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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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Junior Doctors: Low Morale and Burnout

Listen to this massaged program. In the middle you can hear that the Junior Doctors involved at KGT (Kings, Guys and Thomas Hospitals) wanted to extend their thinking to the whole system. But the facilitator denied thus, and kept them “on target”. This is a form of denial. Every politician should listen..

The Fix: Junior Doctors: Low Morale and Burnout on BBC Radio 4 in the evening of 15th September

Junior doctors are the backbone of the NHS, including its emergency services. But more and more of them are now leaving the profession, due to low morale and burnout.

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The 3 myths of the NHS…..& …No learning from other countries – no co-payments, and more scandals..

With Mr Cable suggesting we “Tax the rich” more, and without means tested co-payments for health, as a reasonable additional method of rationing, NHSreality wonders if this is a policy that will win the votes of non members?

Bagehot in the Economist 28th June 2018 opines:

The three myths of the NHS- The National Health Service is a great institution. It is also the subject of fairy tales

There is little mention of the underlying ideology, and the fact that morale is so low because the staff cannot buy in to the prevalent philosophy. However, the correspondence (see below) challenges Bagehot. The first is another expression of denial. The second is the reality of other systems which discourage dependency and encourage autonomy through co-payments. Do we need to “test” our politicians? Do they know that there are better outcomes elsewhere? Of course they do: that’s why they all go privately.

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THE National Health Service’s 70th birthday is turning into an extravaganza. The government has given the service a £25bn ($33bn) present to mark the anniversary, which falls on July 5th. The BBC broadcasts daily encomiums to the wonders of free health care. Jeremy Corbyn, Labour’s leader, wore a large badge celebrating the NHS’s birthday at prime minister’s question time.

The NHS is the most popular institution in the country. In a survey by Ipsos MORI last year, 77% of respondents believed that it should be maintained in its current form and 91% supported its founding principles, that health care should be free at the point of delivery and funded by general taxation.

It is so popular because it is more than just a public service. It is also an embodiment of British values at their best: compassion and decency; waiting in line rather than barging ahead; being part of a national community rather than a collection of self-seeking atoms. These values were central to Britain’s conception of itself in 1948 when the Labour Party founded the NHS as part of its New Jerusalem. Many people cling fiercely to the health service today precisely because it is a reminder of a more egalitarian society and an antidote to our self-seeking times.

Walter Bagehot, the great 19th-century editor of The Economist, argued that the British constitution was divided into two branches: the dignified, which represents the nation in its symbolic form, and the efficient, which gets the work of the world done. The NHS is the most-loved British institution because it straddles this divide. It is dignified because it represents Britons’ collective view of themselves as a decent bunch of people, and efficient because it treats more than 1m patients every 36 hours.

The fact that the NHS spans the dignified and efficient divide not only explains why its birthday is being celebrated with such enthusiasm. It also explains why so much of this enthusiasm is coupled with nonsense and exaggeration. It is hard to remember a time other than a royal wedding when so many commentators have uttered so many half-truths—or indeed non-truths—with such grave conviction. Three myths are particularly cloying.

The first is that Labour summoned up the NHS from thin air; that before 1948 the poor died in the streets but after 1948 they were suddenly equipped with new hips and false teeth. In fact, the government inherited a rich patchwork of charitable hospitals, school medical services and employer- and government-subsidised health care. The 1945-51 Labour government didn’t build a single new hospital or add significantly to the number of doctors. Its achievement was to nationalise a patchwork system and make it free at the point of delivery.

The second is that the NHS is a unique embodiment of compassion. Aneurin Bevan, the health secretary who created it, sold the NHS as proof that, even as Britain was ceding global leadership to America and the Soviet Union, it was still a superpower in one vital area. “We now have the moral leadership of the world, and before many years we shall have people coming here as to a modern Mecca, learning from us in the 20th century as they learned from us in the 17th century,” he declared. But there was far more than morality at play. The service’s roots are in the “national efficiency movement” of the Edwardian era. The 1905-15 Liberal government introduced medical inspections for schoolchildren in 1907 and national health insurance in 1911, among other reforms, because, in Lloyd George’s words, “The white man’s burden had to be carried on strong backs.” After 1948 the NHS was part of a warfare-welfare state that spent 10% of GDP on defence and maintained a large conscript army because it worried that war with the Soviet Union was imminent.

