Monthly Archives: September 2013

The Demographic Time Bomb

The NHS is facing a crisis of ageing. We are living longer even than the average citizen of the US, so something is right about our health system. But we will not be able to cope in the near future and already the Regional Health Services, particularly in Wales, but across the UK are imploding.

Media comment is attached below.

100 not out

The graphics at the end of the attachment are interesting, and here is one courtesy of the Daily Mail on line.

Ninety and over

The Spectator Melanie Phillips reports 27th July 2013:

The elderly are driving the recovery. It’s time for generational jihadists to say ‘thanks’

young-and-old-privileged-generation
UK Population
Demographic Time Bomb
Update 17th November 2013:
Jeroen Spijker and John MacInnes in the BMJ November 2013 argue that current measures of population ageing are misleading and that the numbers of dependent older people in the UK and other countries have actually been falling in recent years
An extract:
F1_medium

Fig 1 Change in life expectancy (in years) in England and Wales within each decade broken down by age group, 1950-2010 (data from www.mortality.org). Life expectancy increased by 2.6 years between 2000 and 2010,  0.1 years of which came from improved infant and child survival and, respectively 0.5 and 2.0 years from lower mortality among 5-64 and ≥65 year olds

The State of Wales: we should all rage against it dying

Update 6th December 2013: We should rage against the dying of Wales by Peter Hoskin in The Times December 6th 2013

Update 3rd November 2013:

House repossessions in the UK. The graphic from The Times 1st November speaks for itself.

Safe as Houses - repossessionsJuly2013

If any of my readers listened to BBC Wales NHS debate this evening (30th September 2013)  (added 1st October and only available until 7th!) they will agree that there was no mention of philosophy, only one of patient self-responsibility and a complete lack of engagement by the Welsh Labour party who did not send a representative.  The “community denial” of the problems facing a disunited and Regional Health Service will not be solved soon, and the culture of fear, lack of openness and dispirited staff is set to continue. The political denial (where greater funding has led to worse outcomes in Wales) is the greatest problem…. meanwhile why not get together with friends and colleagues to rent a property in England where at least you will get choice? I have rarely listened to such a dispiriting program, but I have often listened to a presenter who failed to ask the appropriate questions.

BBC News reports 30th September 2013:

NHS targets review pledge by Carwyn Jones

“Targets for treating patients on the NHS are being reviewed and could be replaced, the first minister has said.

Carwyn Jones said one option was giving doctors the ability to set treatment targets for individual patients instead of setting national targets.

Following the recent disappointing Welsh Health Service news on Singleton and… it is not surprising that the minister wishes to remove any possibility of meaningful comparable statistics with England…

Owain Clarke et Al. report…..

12 September 2013 BBC News reports: Deterioration in emergency NHS care in Wales, says 16th July 2013 BBC news: Wales Audit Office finds NHS ops postponed to cut costs
30 Sept. 2013 BBC News reports: Betsi Cadwaladr C. diff outbreak manslaughter inquiry call
6th Sept 2013: Expert’s concern at lack of Welsh brain injury facilities
30th Sept 2013. Patients at risk as NHS fails to respond to safety alerts

The problems in Swansea Hospitals are printed here in full from The Times 28th September 2013. Bullying and cultural degradation – as predicted by this author. Heart patients die waiting as surgeons bully staff at Swansea hospital

Some consolation can be had from the news that Private Medical Insurance companies such as BUPA are also limiting choice….(Health insurers) and that the reality of insolvable issues is leading to an “NHS at WAR“….. Without discussion of philosophy this decline is set to continue. Whilst most patients are still getting a good service, more and more are not…

Update 1st October BBC News:

NHS Wales: Changes to help health boards ‘balance books’

If I really felt the situation would be any different in 3 year’s time, I would support this change. Because the fundamental philosophy of “everything for everyone for ever” remains the same, I would not support the temptation to overspend in one term of office in order to buy votes to get in for a second term, when the financial reality will hit home.

Update 8th October 2013:

Extra £570m NHS funding in Welsh draft budget !!!!

Update 3rd Nov 2013 Credit contraction offers opportunity to close gaps in health inequities

Professor Sir Michael Marmot, chair of the World Health Organization’s commission on social determinants of health, discusses the impact of the world’s financial crisis on global health.

Not sure how this will help Wales!

