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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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A cross-party solution to NHS pressures?

Laura Keunssberg reports for the BBC News 24th April 2018: A cross-party solution to NHS pressures?

Just before Easter, Theresa May announced she had finally accepted the case for a longer-term, and bigger financial commitment to the NHS.

But how much to pay, and how to find the money is not yet decided.

The Health Secretary, Jeremy Hunt, has appealed to his colleagues for ideas, promising in a letter to all Tory MPs that solutions for the NHS and proposals on social care will be settled by the summer.

But a cross-party group of MPs including former ministers, is again urging the government to convert National Insurance into a specific tax for the NHS.

That proposal is part of a wider set of principles upon which they would base a commission to look at the health service’s long-term pressures, that is being published today.

Most intriguingly, members of the group tell me that Jeremy Hunt is open to their idea.

He has made it plain he accepts there may have to be increases in tax, but hasn’t made a commitment or a case for a particular option.

Potential plan

The government has moved frustratingly slowly for its critics on the fraught and controversial issue of how we should pay for heath care.

Demographics and demand mean the issue is more vital than ever.

The proposals being put forward by MPs as a potential plan are interesting in themselves.

But what’s also intriguing is the fact that MPs of different stripes, officially, have been able to agree them.

I simply can’t remember a different occasion when I have sat across from three MPs from different political tribes and they have not just grudgingly agreed to accept one or other of their rivals’ points, but have deliberately worked together to construct solutions for one of the country’s pressing problems.

Backbench revolution?

There has been a frenzy on occasion recently over whether a new centre party might explode onto the scene.

With frustrations about and suspicion of the front benches of both of our big parties, the idea is raised from time to time, although the genuine evidence of that is scant.

But by their admission, the three MPs I interviewed about their NHS plans are acting together not just because they don’t have much faith in their leaderships to act, but they fear it might be politically impossible for them to do so.

They see this as a gap into which backbenchers might be able to step, and potentially not just on the NHS, but on other issues like housing too.

Don’t write the headlines about a new party, or a new centre, whatever that means.

This is also not a start of some backbench revolution.

We are far from reaching a point where non-ministers can call all the shots.

But it is a growing feature of this minority Parliament that MPs whose places are in the Commons’ cheap seats are making their voices, and Parliament’s shout louder.

Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

It is hard to recruit to West Wales. The “little England beyond Wales” is culturally very different from Welsh speaking Carmarthenshire. I used to think Whitland would be near enough, but no longer.

Doctors choose centres of excellence in cities rather than rural areas to work in.

There is an under capacity in diagnostic physicians, and this will remain the case for 10 years.

Reconfiguring West Wales services gives an opportunity to raise standards, reduce infections, accelerate discharge and improve choice.

The medical model is changing, and teams of specialists raise standards fastest.

There has not been the investment in infrastructure that there should have been to speed transport.

Choice for patients needs to be encouraged by the system. A larger Trust ( preferably all of Wales – why not?) will give greater choice.

If a rural area such as Pembrokeshire wishes to recruit consultants and GPs easily, it needs to recognise the drivers for change in the medical profession. New doctors want to have access to new technologies, tests, and treatments. The medical model now involves large teams of specialists raising their standards together. Access to such centres is meant to be “equal” but in effect, especially in Wales, it is dependent on post code. Choice has been restricted to “within your own trust”, and outside referral restricted unless there is no service within your trust. Consultants and their juniors like to have access to specialist investigations, a complete set of treatment options, and research and teaching opportunities.

So why did I move to Pembrokeshire. I enjoy an independent mind-set, and the challenge of working in remote areas. But I saw the possibilities were better where there was a DGH (District General Hospital), a postgraduate centre and teaching opportunities. All these will go if my local hospital closes, or moves outside of the “little England beyond Wales”. I feel cultural affiliation, and when I seek medical care the first language should be one I understand. (English). Consultants arriving in the area were offered subsidised accommodation in a hospital house whilst they looked for a home. New physicians arriving felt they were cared for …

