If there are 60 million souls in the UK (I know its more) the £6,000,000,000 bill equates at £100 each man woman and child. And you can be guaranteed its an under estimate. The trouble is that I don’t have the option to pay now, and prevent deterioration. I’ll pay later, and possibly with my life.. while successive governments think, and deny. Capital projects are decreed by devolved government in Wales, Scotland, and N Ireland, but centrally in England.
NHS trusts are sitting on a record-high backlog of almost £6 billion worth of repairs or replacements that need carrying out, official figures show.
About £1 billion of the outstanding repairs are “high risk”, meaning that they could result in “catastrophic failure, major disruption to clinical services” and are “liable to cause serious injury and prosecution” if they are not addressed immediately. Examples of maintenance required could include upgrading software on medical equipment, maintaining generators and boilers and ensuring the structural integrity of buildings.
In the year to March there were 17,900 incidents across England in which patients were harmed or put at risk of harm because of infrastructure problems, according to the data from NHS Digital. This is an increase of 800 in a year. Clinical services were delayed, cancelled or otherwise affected because of problems with buildings or facilities on 3,835 occasions, an increase of 1,500.
Chaand Nagpaul, chairman of the council of the British Medical Association, said that there was an urgent need for extra funding to address the NHS’s “impoverished infrastructure”.
The repair bill has risen every year since 2011-12, when it stood at £4 billion, while costs for outstanding high-risk works have more than tripled over the same period. NHS trusts spent a combined £404.5 million trying to reduce the backlog last year but the bill rose by more than £400 million.
Siva Anandaciva, chief analyst at the King’s Fund, a health think tank, said: “Deteriorating facilities and unreliable equipment can expose staff and patients to increasing safety risks, and make NHS services less productive as operations and appointments may be cancelled at short notice.”
For the past four years the Department of Health and Social Care has transferred money from the capital budget to use on day-to-day spending. A spokesman said: “Investment to tackle this maintenance work has increased by 25 per cent from £324 million in 2016-17 to £404 million in 2017-18. We are also investing £3.9 billion into the NHS to help transform and modernise buildings.”
Readers might well ask “What is the legal situation regarding rationing?” Well, as long as its called something else, prioritisation, restriction, limiting or excluding, trusts can, within certain limitations, ration health care. The risk of anarchic rationing by post code was exposed by NHSreality last week. (NHS rationing and the Law by Warwick Heale in Devon) The risk is getting higher….. and as each week draws nearer to Brexit day, UK citizens might wish to consider how they can reduce risk. Private insurance is all very well for “cold care” (Non urgent) but emergencies are unpredictable, A&E s are understaffed, and capacity is limited as well as funding. The safety net which was there when I qualified in 1974 is well and truly holed. I strived to find “good news”, and note the savings on syringes and gloves.. but this is child’s play compared to the waste elsewhere. The return of fear and the ultimate lottery in health care has arrived. The average citizen/punter will not recognise the problem until they or their next of kin are ill….. The current funding and the system for funding health overall is a political decision. The need for change is paramount, but in the Brexit limbo iceberg of today, no important changes are likely. Its going to get worse…
and on 2nd October David Oliver reports: The crisis in care home supply
Mark Smith for Walesonline 22nd October reports: Welsh NHS boss quits and is moving to England to get better cancer care for her husband – Prof Siobhan McClelland says she has lost faith in the Welsh NHS
Michael McHugh 22nd October 2018 in the Belfast Telegraph: Cancer treatment in Northern Ireland receiving ‘sticking plaster’ approach, says campaigner – Co Down woman blasts care available to patients
and Northern Ireland health service facing resourcing crisis amid 1,800 vacancies – health chief Valerie Watts – An extra £100 million has been set aside to overhaul the system as part of the DUP’s confidence and supply agreement.
Richard Youle 3oth September: Health board wants to ditch Welsh-only name because it thinks it’s putting people off working there – But it fears ending up being called Healthy McHealth Board, if it lets the public vote for a new name, following the Boaty McBoatface debacle
A review has found 43 maternity cases where there was an ‘adverse outcome’ since the start of 2016
Adam Hale 9th October: NHS managers ‘used names of U2 band members to cover £700,000 fraud’ – The trio allegedly helped secure payments for building work which had ‘major deficiencies’ and cost £1.4m to rectify
Strand News Service: Boy left brain damaged by ‘negligent care’ at Welsh hospital is awarded millions in compensation – The boy, who is now eight, suffered ‘catastrophic injuries’ in the first few days of his life
NHSreality wonders if it was a doctor who first saw the young man in Tonbridge Wells: Tunbridge Wells man died after misdiagnosis of sepsis symptoms (BBC News 18th October)
And in the Isle of Wight: Isle of Wight hospital trainee doctors ‘left alone’. – Hospital patients on the Isle of Wight suffered as a result of trainee doctors being left to make decisions they were not qualified to make, inspectors said.
