to take for granted its status as a national treasure. Two years on from the Brexit vote the government remains mired in indecision, to the growing frustration of business. For a beleaguered prime minister, instead, it was far easier to show a bit of decisiveness by awarding tens of billions of extra cash to the NHS as a 70th-birthday present.
For prime ministers, spending more on the NHS has always been the easy bit. Whether the health service can make the best use of its additional funding — £20bn-plus for the NHS in England and nearly £25bn for the country as a whole by 2023-24 — is much harder. The NHS is a monolith, slow on its feet but greedy for funds, absorbing a third of all spending on public services, squeezing education, law and order, and defence. It employs 1.64m people across the UK.
Philip Hammond, in his Mansion House speech, said taxpayers would have to contribute “in a fair and balanced way” to the extra funding. Easier said than done. The tax burden is at its highest since the mid-1980s. What used to be easy revenue raisers, such as increasing fuel duty, are politically difficult. Through stealth taxes and explicit tax rises, Gordon Brown was able to find extra money for the NHS. Now it is harder, and that is no bad thing.
Tax-and-spend is never a good look for a Tory government. When John McDonnell, Labour’s Marxist shadow chancellor, rightly accuses the government of unfunded spending commitments, there is a problem. Voters may see this as evidence of the two parties converging.
While polls show an apparent willingness to pay more to fund the NHS, this should be taken with a pinch of salt. Voters see a health service apparently locked in crisis each winter and too big to be efficient. In a report commissioned by the health department, Lord Rose, former chief executive of Marks & Spencer, identified an NHS “drowning in bureaucracy”. The King’s Fund has described the NHS as “overly complex, over-regulating and generating substantial transaction costs”. Last year another report, led by Sir Michael Barber, called for a “change of culture” across public services, with incentives “which reward more and better for less, rather than bigger budgets and more staff”.
Mrs May’s commitment to extra funding for the NHS risks falling into a familiar trap. Unless money is conditional on efficiencies, the chances are that they will not happen. The think tank Reform argues for the Greater Manchester model of devolving NHS commissioning to local level to be adopted widely. It argues that 95% of NHS England’s budget could be devolved. Nothing so radical is likely. We know for certain that the NHS will get more money. We do not know if it will make it better.
Camilla Cavendish’s NHS wish list (“How best to spend the NHS birthday bonus”, last week) hit the nail on the head in calling for more district nurses. Theresa May’s big NHS speech, though positive in large parts, made no mention of them. Sitting with the prime minister last week in that north London hospital room, having been invited there to watch, I was keen to remind her that hospitals are not the full extent of care.
She is not the only politician to suffer from hospital tunnel vision, a condition that has allowed the number of district nurses in the NHS to halve in the past eight years. Ministers cannot act surprised that hospitals are overwhelmed when services to keep us fit and well at home — district nurses and social care — have been pruned back. Jeremy Hunt, the health secretary, recently acknowledged the false economy of cutting social care. He must convince the prime minister on this point.
Janet Davies, chief executive and general secretary, Royal College of Nursing
Cavendish is out of touch with reality. After the longest financial squeeze in history, the £20bn “bonus” will not even meet the 4% budget increase that independent analysis has suggested is needed to maintain current services, let alone offer new ones.
Increasing the number of district nurses and the level of community care for older people is a laudable aim, but the “seven-day NHS” is pie in the sky. Not only has the evidence on weekend mortality been discredited several times over, but we are currently 10,000 doctors short in the health service. With this government’s short-sighted immigration policy, we will struggle to recruit enough staff to fill the gaps that already exist.
Dr Samantha Batt-Rawden, chairwoman, the Doctors’ Association UK
Duty of care
For someone who worked as director of the No 10 policy unit, Cavendish seems poorly informed. GPs in hospitals? We already face a shortage of doctors, and for those we have, 60 to 70 patient contacts a day is the norm.
Primary care deals with 90% of NHS consultations for about 9% of its budget. GPs already “protect” consultants from millions of referrals for early, undifferentiated symptoms. To further deprive primary care of GPs would drive more patients to acute hospital services.
She also suggests seven-day services provided “not just by clinicians . . . but by staff such as physiotherapists and radiologists”. Workers in such professions will be surprised to discover that they are not clinicians and do not work at weekends.
David Oliver, consultant physician, Berkshire
Supply and demand
Cavendish could have added that some of the extra money should be spent on curing the epidemic of stupidity among many of those who are obese or abuse drink and drugs. It is the unnecessary demands on the NHS that are the real problem, and the solution is not simply more funding.