The NHS does a middling job of turning compassion into care—certainly better than America, but worse than several continental countries that rely on compulsory insurance backstopped by the government. The Nuffield Trust, a health think-tank, points out that Britain has markedly fewer doctors and nurses per person than similar countries, and fewer CT scanners and MRI machines. It also has higher rates of mortality for problems such as cancer, heart attacks and strokes. On the positive side, it is excellent at providing long-term care and value for money.

The final myth is that the Conservative Party is perpetually bent on selling off the NHS to the highest bidder. There may be a few ideologues on the right who dream of replacing the health service with an insurance-based system or an American-style public-private mix. But they are outliers. Conservative right-wingers have shied away from acting on their principles. One of the first big boosts in NHS spending came in 1962 when Enoch Powell, an early champion of the free market, splashed out on 90 new and 134 refurbished hospitals. Mainstream Conservatives like the NHS because it gives the government a way of controlling health spending and ensuring value for money. Easy on the champagne

It may seem a bit churlish to turn up to a birthday party and spit on the cake. Myths can serve a useful function in boosting morale, particularly when morale has been eroded by a decade of austerity. But the myths that surround the NHS have also done harm. They have given the Labour Party an excuse to demonise Conservative reforms as “backdoor privatisation” rather than subjecting them to serious criticism. They have discouraged the NHS from learning from other countries. They have made it impossible even to think about boosting NHS revenue by charging patients a nominal sum for visiting the doctor. They may even have allowed scandals to go uncovered because nobody can bring themselves to blow the whistle on saintly NHS workers. Britain is right to celebrate a service that provides all Britons with free health care at a reasonable cost. But they are wrong to treat the NHS as an object of awe rather than a human institution with all the imperfections that being human entails.

Bagehot suggested that any discussion of boosting its revenue by “charging patients a nominal sum for visiting the doctor” is off the cards because of the Labour party’s desire to “demonise conservative reforms”. An alternative view is that bitter experience has taught the public that nominal fees soon begin to grow at an exponential rate to painful levels. Charges for prescription drugs being a good example. “Free at the point of delivery” is a red line that all voters of all persuasions know must be held at any taxation cost. P Corser Selborne Hants.

Bagehot created some of his own myths about the NHS. Edwardian health reforms did not provide the roots for legislation that created the NHS in 1948. Medical inspections of children were precisely that: to tell their parents that their child needed a doctor. Treatment still had to be paid for. Free (or subsidised) health care appeared much later. And Nation Health Insurance, “employer and government subsidised health care”, offered only minimal GP careto a minority of the working population, namely low-waged blue-collar workers. Maternity care aside, the scheme offered nothing to their wives.

The Edwardian reforms were aimed at promoting the physical well-being of the male workforce and armed services. The principles of the NHS were different, based on equality. Why else would you dedicate equivalent medical resources to post-menopausal women? Moreover, thanks to the Trreasury’s parsimony, NHI never developed in the way it did in Germany. There, a Bismarkian Health=Insurance scheme expanded to provide universal cover, the foundations of German Health Care today. Prof Noel Whiteside, Institute for Employment Research, University of Warwick.

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An online complaints box cannot replace structured, professional, trustworthy, depersonalised, “Exit Interviews”.

There are many “ideas about healthcare” and the TED talks is a good place to start.  The letter following from the president of the Royal College of Anaesthetist points out that this “..clearly affects all health and social care workers and more needs to be done to tackle it”. In the absence of exit interviews, and without these being conducted by an independent Human Resources company, NHSreality feels that staff will be slow and reticent to use an internal facility. Things have got too bad. But the suggestion at least acknowledges the reality of the problem of NHS staff morale, and bullying.

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Richard Ford in the Times September 10th reports: Got a gripe? NHS staff to have their own online complaints box

NHS staff will be able to voice complaints and express frustrations about their jobs and bosses in an online service set up by the government to tackle poor morale in the health service.

Staff will be able to use the Talk Health and Care digital platform on their phones and tablets after it is introduced today by Matt Hancock, the health secretary. He wants to hear first-hand from those working on the front line of the NHS, who are the most qualified to advise on what needs to change.

“Millions of hard-working health and care staff turn up to work every day to meet any challenges tirelessly, with unending compassion,” he will say. “But they don’t just do this for money or other contract benefits. They do it to improve and save the lives of countless strangers, and in return it’s only right that they are valued, supported and developed. Too often health and care employers, despite the NHS being the world’s fifth largest employer, don’t get this right. It’s time we hear from health and care staff about what they really have to say about the jobs that are at the heart of this country.”

Mr Hancock has expressed concerns at the high number of bullying and harassment claims from staff and wants to ensure that these problems are not “put into the too-difficult pile” by bosses.