Update 3rd December 2013:

BBC Sean Coughlan reports: Pisa tests: UK stagnates as Shanghai tops league table

and

Pisa ranks Wales’ education the worst in the UK

So not much chance in the competing world for Welsh students outside Wales..

All education is divisive – We must all aspire to excellence, and speak out.

My father, a retired History Teacher, pointed out to me that “All Education is divisive”.

Whilst we have formative education in Medical school, consider how were we originally selected to get in?

At the end of Medical School we have a summative assessment, which a few fail (dividing off the chaff) and a few are “prize winners”, a fact that immediately goes into the Doctors CV. He is proud to achieve excellence.

The object of  education is to prepare the young to educate themselves There is   only one justification for universities, as distinguished from  trade schools.” Robert Hutchins.

When my grandchildren are at primary school they are being assessed as well as taught. Concentration, language, mathematical ability all combine to give some an advantage and some a disadvantage through lack.

The lifelong learner, the owner of the enquiring mind has a duty to aspire. Doctors are such people, and they aspire to be excellent, have research as part of their on-going portfolio, and to “make a difference”. So doctors in peripheral hospitals are less likely to have such an opportunity, and GPs even less. This lack of opportunity can lead to demoralisation and I wonder if this is some of the cause behind the Mid Staffs and other Hospital downgrades.

We as a Medical Profession have a duty to speak out. Nurses and Doctors, Physios and Managers. When we see things wrong we must speak out, when we don’t have exit interviews we should ask for them, and when we are ignored we should not be gagged. There is nothing shameful in aspiring, and any Regional Medical System which aspires to less than excellence should be taken apart and re-built. It will also need new leadership to match its new philosophy..

“First they came for the communists, and I did not speak out—
because I was not a communist;
Then they came for the socialists, and I did not speak out—
because I was not a socialist;
Then they came for the trade unionists, and I did not speak out—
because I was not a trade unionist;
Then they came for the Jews, and I did not speak out—
because I was not a Jew;
Then they came for me—
and there was no one left to speak out for me.”
Martin Niemöller

The big divide is now between those professionals who will, and those who won’t, speak out. Medical Education needs to emphasise this duty as much as any other.

And just to remind you of the gagging

The Telegraph’s By Steven Swinford, Senior Political Correspondent reports 15th Septrember 2013:

NHS ‘covered up’ £4m of gag orders

The head of the NHS has been accused of a “systemic cover-up” after official figures disclosed that hospitals have spent more than £4 million on secret gagging orders.

The Times (Ruth Geldhill) reports 25th September:

Doctor sacked for e-mailing Christian prayer to colleagues loses appeal

“A doctor who was let go for e-mailing a Christian prayer to colleagues has lost his appeal against his dismissal.

David Drew, 65, a consultant paediatrician, claims that he was targeted for being an NHS whistleblower.

He sent a 16th-century prayer by St Ignatius Loyola to colleagues in April 2009 in an effort to motivate the department.

Dr Drew, who had an unblemished 37-year career in the NHS, was told to “keep his religious beliefs to himself” after a review panel investigated his conduct in March 2010……

“We were a very, very happy department with people of different faiths and even some atheists who were quite outspoken.

“But we were senior, intelligent, well-educated people who were not extreme in our beliefs in any way. We co-existed quite happily.”

Dr Drew, who has four children and lives in Sutton Coldfield in the West Midlands with his wife Janet, continued: “My case was never about the religion. It was about the fact the hospital wouldn’t listen to its most senior paediatrician telling them they were cutting costs to the bone and putting patient safety at risk. It’s all about whistleblowing.”

He referred to Robert Francis, QC, who chaired the public inquiry into the Stafford hospital deaths and who called for a ban on gagging clauses that stopped doctors and nurses from speaking out for fear of losing their jobs.

Dr Drew said: “There were five gags put on my case so we’ve never been able to interrogate the process used in the review which led to my dismissal.

“My case is the exact opposite of the transparency that’s being called for in the NHS today.

“We have to give doctors and nurses freedom to safely report when they see things going wrong and putting patients at risk.

“It’s a scandal.”….

The culture of an organisation which behaves like this to a loyal longserving staff member, with no clinical complaints, really needs questioning. Perhaps the BMA or his MP will recommend him for a “gong”.