Peter Mickler, Newcastle upon Tyne
The Prime Minister Theresa May has announced a 70th birthday ‘present’ for the NHS: an extra £20bn a year by 2023, paid for in part by tax rises. It has been received with cries of ‘about time’ and ‘not enough.’ Other voices mutter that we are simply pouring good money after bad into a system that is broken. To go with the funding boost, the government has promised a 10-year plan that “tackles waste, reduces bureaucracy and eliminates unacceptable variation,” but sceptics say we’ve seen those promises before. With an ever-aging population and increasing pressures on the system, is it time for a fundamental re-appraisal of the NHS’s priorities? What is it actually for? Is the job of the NHS to help us when we get sick, or to keep us from getting sick in the first place? Do expensive treatments need to be rationed, and if so, how should we decide who gets them? The sickest, the youngest, the ones with the best chance of recovery or the ones who can’t afford to go private? The mantra of ‘free at the point of delivery’ embodies a fundamental moral principle that makes the NHS the envy of the world, according to many. Others believe it has turned our healthcare system into a religion – and delivered worse health outcomes than different systems in comparable countries. Ultimately, is it fair to ask those who look after their own health to pay for the treatment of those who don’t? Witnesses are James Bartholomew, Dr Brian Fisher, Caroline Abrahams and Dr Kristian Niemietz.
“Between Shipman’s conviction and 2019 around 9 million deaths will have been handled through procedures known to be unreliable”, ( BMJ 2018: 361:k2668 )
Ever since Dr Shipman murdered so many people, we have mostly assumed that unexpected deaths, especially if in large numbers, are investigated. Unfortunately there is perverse incentive for coroners, who have a budget from the government, to reduce costs. Post mortems have reduced in number steadily since the 1970s. BMA fees for post mortems …. you can always ask for one as a family. Commissioners have to cover these fees, and therefore they try to get the coroner to ration post mortems. In addition it will be an interesting dilemma for the Lord Chief Justice. Whether to sue for murder or manslaughter…. In England ( BMJ 2018: 361:k2668 ) New medical examiners will eventually scrutinise all deaths. Tom Luce chair of the fundamental review of death certification and investigation, and Janet Smith, chair of Shipman Enquiry.
Sir, The findings of the Gosport Independent Panel are shocking and will raise further concerns for patients, carers and the public about the use of opioid medication (News, June 21). We would like to reiterate the comments by the Right Rev James Jones that the deaths were related to the administration of “dangerous doses of a hazardous combination of medication not clinically indicated or justified”.
Opioids are widely used within palliative care, and are uniquely effective in managing pain and other symptoms associated with cancer and non-malignant diseases. Side effects can occur but these are usually manageable. Furthermore, appropriate prescribing and continued monitoring can usually prevent serious issues such as breathing problems and drug addiction. Importantly, research has shown that opioid medication does not shorten lives, and may even prolong lives through good pain relief.
Dr Andrew Davies, FRCP
President, Association for Palliative Medicine of Great Britain & Ireland
Sir, Prosecutions resulting from iatrogenic deaths are usually for manslaughter, based on the gross negligence of those responsible for treatment. However, the independent panel has reported that deaths resulted from a practice of “shortening lives through administering opioids without medical justification”. Arguably that meets the legal definition of murder. Since Harold Shipman there has not been a case of large-scale killing by medical personnel. One would hope that, after investigating the facts in full detail, the CPS will have the courage to bring charges of the most serious kind.
Hendon Chambers, London NW4
Sir, The events in Gosport will have been facilitated by our unreliable coroner system. As part of her inquiry into how Harold Shipman murdered some of his patients, Dame Janet Smith recommended that there be an independent coroner service “at arm’s length” from the government. This is not what we have ended up with, and the public cannot have any faith in anything short of a truly national coroner service.
Cowes, Isle of Wight
Sir, Minh Alexander is correct to cast doubt on how whistleblowers would be treated in today’s NHS, even with the “freedom to speak up” guardians that exist. Whistleblowers tend to be, at best, discredited and at worst forced out of their jobs, often on spurious disciplinary charges. Since it is often senior managers who collude to suppress whistleblowers, surely there has to be a role for a new independent organisation outside the NHS to handle whistleblowers’ concerns?