The health secretary will make his announcement during a visit to Southmead hospital in Bristol where his sister, Emily Gilruth, 41, was treated after she was seriously injured in a fall while competing at the Badminton Horse trials last year. She was in a coma for four days after hitting her head. He will meet and thank doctors, nurses and care staff for saving her life.

The most recent NHS staff survey found that 15 per cent of staff had experienced physical violence from patients, relatives or the public, with that figure rising to 34 per cent for ambulance staff. About 28 per cent of staff (47 per cent at ambulance trusts) experienced harassment, bullying or abuse from patients, relatives or the public.

Nearly a quarter (24 per cent) had been harassed, bullied or abused by their colleagues and 12 per cent felt that they were victims of discrimination, a figure that rose to 24 per cent for black and minority ethnic employees.

The Talk Health and Care platform, an in-house service available to the NHS’s 3.1 million staff, will allow them to offer views on improving their shift patterns, juggling home and work lives, speeding up the use of helpful technologies and training and development.

Ruth May, executive director of nursing at NHS Improvement, welcomed the service, saying that it would “help the NHS listen to and support its staff, so that they feel happy, healthy, safe and valued”.

Sean O’Sullivan, head of health and social policy at the Royal College of Midwives, said: “We welcome any initiative to get the views of midwives and NHS staff.

“They will often have solutions to problems they face and ideas for delivering safer and better care. What is important is that this is a real exercise in engaging with staff and that the government act on what staff tell them.”

Mr Hancock has previously been a digital minister and became the first MP to launch his own smartphone app earlier this year. When the app was found to collect its users’ photographs, friend details and contact information, Silkie Carlo, director of the privacy rights group Big Brother Watch, called it a “fascinating comedy of errors”.

NHS MORALE AND THE NEED FOR REST
Sir, Matt Hancock’s work to develop a digital platform so NHS staff can voice their concerns is a welcome move to better understand poor morale and bullying among our doctors and the wider healthcare staff. (“Got a gripe? NHS staff to have their own online complaints box”, Sep 10). The Royal College of Anaesthetists’ own surveys show that poor morale (and to a much lesser extent, bullying) can be an issue across all grades of our members, but it clearly affects all health and social care workers and more needs to be done to tackle it.

One immediate step that the government could take to improve the welfare and morale of NHS staff is to ensure that all hospitals have adequate rest facilities. Thousands of NHS staff do not have a dedicated room to rest at the end of their shift, and tired doctors and other frontline clinical staff are at risk of being killed and injured in accidents while driving home exhausted. This needs to be urgently addressed.
Dr Liam Brennan

President, Royal College of Anaesthetists

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There are thousands of “ranting doctors”, but they keep their rants to themselves. Times for honest and open “exit interviews”.

Whistleblowing in the US – helping to change the organisational culture? No comparison with state owned organisations.. Exit interviews better and less destructive..

NHS pays £100,000 a day for mistakes. We do have a choice, and we dont have to wreck it..

Once again, reporters are omitting to mention that this “may” only be the figure provided by the DOH in England. There is no NHS, so what are the comparable figures for the 4 regions of the UK? Devolution has failed in health and education in Wales, which are more expensive and of lower quality than England. The litigation budget in Wales is extraordinary…. More and more people are aware of the safety net failures, and are paying for private care. No fault compensation is a reasonable way forward. Providing more home grown and trained doctors and nurses will also help…

See the source imageThe Times reports September 13th: NHS pays £100,000 a day for mistakes

Three patients a week are being compensated by the NHS after claiming that botched care left them without a limb, unable to see or suffering from cosmetic scarring.

In the past eight years the NHS has paid out compensation to 810 patients who suffered needless amputations, 340 who were left blind after poor hospital care and 269 who sustained cosmetic injuries as a result of negligent treatment, the latest figures show.

NHS Resolution, which resolves compensation claims, paid out £3.2 billion meaning the cases are costing the NHS more than £100,000 a day.

The biggest group of claimants was people who won legal cases against hospitals saying that negligent care meant they had to have an amputation.

The compensation paid out over the past eight years to the 810 people who had lost a limb totalled £2.2 billion, meaning that the average payout for the loss of an arm or leg was almost £300,000.

The average compensation cheque for loss of sight was about £250,000 while the average claim for scarring after cosmetic surgery was about £30,000.

Joyce Robins, of Patient Concern, a patients’ rights group, said: “It is absolutely unbelievable that you go into hospital for care and then you end up suffering more. Much of the problem is down to the system being overstretched. We just don’t seem to have enough people to look after patients.”