Its getting more serious.. Reform or die

Reform or die: the only NHS prescription

The Sunday Times 11th August 2013 reported:

“Too often in the 65-year history of the National Health Service the  politicians running it have reached for the easiest palliative — more money — to ease the discomfort….”

Too true. But there is no mention of a new philosophy in this leader, and the reason that the NHS was founded – “In place of fear”. Patients are regaining fear because our politicians and the media refuse toi address the really big issue.

The Sunday Times’ Jon Ungoed-Thomas  reports 22nd Sep. 2013:

“NHS coughs up £1.2bn to lawyers”.

MORE than £1.2bn has been earmarked by the NHS to pay lawyers who pursue compensation claims against hospitals.

The NHS Litigation Authority, which is responsible for handling negligence claims made against health service bodies in England, has revealed that about one-fifth of a £5.8bn provision for unresolved clinical compensation claims against the NHS has been set aside to meet legal costs.

No-win, no-fee lawyers have been blamed for the escalating legal costs of compensation claims. The proportion of legal fees paid out to claimants’ solicitors in relation to the damages received by the patient has risen steadily in recent years.

In the last financial year the ratio of claimants’ legal costs to the actual damages paid to the patient was 44.3%, compared with 33.2% five years ago.

The Daily Mail also reports this story:

Spending on NHS bureaucracy has almost doubled in four years, research shows.

Nearly £1.2billion went on administrators and clerical staff in Primary Care Trusts in 2007/8, a rise of 81 per cent since 2003/4.

The total is nearly twice as much as the £700million the Health Service spent on anti-cancer drugs last year, with some patients being denied life-prolonging medication.

This NHS funding squeeze will kill the system

reports Colin Leys 20th September in The Guardian

It is a cruel illusion to pretend the NHS can keep providing good services while its budget is slashed. Tax rises would help

BBC News’ Nick Triggle reports 23rd September

No action over Stafford Hospital doctors and Katherine Murphy of the Patients Association says:

“The general delay in holding individuals to account for failings at Stafford is outrageous.

“Years on, and after huge numbers of avoidable deaths, we have still only just scratched the surface of holding the nurses, clinicians and managers to account for the failings that occurred.”

This is correct. The “game” being played by managers is impossible to win. Everything for everyone for ever is unsustainable and without rationing the players know they are losers. SO how do you protect yourself? By spreading responsibility so wide that n0-one person can be blamed for anything systemic, and making sure there are scapegoats for the more specific tasks.

20 September 2013 Nick Triggle Health correspondent reports for the BBC:

Power to the patients. “Patient power is definitely in vogue.

Tuesday saw the launch of the new hospital inspection regime. The revamped process involves patients sitting on the teams that go into hospital and regular public meetings at each site that is visited.

Meanwhile, the results of the new PLACE programme – inspections which look at the non-clinical aspects such as cleanliness, building design and food – were also released this week.

As part of the changes made to the previous regime, lay representation on the inspection panels has been beefed up. Half of the members now have to be patients…..”

In August he asked: “How many reviews does the NHS need?”

“NHS reviews are getting a bit like buses. Miss one and you don’t need to wait long for another to come round the corner.

A month ago there was the Cavendish Review into healthcare assistants, and then two weeks later the Keogh Review into mortality rates, which led to 11 trusts being put into special measures, was published.

Now it is Prof Don Berwick’s review on patient safety.

All three were commissioned off the back of the Francis Inquiry into the Stafford Hospital scandal….”

The Times reports September 2013 :

Cancer drugs fund ‘to be extended’ until 2016

Thirty NHS trusts ‘set for deficit’ By Adam Brimelow

Charities warn government over ageing population

And finally the problems in Swansea Hospitals are printed here in full from The Times 28th September 2013. Bullying and cultural degradation – as predicted by this author.Heart patients die waiting as surgeons bully staff at Swansea hospital

Costing the NHS

The BBC has a series of programmes on the Health Service available on “Listen Again” or iplayer.

This summer NHS England called for a public debate to find ways of renewing and revitalising the NHS. One of the widely reported claims in its report “The NHS belongs to the people: a call to action” was that continuing with the current model of care in England could lead to a funding gap of around £30bn by 2020/21.