Dennis Campbell on 21st October in the Observer: NHS £20bn boost risks being spent to pay off debts, experts warn – PM urged to write off £12bn in hospital overspending or extra healthcare will be unaffordable
What is the common theme in all these reports? The inability of the state to provide everything? NHSreality’s theme is that rationing has to happen, in any health system. Its just that it should be honest and overt, rather than dishonest and covert. Car parking is free in Wales, which means the doctors avoid subsidising their trust, and after a time, when their patent is near to expiry, new drugs are usually accepted. But the problems of systematic rationing could seem insignificant to the problems of anarchic rationing. If there’s no agreement on Brexit, patients with chronic conditions could be in trouble with the “just in time” supply system operating currently in the UKs 4 health systems. Rationing by anarchy is not a method I was expecting when NHSreality began…
The care of Doctors, and their ability and time to care needs to improve. So does continuity of care…. This is not the work of one leader, or one health minister, although it is tempting to allocate blame.
Iona Heath (Back to the future – Iona Heath BMJ 2018.writes a seminal and thoughtful essay:
Her last paragraph is worth reproducing, but before this she regrets the ending of continuity, and acknowledges the relative inefficiency of new pharma and technologies, Private Finance Initiatives, the conflict between the needs of society (populations) and individuals, and the need to reinstate teams that care for their patients, and for each other. She indirectly challenges the “free at the point of access” philosophy, pointing out that prescription charges and other co-payments are already in place (In England). She avoids talking about the merging of heath (free) and social care (means tested) and co-payments. She also fails to look at other systems, but her intent is clear. Look again at what we used to do well – before it’s too late.
….Things that should change
We all, professionals, patients, citizens and policymakers, need much more recognition of the limits of medicine and the intrinsic uncertainties of its practice. Applying general scientific truths to individuals will always have unpredictable results and, however sophisticated (and expensive) our technology becomes, all of us will sooner or later get sick and die. There is far too much false certainty in our simplistic descriptions of cause and effect and, when things go wrong, this makes it much easier to blame clinicians struggling to do their best at the frontline of care.
The longstanding democratic deficit within the planning, organisation, and regulation of the NHS needs to be acknowledged and tackled, perhaps through a system of elected regional government, in parallel with the devolved national governments. The deficit is in no way resolved by the current system of appointing the great and the good to the boards of NHS bodies and creating patient participation groups, however dedicated and worthy, because none of the participants are in any way accountable to a wider electorate.
So, let’s hold onto the best, change with more caution and care, and celebrate the NHS at 70.
Adrian O’ Dowd reports: Doctors need to improve their conversations with dying patients, says RCP – BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4330 (Published 19 October 2018) Cite this as: BMJ 2018;363:k4330
Doctors need to speak to patients with terminal illnesses in a timelier way and handle conversations with greater compassion and confidence, says a report from the Royal College of Physicians.1
The report, which examined why clinicians find it difficult to talk to patients about death, found that some doctors thought that death could be perceived as a failure and that modern medicine was expected to cure all ailments. However, evidence from patients and carers indicated that many people wanted to talk about death and that planning helped them feel more empowered about their care and decision making.
Almost half of all deaths in the UK are estimated to occur in hospital, and many patients admitted to hospital are in their last year of life. The college said it believed it was essential for doctors and other professionals to have the knowledge and skills to undertake sensitive conversations at an appropriate time when patients were ready.
The report was based on conversations with doctors at all levels, patients and carers, and medical organisations.
A range of clinicians from medical students to consultants said that they were uncomfortable about initiating conversations about the future with patients. Students and junior doctors had little practice with real patients and said that training did not prioritise the “soft” skills they needed.
Other barriers to talking about death included confusion over whether hospital doctors or GPs should be having the conversation, workforce pressures, lack of privacy, lack of prioritised time for conversations, and the need to be sensitive to different cultural and religious beliefs.
One key issue identified by the report was that healthcare professionals needed to begin conversations about planning for care at the end of life care nearer to when patients are given a terminal diagnosis. Early conversations give patients more choice and control over the remainder of their lives.
The evidence showed that patients who had these conversations and had care plans put in place had a better experience than those for whom the conversations came in the final days or hours of life.
The authors offer solutions and resources to help build clinicians’ compassion and confidence in this area of care and detail four case studies of hospitals that lead the way in supporting conversations about care at the end of life. The report highlighted the University Hospitals Bristol supportive and palliative care team for its Poor Prognosis Letter Project, a scheme that has enabled local GPs to identify patients approaching death more easily and earlier, so they can start discussing end of life care.
The Royal College of Physicians’ president, Andrew Goddard, said, “This report is a big step forward in helping patients, relatives, and doctors to talk honestly about death and dying.