Within GP, the clinical variety and opportunities have reduced, and there is much less room for manoeuvre in todays group practice experience. The shape of the job has changed, and the people in it have changed too. Now it is 80% female reflecting the underperformance of males at age 18 when applying for medical school. It may change even more, because with too few diagnosticians, digital consulting, without an examination may expand, with resultant litigation risk. ( Murray Ellender GPs must embrace digital future – The Times 23rd April 2018 )

The threat to move our hospital outside of our county, and into another tribal area, will not be taken lying down. So we need a solution that allows consultants all the things they want, and our, mainly female, GPs to get what they want. With a 10 year deficit and shortage of diagnostic doctor skills, we have to centralise in some way or other. ( Patients want all services as close as possible, and many would choose local access instead of lower death rates. They will also demand it is all free, for everyone, everywhere, for ever. )

If we take out the hospital we take away part of the culture. House prices will fall further as professionals leave, and choose to live near tertiary care centres. The already dilapidated and sometimes empty heart of the county town will get even more squalid and forgotten. Yes, we can replace one culture with another, more cynical one. People are already disillusioned in the shires, where the vote went against staying in the EU, even though the people there had more to lose. Taking away their hospital without persuading them that it is for the greater good could lead to civil unrest…. and they will also have a Welsh language school they never asked for.

In the end we have to make the new solution attractive to medical applicants, and that means combining Hywel Dda with Swansea so that hospital jobs are rotated, the educational and research opportunities are there for all, and the important services; stents, stroke and radiotherapy are all provided on site. Without Swansea the new hospital needs more money to have the facilities needed to help recruitment and even then it may not be enough.

Dirty surgery such as gut emergencies should be treated in on of the old DGH theatre suites, and the rest of old DGHs become community care recovery centres. The funding must also be changed, so that all the country, patient and professionals, realises that financially, it is founded on a rock rather than sand. This will win hearts and minds.. but it is tough love.

My personal belief is in means related co-payments, scaled and managed centrally. I have some concern about how to deal with citizens who have cash flow poor, but are asset rich, but this can be debated once we agree to ration and use co-payments.

The three options are all reasonable, given the under capacity and recruitment problems described, and NHSreality goes for a new build in Pembrokeshire, along with new roads. If this were done, and/or the trust combined with Swansea, there would be a great improvement in services for West Wales patients. The finances are a different matter, and I expect continued denial all round.

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

Who wants to be a Hywel Dda board member? “Hywel Dda health board looks at hospital closure options”. The obvious solution is to promise a new build at Whitland, and a dualling of roads west.

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

A poisoned chalice. Advertisment for Chairman of Hywel Dda…

Hywel Dda Health Board chief executive Trevor Purt to leave his post

Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

Image result for radiotherapy cartoon

 

NHS care funding a ‘postcode lottery’, says watchdog

The health watchdog, no less, says “NHS care funding a ‘postcode lottery’, (BBC News 20th April) and this should not surprise readers of NHSreality. Health care, especially in Wales and the rural areas is a lottery, as well as social care. My own mother, now 93 is demented and in a nursing home near Norwich (because we managed to get her in before she was so lost she could not adapt), but if she was a new patient she would be in an Elderly Mentally Infirm home, of which there are not enough. A retired teacher, and taxpayer, she has had no help from the health budget, but she does get attendance allowance. The population explosion in elderly nonagenarians and centenarians is coming, and we have no way forward planned for the expense. It worries those of us who are retired, and vote, that none of the political parties has a solution. Merging health and social care budgets simply compounds and obfuscates the problems.

Care patients are being hit with large bills because of a postcode lottery for NHS funding, a consumer group says.

Which? said people can be “25 times more likely to get their costs covered depending on where they live”.

It found South Reading Clinical Commissioning Group (CCG) paid social care costs for 8.78 patients per 50,000 people while Salford funded 220.38.

The Berkshire CCG said Reading has a very low elderly population – 12% against the national average of 17.7%.

The consumer group analysed NHS funding data for October to December 2017.

It found vulnerable people in England with the most expensive medical needs were not treated in the same way regardless of where they live.

The NHS continuing healthcare scheme is administered by local CCGs. It gives medics a national framework to assess patients, including older people with conditions such as dementia and motor neurone disease.