In this special programme, Julian Worricker looks at the growing demands on the health service in the UK, the willingness of the public to fund a service that meets those demands and the scope for savings without compromising care. Can the UK afford a health service that follows the NHS core principles: one that meets the needs of everyone, is free at the point of delivery and is based on clinical need, not ability to pay?

Joining Julian are:

Prof John Appleby, chief economist, the Kings Fund, Christina McAnea, UNISON head of health, Don Redding, policy director, National Voices, Dr Mark Porter, chair of the BMA ruling council, Stephen Dorrell MP, chair, Health Select Committee, Tony Whitfield, director of finance, Salford Royal NHS Foundation and president of HFMA, Sandie Keene, president, Association of Directors of Adult Social Services, Andrew Dillon, chief executive, NICE, Karen Taylor, research director, Deloitte UK Centre for Health Solutions, Dr Clare Gerada, chair, RCGP, Anita Charlesworth, chief economist, Nuffield Trust, Chris Hopson, chief executive, Foundation Trust Network, Christoph Lees, obstetrician, founder of Doctors Policy Research Group, Andrew Haldenby, director, Reform and Sir David Nicholson, chief executive, NHS England.

Presenter: Julian Worricker Producer: Simon Tillotson

I was disappointed in the first as the panel never addressed the politically dangerous ground of rationing. Therefore rationing will continue covertly and post coded.

Costing the NHS – live page

Follow the debate, read the latest comments and find extra information about the topics.

http://www.bbc.co.uk/programmes/b03b0qb2

http://www.bbc.co.uk/programmes/b03bqmv8

The second link is to

NHS: Changing Culture

Lesley Curwen investigates cultural failings in the NHS. This is on Wednesday 18th September. It might be the most interesting as all interviewed consultants so far have agreed that the problems are with management.

NHS culture has been condemned as “broken” and as “insidiously negative”. Business journalist, Lesley Curwen, asks what NHS managers were doing when appalling patient care was happening on their watch.

In the first of two programmes, she tracks the initial introduction of managers into the NHS and explores the responsibility that NHS leaders now shoulder for creating both good and bad cultures.

Robert Francis QC spells out why he believes the primary cause of the scandal at Mid Staffordshire was management failure, and the clean-up executives, sent in to run the scandal hit Trust, describe the culture of denial that dominated when they arrived.

As the NHS adapts to the radical reforms of 2013 in the midst of unprecedented financial challenges, Lesley visits both struggling and thriving hospital Trusts to discover how their leaders and managers are trying to create positive and open cultures, where staff are supported to provide the very highest standard of care to patients.

Producer: Fiona Hill.

I listened to this carefully, and although the history of managerial inadequacy and incompetence is clear to hear, no potential solution is proposed to this cancerous and festering culture.

If you wish to see clips from

Surgical Cuts

Mukti Jain Campion investigates a pioneering Indian model of cut-price healthcare.

If I can record any of these digitally on Iplayer I will post as update.

You might also like the Kings Fund spoof:

And an update 25th September 2013 in case you dont think rationing is happenning..

The Daily Mail (Jenny Hope Medical Correspondent) on 20 September 2013 reports:

16,000 cancer patients a year to be denied vital medicine as Government’s  specialist drugs fund is wound up

  • 16,000  patients will be denied drugs when the fund is wound up
  • Cancer charities  are calling for the  Government to pledge it will not go back to days when  patients ‘had  to beg’ for life-prolonging drugs
  • Four out of every  five people believe Britons should get cancer drugs that are widely available in  other European countries
  • The £200 million  a year Cancer Drugs Fund which began in April 2011 has led to 30,000 patients in  England getting drugs banned on the NHS

At least this rationing is now overt.. I happen to agree with this decision.

 

 

Alarm over ‘high’ death rate in English hospitals – A Special Posting and advance notice of Radio 4 program

After a few weeks off and due reflection I have decided to post the occasional highly relevant news stories.

The Times’ Chris Smythe 12th September reports:
“Patients in hospitals in England are 45 per cent more likely to die than those in the US.

Death rates in the NHS are notably higher than in six other developed countries, according to an international “smoke alarm” system from an academic who helped to spot the Stafford Hospital scandal.

Professor Sir Brian Jarman (of Imperial College – and famed for many reports) says that comparisons with countries in Europe, North America, Asia and Australasia suggest that structural and cultural problems that contributed to appalling care at the hospital have been claiming lives across the country.