“We must minimise the barriers in our systems and culture that prevent this happening. This is not just about palliative care in the final days but about having a series of conversations much earlier after a terminal diagnosis.”
UK governments need to take note of the honesty of others.
Some New Zealand dialysis patients have had their treatment rationed because of ineligible patients turning up for emergency care, according to government documents
However, the Ministry of Health says New Zealanders who need dialysis are not losing out due to ineligible kidney patients putting demands on the health services and Immigration New Zealand told RNZ there was no evidence treatment rationing was “currently happening”.
Documents obtained by RNZ from Immigration New Zealand (INZ) include slides from a presentation by its chief medical officer on the costs and demands on the health system, made in a meeting with the Immigration and Protection Tribunal last year.
Two pages discussed how some kidney patients were dying faster because their dialysis treatments had been cut back to allow urgent treatment of foreign patients.
Under the heading ‘Health Screening; Concerns’, one slide said “we have had to ration dialysis due to lack of resources to deal with demand.”
“When we get ineligible overseas patients turning up we are obliged to treat them urgently but we are often full in which case we will reduce the dialysis our existing patients are having in order to fit everyone one.”
INZs chief medical officer said at times staff said they have had to reduce dialysis sessions to twice a week and patients “get sick and die quicker” at that level.
INZ director policy integration and immigration Nick Aldous – in response to RNZ questions about the presentation – said there was anecdotal evidence of ineligible kidney patients, but did not say when it happened.
“The scenario [in the two pages] was based on anecdotal evidence from an earlier point in time. We don’t have any evidence that this is currently happening.”
The Ministry of Health on Monday said there was a small number of ineligible patients receiving dialysis but this doesn’t affect treatment for New Zealanders.
“People who need dialysis are receiving it according to clinical need.
“Dialysis services are under pressure because of the growing population as well as obesity and type 2 diabetes,” a spokeswoman said.
Patients ineligible for publicly funded healthcare include tourists, except for those from the UK and Australia, which have reciprocal health agreements with New Zealand.
However, detailed immigration medical assessments before visas are issued are not compulsory for many temporary immigrants.
And ineligible patients do not have to pay for healthcare costs upfront.
Slides from the INZ presentation, obtained under the Official Information Act, refer to the world-wide numbers of diagnosed diabetes cases, many of which come from New Zealand’s immigrant source countries in Asia and the Pacific. There are also a number of undiagnosed cases.
The slides also looked at the cost of mental illness among immigrants on the health system.
“We have had to stop training patients for home dialysis which has meant more hospital beds full up and at times we have had to limit patient dialysis sessions to two per week per patient.
“The minimum acceptable standard is three sessions per week, below that, patients get sick and die quicker.
“But we have had to ration dialysis due to lack of resources to deal with demand.
“So the care our patients receive is impacted when we are working above our capacity.”
Kidney Health New Zealand’s national education manager, Carmel Gregan-Ford, said dialysis was rationed a few years ago but she has not heard of it more recently, although ineligible patients are still an issue.
“I have people who ring me on the 0800 line who are telling me, coming from overseas, telling me they’ve got friends coming next week and they need a place to dialyse,” she said.
“And I say to them you can’t come, there’s nowhere you can dialyise and they’ll come anyway and present to emergency clinics and hospitals and they have to be dialysed, so I don’t know how that can be prevented.”
Immigration New Zealand director policy integration and immigration Nick Aldous said the presentation – referred to in the official information – was given in mid-2017.
He said the slides were part of a “scenario” designed to provoke discussion about health service costs and demands.
“It uses dialysis treatment as one example for the scenario.
“This scenario was based on anecdotal evidence from an earlier point in time.”
According to Ministry of Health guidelines, district health board renal services must all offer home dialysis.
The National Renal Advisory Board published guidelines on access to renal replacement therapy which says that home dialysis is most cost effective and provides people with the best quality of life.
In 2016, there were 2750 dialysis patients in New Zealand, but there is no data on how many were overseas’ patients.
About 400 people died while on dialysis in New Zealand that year.
It is not clear how many DHBs are affected, and by how much overall, although the three Auckland DHBs receive partial compensation from the Ministry of Health for the cost of treating ineligible patients for all health conditions, where the immigrant or tourist has not repaid that debt. Last year that was $5.5 million.
The comments on health rationing were made at an annual training session of the Immigration and Protection Tribunal.
The tribunal, which can overturn deportation on humanitarian grounds, had until last year commonly been granting immigrants needing dialysis temporary visas on appeal, to allow them to continue their treatment.
But in a decision in June last year, it put future appellants on notice that they should not presume that would continue and said it was preferable that they put their cases to the Immigration Minister.
And since then it has ruled in two cases that immigrants had exceptional humanitarian circumstances but said that was outweighed by the public interest in minimising health costs and upholding the integrity of the immigration system.