Top five funding CCGs [per 50k of population]

  • Salford – 220.38
  • Thurrock – 146.49
  • Wolverhampton – 141.19
  • Sutton – 131.96
  • Sunderland – 120.29

Bottom five funding CCGs [per 50k of population]

  • Luton – 20.49
  • Newbury & District – 19.33
  • Wokingham – 18.78
  • North and West Reading – 18.45
  • South Reading – 8.78

Which? also found there were inconsistencies with people living in the same region.

People in the Wolverhampton CCG are more than five times more likely to have their care funded (141.2 patients per 50,000) than their neighbours in Sandwell and West Birmingham (26.3 per 50,000).

Which? also found that nearly all areas are failing to meet the national framework guidance that in most cases people should not wait more than 28 days for a decision about whether they are eligible for funding.

It says it also found examples of families having the funding withdrawn suddenly. One woman was saddled with a £96,000-a-year bill after the needs of her mother – who has severe dementia – were reviewed.

A Department of Health and Social Care spokesman said: “We expect NHS England to ensure those with the highest and most complex health and care needs, who are eligible for this type of funding, have easy access wherever they live in the country so people can get the care they need – and deserve.”

Orkambi rationed for Cystic Fibrosis

It is expensive to develop new drugs. Britain and the UK has a 12 year patent rule, after which the drugs can be made competitively in a “generic” form by any company that can master the production. Development is expensive and a long term risk for companies and investors. Many products have been refused funding by the health services of the UK, until their patent is about to expire, or has expired. Other countries have similar rules. This all means that the payback for investment must be covered in 12 years…….

If governments want to share in the pricing decision, then they need to share in the risk of the research. And of course this will include many failures. 12 years seems a reasonable time frame for payback, until you or your next of kin is the potential beneficiary, and the treatment is effectively rationed. There are many new drugs to come, especially genetically engineered ones, but risky investment will cease if the payback time is reduced. It is a great shame that patients with cystic fibrosis cannot be funded for a new drug. It is, however, reasonable rationing, or tough love. But those who need it in 12 years time can be hopeful that it will be affordable then.

Cystic fibrosis: Company urged to lower cost of life-changing drug – BBC News 21st April 2018

Health ministers have urged a pharmaceutical company to drop the price of a life-changing cystic fibrosis (CF) drug for NHS patients.

Vertex Pharmaceuticals’ Orkambi costs £100,000 a year per patient, and has been deemed too expensive for the NHS.

The company rejected an NHS England counter offer, saying it was not enough to fund research into future medicines…..

 

 

Do you have a right to forbid your notes to be filed electronically? We don’t know..

Whilst GPs have relatively well proven and secure IT systems, with a limited number now offering a high standard service, Hospital systems are multiple and disconnected. They are different to GP systems in that they do not collect all the social data, family history and accumulated evidence of years of family general practitioners. My own practice computerised fully in 1988. Hospital records are still kept on paper in out patients in our local DGH. It is worrying to think of the potential for mistakes in disconnected systems, and Chris Smyth in the Times alerts us on April 18th 2018: Every hospital tested for cybersecurity has failed

Is the potential risk from poor systems greater than the gain to the patient? I have never been asked if I give permission for my hospital notes to be on computer. Patients in GP do have a right to exclude their notes from being shared. Do you have a right to forbid your notes to be filed electronically? We don’t know.. Surely it’s time for my notes to be on a “card”, which when I pass to the doctor, is giving permission for access?

Image result for medical notes cartoon

All 200 hospitals and other NHS organisations that have been tested so far have failed cybersecurity checks, according to a report by MPs.

Some hospitals have not fixed the original vulnerability that led to last year’s cyberattack and NHS chiefs are not working fast enough to protect the health service, even though a repeat is a matter of “when, not if”, the public accounts committee (PAC) says.

Despite promises that lessons had been learnt from the WannaCry ransomware attack nearly a year ago that crippled a third of NHS hospitals, a report released today finds there is still “a lot of work to do” to avoid more disruption when they are targeted again.

Yesterday spy masters in Britain and the US issued an unprecedented warning that tens of thousands of devices had been targeted by Russian hackers preparing for an attack on British infrastructure. Security chiefs are braced for cyberattacks on vital services, including the NHS, as relations with Moscow deteriorate over the nerve agent poisonings in Salisbury and a suspected chemical weapons attack by the Russian-backed Syrian regime.