The warning comes as the Royal College of Physicians (RCP) sets out a blueprint for a “once in a generation” transformation of hospitals.

More than 220,000 patients die in English hospitals every year and Sir Brian’s figures suggest that many of them might have lived if care matched that in other countries.

The NHS compares particularly badly on conditions that often affect the elderly, with death rates for illnesses such as pneumonia and septicaemia respectively 46 and 27 per cent higher than the international average. ….”

….”The data looks at years from 2004 to 2010 and Sir Brian said there were signs that the NHS had been narrowing the gap in recent years when projected forward to 2012.

“We have dropped faster than other countries and we’re getting to the point where we should be,” he said. But England’s projected death rates for 2012 are still 45 per cent higher than the US.

The data looks at years from 2004 to 2010 and Sir Brian said there were signs that the NHS had been narrowing the gap in recent years when projected forward to 2012.

“We have dropped faster than other countries and we’re getting to the point where we should be,” he said. But England’s projected death rates for 2012 are still 45 per cent higher than the US.

Mr Hunt said: “This Government has shone an unprecedented spotlight on poor care. Sadly, warnings about high death rates were ignored too frequently in the past.”

The RCP report Care comes to the patient: Future Hospital

A new report from the Future Hospital Commissionrecommends that in future, care should come to the acutely ill patient, rather than the patient being moved around the hospital. 

News for Jarman death rates report

NHS death rate is one of worst in the West: Patients 50% more likely to die of neglect than in US, says study

Daily Mail ‎- 56 minutes ago

Figures obtained by Professor Brian Jarman, in an exclusive report for Channel 4 News, show that the death rates in English hospitals last year

Hospital death rates in England 45% higher than in US, report finds

The Guardian‎ – by Randeep Ramesh‎ – 1 hour ago

“More doctors needed to lower death rate

ITV News‎ – 6 hours ago

  • NHS hospital death rates among worst, new study finds – Channel 4

    1 day ago – NHS hospital death rates among worst, new study finds Numerous reports and inquiries have revealed serious failings in the Jarman was able to identify the higher than expected mortality rates at the Mid Staffs trusts.

    Do we admit more people to die than other countries? Is death at home less acceptable in the UK?If the Regional Health Service in England (note lack of comparison with Wales Scotland or N Ireland where things may be worse still) has worse death rates than the US alone, this might be understandable, as their hospitals are largely private or HMI (Health Maintenance Organisation) owned and funded by some form of individual or group Insurance. The US system is not comprehensive, These facts, and the result many are excluded, may mean the comparison is not valid, But for the English region to be 7th in the league table needs to be explained…. Is it that we exclude nobody which accounts for our results? What is the trend over the last 9 years say, at 3 yearly intervals? Givent the gagging, declining standards, ostrich like political philosophy, two syllable media and the financial pressures I will not be surprisd if the headline is factually correct.

    A graphic needs to be added…

    Just looking at the news coverage of the NHS recently and since the last posting, I include some selected articles.

    NHS staff ‘miss signs of blood-poisoning’ reports Chris Smythe on September 13th in The Times:

    “The NHS ombudsman has criticised a failure by doctors and nurses to prevent thousands of deaths each year as a result of blood poisoning.

    As many as 37,000 people die annually from sepsis, and Dame Julie Mellor said it was “time for the NHS to act and save lives”. In a report, she recounted the cases of ten patients who died after the signs of sepsis — in which the body’s immune system over-reacts to an infection — were missed…..”

    This reflects the shorter hours, leading to reducing standards of medical training and education. (Eurpoean Working Time Directive – EWTD) Doctors who work only a 38 hour week will see far less than those who work a 98 hour week.. (which my generation used to do on the week of a wekend off!) They will be less aware and suspicious of septicaemia as a diagnosis.  Interestingly, the French and the Germans don’t worry about breaking the EWTD….

    Hunt: NHS data protection fear must end – Chris Smtythe in The Times 13th September 2013 reports:

    “Jeremy Hunt has attacked a “computer says no” NHS culture that stops  doctors and nurses sharing life-saving information about patients.

    Staff will be given an explicit duty to be more open with patient records when  it could improve care, the Health Secretary announced yesterday. Mr Hunt  said it was unacceptable that patients failed to get the treatment they  needed because bureaucratic rules on data protection meant organisations  refused to share data.