The most recent one, in April, ruled that a Fijian man married to a New Zealander but who failed the visa requirements and was going to be deported, can stay for a year so that he can sell land he owns to pay for dialysis or a transplant.
In a statement, INZ said it introduced eMedical in 2014, an immigration health screening system that allowed for greater oversight of applicant health information, better decision-making on applications, and the monitoring of health changes over time.
It said it had a Memorandum of Understanding with several district health boards, which allowed DHBs to confirm the eligibility of patients for treatment, and had been working with DHBs to improve understanding of the criteria for eligibility, and how they were applied.
– Editor’s note: This story has been updated with additional responses from government agencies and clarifies that treatment rationing isn’t happening currently, but has happened on a small scale in recent years.
There is a history of rationing new advances in medical care differently in different post codes and regions. Some things are too important for this type of random care. If it was open and honest, and announced in advance, for some cheap services rationing is appropriate: but of course it is not allowed to be talked about. The perverse incentive for commissioners to get away with what they can is too great..
Faith Eckersall reports in the Daily (Dorchester) Echo 12th October: Diabetics to confront councillors over postcode lottery – DORSET diabetics – including some children- will be part of a delegation at the county council on Wednesday to campaign for new testing technology free on the NHS.
Currently people with Type 1 diabetes must use the painful and inconvenient pin-prick method to check their blood sugar levels but Flash, which must be paid for in Dorset, works on a pain-free patch and scanning device.
The protestors are angry that despite the government’s NICE drugs and medicine rationing committee approving the use of Flash Glucose Monitoring on the NHS, Dorset Clinical Commissioning Group has not made it freely available, as has happened in adjoining health areas.
The CCG is running a six-month pilot of the Freestyle Libre blood glucose monitoring device for 200 people in three specific groups of diabetic patients in the county. But protestors point out there are 5,000 diabetics in Dorset who could potentially benefit and say no further testing or pilot is needed.
Diabetes UK south west regional head, Phaedra Perry, said: “The Dorset Clinical Commissioning group should make Flash available immediately to all people with diabetes in the area who can benefit, and not to just a very limited group of 200 patients for six months.
“Commissioners here are out of step with neighbouring CCGs which have agreed to prescribe it. Dorset is one of very few areas in the south west where Flash is not available and is effectively imposing a postcode lottery on diabetes technology.”
NHSreality feels that the culture in Westminster reflects the culture in the nationalised industries as a whole, and the health service being the biggest. It is also the biggest bully, with most fearful staff, and who feel most gagged… Starting again using local pride may help, but some areas may fail to recruit… Perhaps these should be the first to be released from the shackles of Political Interference. Co-payments should be allowed.
We cannot address the culture of fear without better management and it cannot come from inside. Even if the skills were there, which they are not, the staff would not trust them. We need an outside provided HR company to do “Exit interviews” on all staff and board members, and to report dispassionately and in a depersonalised way, at regular intervals. Somehow this needs to be amalgamated into an annual public report for localities, and regionally, and nationally. We need to hear the views of all staff who leave a job, move departments, or retire, or emigrate.
But then, you and I know what the result will be….
So at the same time, because we know the outcome, we need to be planning the changes necessary to reverse the decline. I admit that I cannot see the way forward, especially when the official line is “everything for everyone for ever” and no overt rationing applies. We are creating a dependency culture. We are discouraging autonomy. In work with the GIG economy we are creating a slave culture. I see several “Spartacus” like revolts ahead, and the destruction of the whole state health and social care empire unless we have much more honesty and much better leadership.
If we apply zero budgeting and allow local trusts to run themselves without any government interference, restraints, or banal performance indicators, we will get large differentials in health care, but morale will rise. Staff can feel involved and “begin to enjoy themselves”. After a time best practices will emerge, and convergence of standards, but this will take a decade(s). Meanwhile we need to lift the restriction on medical school and nursing training places, so that we have an excess of staff, even allowing for the dropout rate. We need to acknowledge that no state cannot keep up with the advances in medical science, (see The NHS is being impeded by greedy drug companies ) and therefore we need to ration health care. Cradle to grave, without reference to means,……? The drug companies are out to make a profit, and it is not drugs which improve the health of populations. (See the USA) They do improve the outcome for individuals, but that is different.
How we do this is the big debate which has not even started. NHSreality suggests means related co-payments, both for health and social care. Then there is the litigation…. without no fault compensation, the combination of reduced resources, short termism and declining standards (see baby death rate) will ensure more and more opportunities for citizens to litigate. Reducing tax relief on pension contributions is another tempting short term fix…
BMA 20th September : Survey of UK doctors highlights blame culture within the NHS
BMJ October 12th: Creating joy in work is the only way to save the NHS