Ministers accept that “cyberattacks are now a fact of life and that the NHS will never be completely safe from them”, the PAC reports.

Although almost 20,000 hospital appointments and operations had to be cancelled during last year’s attack, today’s report says that the NHS was “lucky” and if it had not happened on a Friday afternoon in May, and the virus had not been quickly disabled, the effect would have been far worse.

Meg Hillier, chairwoman of the PAC, said: “Government must waste no time in preparing for future cyberattacks — something it admits are now a fact of life. It is therefore alarming that, nearly a year on from WannaCry, plans to implement the lessons learnt are still to be agreed.”

All 200 trusts tested on cybersecurity by NHS Digital have failed, the MPs said. “We are told that this was because a high bar had been set for NHS providers to meet the required standard but some of the trusts had failed the assessment purely because they had still not patched their systems — the main reason the NHS had been vulnerable to WannaCry,” they added.

“I am struck by how ill-prepared some NHS trusts were for WannaCry, in many cases failing to act on warnings to patch exposed systems because of the anticipated impact on other IT and medical equipment,” Ms Hillier added.

Today’s report details how staff had to resort to using WhatsApp to communicate because they had shut down emails as a precaution, while some hospitals called the police because they did not know who to speak to in the NHS.

Matt Hancock, the secretary of state for digital, culture, media and sport, said on BBC Radio 4’s Today programme this morning: “There’s clearly much more that needs to be done. The NHS has made improvements since the WannaCry attack last year, but one of the challenges in cyber security is that the criminals and the malicious actors who are trying to harm our cyber security are moving fast, and you have to run to stay still. You can’t just make one update, you’ve got to constantly be updating.”

Lord O’Shaughnessy, the health minister, said last night: “We have supported [cybersecurity] work by investing over £60 million to address key weaknesses and plan to spend a further £150 million over the next two years.”

Image result for medical notes cartoon

 

Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

The medical model is changing. More specialisation raises standards, and chances of a long life.  Specialist units with teams of professionals raise standards quicker than smaller units. Recruitment of altruistic young doctors, and other staff,  is easier in specialist (tertiary) units. Hywel Dda has none of these.

In my own area, a rural English speaking part of West Wales, with a population 3 times the size in summer, the threat to close our hospital is about to cause civil unrest. A new build in Pembrokeshire would reassure the Medical Executive Committee of local consultants, but the politics of Wales mean that it could be over the border in Carmarthenshire. This is a completely different area, and the two tribes are separated at County Council as well as Hospital. The majority English speakers feel threatened by a minority Welsh speaking “caste” taking over the culture of their hospital. This may not happen, but it is the perceived threat. In addition there is difficulty recruiting doctors to West Wales, Carmarthen more so than Pembrokeshire, and the lack of choice for patients within their post code rationed region, is demoralising. It splits the population.

The demographics, and especially in the future, mean that more and more elderly will retire to Pembrokeshire. There are two towns with building consent to expand in the National Park, Freshwater East and Broadhaven. This is where the population will expand. This is where demand will come from.

The poor road and transport links, and the absence of a routine air ambulance, mean that if services are moved East of Narberth, patients from Dale and St David’s will have too far, too slowly, to travel.

The sensible option is to close Carmarthen, (already falling down), and Llanelli, which is near to Swansea, and to combine the Swansea and Hywel Dda trusts. In this way there would be more choice for patients, and recruitment would be less of a problem. If the trust insisted appointees did some of their time in Withybush there would be fairness and service. But this is not one of the options offered by Hywel Dda, as this would require a change in the rules of the game, decided by the Welsh Government. Indeed, common sense would make all of Wales into one trust. Then there would be maximal choice (In Wales) and although there are two waiting lists (one for English – fast, and one for Welsh – slow) at Oswestry, it would enhance choice and standards.

My solution puts the Welsh speaking area of Carmarthen between two larger English speaking areas, which would not be politically acceptable.  It has to have stroke thrombolysis and stent insertion, as well as radiotherapy services.