    “There are examples where people have been overzealously interpreting rules on  data protection without thinking about what the interests of the patients  were,” he said.

    Senior doctors complain that data protection has become the “health and safety  of the NHS” as inflexible procedures get in the way of common sense.  Patients arriving in A&E often suffer because staff there struggle to  access GP records on allergies and existing conditions because of IT  failures and confidentiality concerns.

    “Older people tend to have multiple conditions so for them the ability to talk  to people who know their medical history is incredibily important,” Mr Hunt  said.“The default should not be ‘computer says no’.”

    A review  on patient data was led by Dame Fiona Caldicott, who said: “The culture  in the health service has unfortunately become one of anxiety, some say fear  [over data protection laws].”

    She carried out an earlier view in the 1990s which led to tightening of rules  on patient confidentiality but she said an “aura” had since built up that  scared health workers away from sharing data when needed.

    Her review sets out principles of how NHS staff should protect confidential  patient data and affirms patients’ right to opt out of having their  information shared. However, it also found that some patients had been  denied access to their own records because NHS bosses were so scared of  fines for breaching data protection laws.

    In a  response published yesterday, the Department of Health said: “The duty  to share information can be as important as the duty to protect patient  confidentiality.

    “The common law ‘duty to care’ includes a requirement to share information but  often professionals and staff are prevented from doing this by their own  organisation’s procedures.”

    Paul Hodgkin of the campaign group Patient  Opinion said: “The stories we get are people saying, ‘I had to tell my  medical history 15 times’, or ‘When my husband went to a new hospital they  couldn’t access his notes and X-rays’.

    “There are concerns about privacy but people are bothered by care that isn’t  as good as it should be because Dr X couldn’t read their notes.”

    Tony Calland, of the British  Medical Association ethics committee, said: “I would agree with Jeremy  Hunt that there has been too much of the ‘computer says no’ culture … but  to imply that data should be flying around all over the place is not  helpful.”

    The first duty of a doctor is to put the patient at the centre of his concern. Surely this should be true of the profession as a whole?

    It is 30 years since my own GP surgery computerised. About 10 years later I suggested that all GPs in my area moved to one computerised notes system. (The one type of notes needed everywhere in the health services is the Primary Care notes… and if one system is dominant everyone: casualty, Intensive Care etc etc will move to it. Suddenly the profession is “putting the patient at the centre of its concern”…. If readers wish to read more on medical Ethics I suggest Daniel Sokol’s site.

    The Independent’s Alex Delmar-Morgan , following a survey of 1000 health workers done by the Chartered Institute of Personnel an Development (CIPD) reports 9th September:

    “Doctors and nurses say they feel ‘bullied and under pressure’

    and as a result Chris Smyth in the Times infers that:
    On 7th September the BBC and the Cambridge News (specially relevant for David Gray’s family) reported that:
    It’s about time that the communication skills and cultural awareness tested for in General Practice licensing exams were applied at all doctors.
    If you wish to hear Clive Anderson interviewing Lawyers on Whistleblowing there are two opportunities on Radio 4:
    Wed 18 Sep 2013 20:00 & Sat 21 Sep 2013 22:15
    The BBC Wales (Daniel Davies) reports 9th September:
    Well of course gaming (playing a system for advantage) are going to happen in a system which denies choice (see my advice page) and assumes that all hospitals provide the same standard of care, and fails to subject itself to other regional comparisons. The refusal to allow patients choice in Wales will inevitably lead to increasing inequalities, exactly the opposite of what the Welsh Assembly says it would like to achieve.
    The BMJ deputy editor in the edition 24-31st August 2013 comments “The NHS in the age of anxiety, rhetoric and reality” on an essay by Rudolf Klein which says that:
    “A dangerous gap is opening up between rhetoric and reality as the NHS faces a grim fiscal future, Rudolf Klein argues. High flying ambitions for transforming the NHS are not matched by achievement, and austerity will compel a new agenda of minimising harms rather than maximising benefits”.
    So its not just Wales which will have to tolerate lowest common denominator medicine.. At least the pain is to be shared around.. The editor could have replaced “anxiety” by “fear and referred back to Aneurin Bevan and his 1952 book, and why the then National Health Service was founded.