St Helens, Merseyside
Sir, If our new system of “freedom to speak up” guardians had been in place when the nurses at Gosport spoke up they would have been listened to and the right actions would have been taken. The “freedom to speak up” guardian can escalate matters directly to the chief executive and the board, and if necessary to the National Guardian’s Office and in turn the regulators. In the past year more than 6,700 cases have been raised with guardians by NHS staff in England to keep patients safe, support staff and start the culture change that we want to see in the NHS.
Dr Henrietta Hughes
National guardian for the NHS
We are going bust, and without rationing we will only dig a deeper hole. We face lower standards and continuing decline unless we address the reality that we cannot afford Everything for everyone for ever.
The analysis at the bottom of the page in the Times is partly correct, and just needs to admit to failure if we fail to ration overtly. It is not on line, but the comments are worth attention as well, realising complexity. We already means test Social Care payments, so why not means test health payments?
NHSreality is very concerned about the amalgamation of Health and SS into one budget, as this will make the need for rationing, currently covert, more evident. The health budget is beyond control, and growing exponentially…
….The Conservative splits over Brexit have left No 10 reeling from one political crisis to the next, rather than taking time to think of the country’s long-term future. “Every day is about survival,” says one former No 10 aide. “Theresa May was always cautious but her confidence and her political capital were completely destroyed by the election last year.” The row over the “dementia tax” during the campaign has created a neurosis in Downing Street about the funding of social care, but not dealing with this crisis will be more damaging for the country in the end.
On housing, prisons and immigration, the Tory leader is the “roadblock to reform” whose caution has become more entrenched with each Westminster disaster. Businessmen who visit No 10 find themselves repeating ideas that were received enthusiastically, but never implemented, on previous occasions. One compares it to Groundhog Day but leadership is about progressing rather than being stuck in the same place. “There are occasional flashes of radicalism — when she’s surrounded by the right people — but in her heart of hearts she’s a cautious person,” says one former aide. “It’s all about managerialism.”
On the NHS and social care, Mrs May must be bold rather than simply managing decline.
…Announcing a £20.5 billion annual increase to the NHS budget by 2023 the prime minister said that the government would “consider any proposals from the NHS on where legislation and current regulation might be creating barriers”. Last year’s Conservative manifesto had included a similar policy but change in this parliament had been thought unlikely.
In a speech at the Royal Free Hospital in London she alluded to legislation introduced by the Health and Social Care Act 2012 that created hundreds of clinical commissioning groups, responsible for planning and purchasing health services, distinct from trusts that provided the care.
The reforms cost about £1.4 billion and were designed to to give GPs more power over the way money was spent on patients but they were criticised for being too complicated and disruptive. Mrs May said: “I think it is a problem that a typical NHS clinical commissioning group negotiates and monitors over 200 different legal contracts with other, different parts of the NHS.”
Chris Hopson, chief executive of NHS Providers, which represents hospitals, said: “The existing legislation continues to be a barrier to more integrated care and causes unnecessary bureaucracy, so we welcome the prime minister’s offer for NHS leaders to develop proposals for how the legislation may be simplified.”
Mrs May said that the structure of the NHS was too bureaucratic. She added: “Where legislation is making it harder for professionals from different parts of the NHS and different local authorities to work together we should be prepared to change it. Where it is resulting in overly bureaucratic processes we should be prepared to change it. And where it is making it harder to hold NHS leaders accountable for delivering better outcomes for people we should be prepared to change it. We must learn the lessons of the past and not try to design or impose change from Whitehall.”
Mrs May’s money will make no difference and will not create trained staff. If she admitted there would be no dividend for at least 10 years she would be more honest.
What if she buys more scanners – where are the radiologists to report and where are the radiographers to provide, and the oncologists to define the treatment, and radiotherapists to treat?
Where is the plant to provide the projected radiotherapy needs?
So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?
….”to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.”
Without this no administration can win the hearts and minds of the professionals who man the system. They know the truth, which is that there has to be rationing; by exclusion, restriction, exception, reduction, prioritisation, etc. What we don’t like is unpredictable post-code rationing which differs for different people with the same condition.
Weeks — months — of furious speculation, and it all boiled down to a simple set of numbers. Would the settlement be closer to 3 per cent or 4 per cent? For five years or ten? Could Theresa May hit the magic figure of £350 million a week? Would Philip Hammond even let her?
Finally, we have some clarity. The NHS will receive, as its 70th birthday present, a real-terms annual funding increase of roughly 3.4 per cent. Not as much as some wanted, but more than many feared. And though it is being billed as a “Brexit dividend”, the prime minister ominously admits that “as a country” — by which she means as individual taxpayers, present and future — “we need to contribute a bit more”.