In the 1970s a new DGH was built to replace the old first world war “county Hospital”. The population supported Eirian Williams in his endeavours to keep Pembrokeshire’s hospital. Not many of his supporters are still alive, but the principle he applied still remains: there is more pride and cultural affinity with ones own hospital. In the future many services will be in the community and closer to the patient. Whatever decision is taken is relatively short term, as we have to start putting money into community care. If the new hospital goes ahead, then the former DGHs could be reclassified as “community care” and rehabilitation and recovery can happen at these places. In the end we can only have quality care in hospital if there is enough capacity to leave the hospital.

BBC News 24 hrs ago: New hospital and Withybush changes in Hywel Dda shake-up plan by Owain Clarke

The Western Telegraph reports 19th April: Withybush to lose A&E under new plans.

Local politicians, without a utilitarian approach, are always going to object. (Tenby Observer)

Look at the Hywel Dda site for “transforming” services”, and fill out the feedback Questionnaire.

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

Families asked to feed dementia patients…. How do we design a system that is fair to both the well spread, and the very locally based families?

Redefining the relationship between doctors and patients… When not to put the patient at the centre of your concern…

 

 

Computer flaws ‘cause hundreds of NHS patients to die each year’

This news item begs the question: “Do I have a right to refuse hospitals to record my notes on computer? or Can I insist on a paper record for my notes”? Most hospitals have both paper and IT, which is a wonderful recipe for mistakes. Informed patients are at an advantage in a failing health service, but a new form of “Iatrogenesis” is computer and technology driven. Some patients and their families are taking photographic copies of paper notes so that any amendments, if there are problems, will be self evident.

Kat Lay reports in the Times February 7th: Computer flaws ‘cause hundreds of NHS patients to die each year’

Hundreds of NHS patients die each year because of computer problems including bugs, viruses and design flaws, a report has claimed.

Experts said that there was “not a word to describe how bad” the computers that hospitals relied upon were. These computers were used for vital tasks such as keeping records and delivering cancer drugs, academics from Oxford and Swansea universities said.

While it was possible to write software that was “correct, safe and secure”, there was little incentive for manufacturers if it was not a precondition of the packages being bought by NHS bodies, they said.

Martyn Thomas, a visiting professor in software engineering at Oxford, and Harold Thimbleby, a professor of computer science at Swansea, were speaking before a Gresham College lecture at the Museum of London yesterday. A typical NHS trust has 150 types of computers for administration, communication and professional support and many more embedded in medical equipment.

The extent of poor IT leaves hospitals vulnerable to cyberattacks that could kill “a lot of people”, Professor Thomas said. The researchers argued that on a “conservative” estimate bugs, viruses and design flaws in those systems led to between 200 and 880 deaths each year.

The Grenfell Tower fire last year killed 71 people, the Ladbroke Grove train crash in 1999 killed 31 and the 1988 Piper Alpha disaster killed 167, they said, and all prompted public inquiries. “What will it take before we get our public inquiry? When will we have the ‘radical changes’ in healthcare regulations?” they asked. They offered examples of poor IT harming patients. In North America the Therac-25 radiation therapy machine overdosed and killed patients between 1985 and 1987. In Britain an error, since corrected, in the QRisk calculator used by doctors to predict a patient’s risk of heart attack or stroke is feared to have led to the incorrect prescribing of statins to thousands of people.

They said that nurses and doctors were often blamed for errors that had been caused by the computers they were using. Simple design features could be adopted, they said, that have been proven to reduce errors. For example, if nurses use a numeric keyboard to enter numbers into a computer they make twice as many errors as when they use arrow keys to adjust the figure shown on a screen.

The Wannacry cyberattack last year, in which hackers encrypted NHS records and demanded a ransom to unlock them, led to almost 20,000 hospital appointments being cancelled. “There were lots of problems, and that was not even an attack on the NHS — they were just collateral damage,” Professor Thomas said. The researchers said that the regulation of computers used in hospitals was inadequate.

A spokesman for the Department of Health and Social Care said: “Patient safety is our priority, and our £4.2 billion investment in technology will help eliminate avoidable harm. It’s encouraging that there were no reports of patient harm or of patient data being compromised in the Wannacry attack. We are re-doubling our focus on cybersecurity with an extra £46 million to improve resilience in major trauma centres and support at risk organisations, with a further £150 million committed by 2020.”