An official from the regulator, NHS Improvement, said: “Providing patients with high quality and effective care is a priority for hospitals.

The NHS successfully provides safe and compassionate care to hundreds of thousands of people per day, so incidents where this doesn’t happen are thankfully very rare.

However, it is vital that when they do, hospitals investigate and take action to improve.”

See the source imageThe blame game. The proliferation of compensation claims – needs a “no fault compensation” cure, possibly through a social insurance fund.

Fully home grown doctor workforce – Medicine thrives on experience from abroad. There is irony in a short term recruitment solution ..

The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

How much does NHS Wales spend? You can find out the basics, but not in comparison with England yet.

A plea for No-Fault compensation: please politicians, think long term.

This is starting to add up. Overseas patients, fraud and litigation… are costing us all dearly.

See the source imageThe Express Anna Behrmann in 2016 reports : NHS lines up £56billion of budget to pay for legal costs of negligence cases

THE NHS has set aside almost half of its entire budget to cover compensation payments and legal costs, it has emerged.

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Hospital job vacancies top 100,000 due to bad planning. NHSreality adds political short termism, & high sickness and absenteeism..

The bad planning is built into the system it seems, as successive and different administrations under ministers of health of many different persuasions have fallen into the same trap. Undercapacity. The 4 health services reports their staffing levels on different sites. It is accepted that the health services combined are the largest employer in the country, and have the highest absenteeism.

England, WalesScotlandN Ireland

The total full time equivalent workforce is unknown as so many are actually in the GIG economy, work part time, or are part of a  sub-contracted service. It is not all due to bad planning. Some blame must fall on our first past the post political system whereby no elected MP considers any problem solving with a time horizon longer than the next election. It is made worse by the largely female workforce, the part-time working, and the high sickness levels. 

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Kat Lay reports “on line” with a different heading on September 12th in the Times: National emergency risk as NHS vacancies top 100,000

More than 100,000 NHS jobs are unfilled and vacancies are increasing, according to the hospital regulator.

Experts said that there was a risk of a national emergency because of “a long-term failure in workforce planning”. The figures are part of a performance report from NHS Improvement in which it said that the underlying deficit in hospitals was £4.3 billion.

Some 11.8 per cent of nursing posts were not filled between April and June, a shortage of nearly 42,000. In London, which had the highest vacancy rate, the figure was 14.8 per cent. In England 9.3 per cent of doctor posts were vacant, a shortage of 11,500.

At the end of June there was a total of 107,743 vacancies, up from 98,475 at the end of March.

Siva Anandaciva, chief analyst at the King’s Fund think tank, said: “Widespread and growing nursing shortages now risk becoming a national emergency and are symptomatic of a long-term failure in workforce planning, which has been exacerbated by the impact of Brexit and short-sighted immigration policies.”

The report said that trusts had had to use bank and agency staff to ensure that posts were filled, spending £805 million on bank staff and £599 million on agency staff in three months, £102 million and £32 million over budget respectively.

Those costs were partly responsible for hospitals missing their savings target by £64 million, the regulator said, although it added that the plan had been “ambitious”.

The way vacancies are recorded has changed, but in 2008 the vacancy rate for nursing staff was 2.5 per cent and for medical and dental staff 3.6 per cent.

At the end of the first quarter of the financial year trusts in England were £813 million in deficit. The report included the sector’s underlying deficit for the first time, which reflects its financial position without taking into account one-off savings such as land sales or non-recurrent funding. That was £4.3 billion.

Sally Gainsbury, senior policy analyst at the Nuffield Trust think tank, said: “That means services were lacking the equivalent of 18 days’ worth of funding last year.”

The report said that A&E attendance was 6.23 million from April to June, 220,574 more than last year.

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The NHS culture is sick – and so are its staff – But is there any “quick fix”?

Physiotherapy and counselling for NHS staff in drive to cut sickness rates

Waste in the Health Services. It;s mainly due to staff absenses…

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Do we want reduced access and less efficiency? GPs are self employed, and they take dividends. Salaried staff are far less value to the state. Politicians are uninformed and short termist..

Successive increases in the health budgets in Wales have not helped….. Brexit will make it worse… We all seem agreed, so why not change direction?

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How should we care for our mentally ill children? Would society choose more risk for closer care?

Jonathan Owen for the BMJ reports 4th September 2018 (BMJ 2018;362:k3769 ) : Children are still being forced to travel far for mental healthcare and a map in the printed article shows the few centres capable of looking after these difficult children. There is another on the internet..