What has been almost completely buried in the coverage of this story, and was certainly overshadowed in her interview on The Andrew Marr Show yesterday, is an equally important aspect of the prime minister’s announcement: her insistence that the money must be spent wisely.
It’s often said that analysts at the Commonwealth Fund consider the NHS the world’s best healthcare system. It’s less often said that it actually came 10th out of 11 nations in terms of “healthcare outcomes” — in other words, the most important bit. Compared with its rivals, the NHS has far too many deaths from strokes and heart attacks, and our closest peers in terms of survival after a cancer diagnosis are Chile and Poland.
As the debate over the funding settlement reached its height, we at the Centre for Policy Studies carried out some simple analysis. It showed that as NHS funding goes up, productivity tends to go down: in other words, it does more with less, and less with more. The most notorious example of this was the great Blair/Brown splurge, which was, as the prime minister points out, misspent to a quite scandalous degree.
It’s not just about the headline figures. Talk to anyone in the NHS and you will come away with a laundry list of complaints about how the service works: the profusion of quangos; the targets and funding mechanisms that often incentivise, or force, people to act in the wrong ways; the fact that it is still far too hard to reward and replicate good performance, both by trusts and individuals, and punish bad.
This is why Mrs May was right to insist that the new five-year budget settlement — itself a welcome injection of certainty — be accompanied by performance improvements. That NHS leaders will be held to account for how it is spent, that the health service will have to become more efficient. That structural issues such as slow adoption of new technology and the disconnect between health and social care must be addressed.
But there is still a limit to what this government, or any government, can do. That is why the prime minister, as the NHS turns 70, should appoint a cross-party royal commission: taking NHS England’s current plan as its starting point, but going beyond that to deliver a full examination of the health service and how it can improve.
The difference between an NHS that matches its best productivity performance over the coming decade, and one that lives down to its worst, is vastly greater — in terms of patients seen, operations carried out and lives saved — than between the prospective funding settlements.
In other words, to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.
We will not know until the budget how the new cash will be found (though freezes to tax thresholds are rumoured). But economic growth of 1.5 per cent and NHS spending growth of 3.4 per cent is not a circle that can be squared for ever, unless we either want the state to amputate many of its other functions or to end up paying far more tax: approximately £1,000 extra per individual taxpayer by the end of the decade. (Remember: just as voters complain about the NHS, they complain equally bitterly about the pressure on their pockets.)
Yet if you suggest that part of the answer could be to find ways to deliver extra funding to the NHS outside of general taxation — from charging for missed appointments to introducing top-up payments to get more money from richer patients — you are castigated as a heretic. This, again, is an area where a royal commission could make progress, without the usual party-political brickbats.
The humbug that often surrounds the NHS has a real cost because it stops the health service working as well as it could or should. A few days ago, for example, the head of a left-wing think tank grandly tweeted that “the #NHS is as much a social movement as it is a health system”.
But the NHS is a health system, one that all of us rely on. Yes, it’s packed with dedicated staff, many doing impossibly difficult jobs for little money. But sinking into a sepia-tinted, Danny Boyle reverie about #OurNHS and the #TirelessAngels within it is not the way to make it better. Nor is thinking of all of its problems in terms of how much cheapskate politicians put in, rather than what the rest of us get out.
Robert Colvile is director of the Centre for Policy Studies
There is an ennui in the minds of the nations’ GPs. Disengaged and devalued, and with a job they used to enjoy, the older ones are retiring, the younger ones are leaving early, and those who remain to put up with the conditions are going part time. Throwing money at the problem will not help …. I have resigned myself to the fact that, in the Welsh Health service, I may not see a disgnostic doctor in my final illness. I am likely to see a paramedic or a nurse practitioner. Their skills may be many, and they might be experienced, but they are more likely to miss the “black swan”. A colleague (retited anaesthetist) presented elsewhere with atypical chest pain and symptoms and managed to get treated for his aneurysm before he would have died….. It seems incredible to us retired GPs that the most efficient system in the world, 20 years ago, where 90% of the work was done by 10% of the workforce, has been demolished. Yes, it is too late for me, but it can still be saved if we take the unpleasant medicine. What a boost for Private Healthcare….
One of the difficult discussions a GP can have is whether to raise the possibility of the “private” option with a patient. Some doctors leave it up to the patient to raise the issue, and some believe they should raise it if they feel the patient might be best served privately. What is the answer? In NHSreality opinion, all GPs and consultants should discuss the BRAN test… If a doctor’s first duty is to “put the patient at the centre of their concern”, he needs to point out that infections could be lower away from his DGH, and that survival rates are better in centres of excellence.
Should oncologists come out honestly about what is not available, but what they might like to give? Not without consulting with another Dr, preferably the GP.
Patients will be told to challenge their doctors under guidance suggesting they should question the drugs and treatments they are offered.
Doctors and patients should follow what the Academy of Medical Royal Colleges has called the “Bran” test, which asks about the Benefits, Risks and Alternatives to a treatment, and what would happen if they did Nothing.
The academy, which represents 24 medical royal colleges and faculties, issued the guidance as part of a programme designed to reduce over-medication and decrease interventions of little or no value.
“This is all about enfranchising patients and giving them a sense of ownership of the way they are treated,” Professor Dame Sue Bailey, who leads the campaign, said. “Too often patients just accept what a doctor is telling them without question. We want to change that dynamic and make sure the decision about what treatment is taken up is only made when the patient is fully informed of all the consequences.
“Too often there’s pressure on both the patient and the doctor to do something, when doing nothing might often be the best course of action.”
The first part of its programme, published in 2015, encouraged the NHS to stop using 40 tests, treatments and procedures, including plaster for “buckle” wrist fractures in children. The latest tranche comes after NHS England said last year that it would no longer fund certain treatments including some dietary supplements and homeopathy.
The academy has now listed more than 50 further tests, treatments and procedures, which they said “may have little value or could be replaced with a simpler alternative”.
The list includes a recommendation to extend the length of contraceptive pill prescriptions to a year, to reduce visits to the GP, and simplifying advice on vitamin D supplementation to tell everyone to take them during the winter, not just the frail and elderly. It also says that doctors should not use drug treatments to manage behavioural and psychological problems in patients with dementia if they can be avoided, and talk to relatives and carers before a diagnosis, rather than just relying on a basic cognitive test.
Antibiotics in dying patients, the academy said, could be avoided because they “may not prolong life and can cause discomfort through side-effects”.
The advice is supported by Healthwatch, a watchdog. Imelda Redmond, its national director, said: “The campaign is all about encouraging meaningful conversation between doctors and patients, enabling people to have a greater say over their treatment and care while also ensuring precious NHS resources are used to their best effect.”
• A senior health service official said last night that four in ten GPs quit the NHS within five years of finishing their training. Ian Cumming, head of the NHS’s staffing body, said: “Forty per cent of all the people who completed training five years ago as GPs are not working in substantive GP employment or as long-term locums. They are doing short-term locums, they are doing other things.”
Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions. If the people have a choice they will choose local, ahead of improved outcomes and travelling. As the population ages, and more people survive cancer, we will need more radiotherapy and oncology services. The shortage of Radiologists and Oncologists is so severe that the potential for improvement is threatened.
The NHS will be expected to improve cancer survival rates and put a greater focus on maternity safety under a multimillion-pound funding package due to be announced within days.
Theresa May appeared poised to set plans to boost the NHS budget by more than 3 per cent after intensive meetings yesterday between No 10, the Treasury and the health team.
At a conference of health service managers in Manchester, Jeremy Hunt, the health secretary, said: “We need to make sure we unite the NHS and British people with a small set of bold ambitions as to how we want to transform our system. To get our cancer survival rate to the best in Europe; to transform our maternity safety so it is as good as Sweden; to truly integrate health and social care; to make sure we have waiting time standards for mental health that are as strong and powerful as the standard for physical health.”
He was still having “difficult” discussions with Mrs May and the Treasury over the precise details of a long-term funding plan, but an announcement is expected soon. NHS leaders say they need funding increases of 4 per cent a year, in line with assessments by think tanks. The Treasury is thought to be reluctant to provide that much.
Brexiteers want rises in health service spending to be funded by the so-called Brexit dividend — money available after Brexit that would have gone to the EU. They worry, however, that Philip Hammond, the chancellor, will suggest funding it through tax rises.
NHS sources fear that a “big picture” announcement could amount to a fudge because it will not spell out the exact funding increases on offer. That would mean health chiefs including Simon Stevens, chief executive of NHS England, waiting until November for the details.
There is also likely to be disappointment at a decision to keep social care funding, which is delivered through councils and is the subject of a forthcoming green paper, separate.
A report from the Institute for Public Policy Research, a left-wing think tank, has called for social care to be free of charge for people with substantial needs as part of a new long-term health funding settlement. Social care is currently means tested. Making it free would bring the care system into line with the NHS, where healthcare is free at the point of need.
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.