There are so many risks associated with teenagers with anorexia and eating disorders. The level of supervision needs 1:1 staffing or even more, and there is always the blame culture looking to find a scapegoat if things go wrong. The state safety nets it’s risk with fewer centres which are properly managed and staffed. The public, and parents (before there is a disaster) always prefer closer care. This is the same argument which is going on writ larger in rural areas when considering A&E and inpatient specialist services. With not enough money and not enough staff we have to compromise. The number of children with cancer each year (1300) only just exceeds the number with mental health problems (1039 – see below), and no parent rejects travelling for the best cancer treatment. Why should they resent the travelling for mental health? The reason is that mental health care is not short, or time limited, it is chronic and usually repetitive. By the time mentally ill children present there is a deep seated problem in non-compliant patients, often manipulative, and sometimes dysfunctional families. Accidental suicidal attention seeking is possible.. Cancer on the other hand has compliant patients and families…. Would society choose more risk for closer care? Prevention might be a better approach, with more family therapy options, at local level…. Given the number, this is reasonable rationing of resources. Will the situation be made worse when we have to call people “fat” rather than “obese” because we GPs need better language? (New drive to encourage doctors to write to patients in plain English)


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Dennis Campbell in the Guardian 29th August reports: Children forced to travel hundreds of miles for NHS mental health treatment

Exclusive: NHS England figures reveal some under-18s sent as far as 285 miles for inpatient services

Children and young people with serious mental health problems are receiving treatment as far as 285 miles away from their homes, despite a pledge to end such practice, because bed shortages in some areas are so severe.

Experts say sending highly troubled under-18s to units far from their family and friends can be frightening for them, reduces their chances of recovery and increases their risk of self-harm.

In all, 1,039 children and adolescents in England were admitted to a non-local bed in 2017-18, in many cases more than 100 miles from home, figures collated by NHS England show. Many had complex mental health problems that often involve a risk of self-harm or suicide, such as severe depression, eating disorders, psychosis and personality disorders.

Patients from Canterbury, in Kent, were sent 285 miles for inpatient mental health care, those from Cornwall and the Isles of Scilly 258 miles and those from Bristol 243 miles.

Bed shortages meant that in 119 of the NHS’s 195 clinical commissioning groups (CCGs) at least one patient under-18 was sent out of the area for care last year, the statistics show.

NHS England has acknowledged that the separation from relatives and isolation that very vulnerable patients experience during out-of-area placements can be damaging.

Its own policy states that in order to maximise the chances of recovery, “patients should be treated in a location which helps them to retain the contact they want to maintain with family, carers and friends and to feel as familiar as possible with the local environment”.

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New technologies and rationing by post code/region. New treatments and assessments are not available to all UK citizens.

Its good news that we can embrace new technology, and quickly, but the decision raises other issues. Mainly to do with rationing honestly… Other new technologies will follow (Hope of cure for men with aggressive prostate cancer) but whilst there are 4 different health systems, and announcements only apply to one of them, we in Wales will wonder if we can afford what England can. Only this week a friend went to London for a new prostate cancer assessment test (mpMRI) which is not available in Wales. (Sign the petition on line) ( He went Privately) Assessment and staging of Prostate Cancer is essential, and there are far more sufferers than there are with leukaemia.

Paul Kelso for Sky News reports 5th September: NHS England nets ‘game-changing’ childhood leukaemia treatment

The therapy – which has a list price of £282,000 per patient – is currently only available in Europe as part of clinical trials.

The Times also reports: Game-changing NHS treatment to save children with leukaemia

The Telegraph: NHS to fund “game changing” personalised cancer drug.

But can we afford these treatments without rationing the high volume and low cost treatments? How does such technology fit in with “personal health budgets”?

High Tech advances hit NHS funding. A proper debate wont happen however.

Interesting suggestion low cost for high volume treatments to be excluded… GPs will take no notice as their job is to put their patient “at the centre of their concern”.

World class cancer care (and Mental Health care) is possible, if we ration the high volume low cost treatments…

The cost of high tech treatments – that if these become “universal” then the low cost high volume treatments need to be paid for.

Trials of personal budgets will have long term perverse outcomes in an ageing society. Health costs are rising, and geographic variations will become greater….

Wales ‘behind’ in technology to detect prostate cancer – BBC News

Prostate Cancer breakthrough with a more accurate test (Scotland)

PET scans for prostate cancer (Birmingham)