Monthly Archives: October 2013

The NHS in the age of anxiety: rhetoric and reality—an essay by Rudolf Klein

 I missed this essay from a much rspected elder when  holiday.

Essay: The NHS in the age of anxiety: rhetoric and reality—an essay by Rudolf Klein. BMJ2013;347doi: 21 August 2013)

Cite this as:BMJ2013;347:f5104
“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

Statistically there does not seem to be much wrong with the National Health Service. At the turn of the year, the Department of Health could report that “key performance standards” had been maintained even as fiscal austerity began to bite.1 Some, such as hospital infection rates, had even continued to improve. Further, the department expected the NHS to have passed the halfway mark towards achieving its £20bn (€23bn; $31bn) savings target by the end of the 2011-12 financial year.2 A more recent sample survey also suggests that there has been no deterioration in performance, bar a marginal increase in the number of patients waiting for more than four hours in emergency departments.3

Organisationally, too, the NHS seems to be a success story. It has successfully implemented the disruptive and distracting Lansley programme of change. This involved closing down 170 organisations, creating 240 new ones, making 10 000 staff redundant, and then re-employing 2200 of them.4 NHS England, as the NHS Commissioning Board has chosen to style itself, is now in charge of the service, churning out instructions, consultations, and exhortations at a manic rate. Yet it would be surprising if the public and patients noticed any difference in the way the NHS operates, so smoothly managed has been the transition; it is those working in the service who have absorbed the shocks and pain of change.

Bad news stories

But, of course, there is another story to be told: that of the NHS stumbling into crisis. The three volumes, 1781 pages, and 290 …

read the whole essay – Klein-bmj.f5104

The deterioration in performance in Wales, with waiting times twice as long as England is significant and serious. Hywel Dda Trust exclusion of Hip/Knees is rationing under any name. But the English NHS is also in trouble as choice is relatively inappropriate for common conditions, and unavailable for those with travel challenges. Klein avoids recommending rationing, which by itself would still not be enough. The  4 organisations have such high overheads in the form of administration, sickness and absence, and litigation etc. that although I hate the idea, I am more and more inclined to make each trust/hospital completely independent so that new cultures and organisations evolve. Some will go bust… and there will be a great deal of short term pain, but it should all be worth it if we can streamline the service and avoid the current “swimming in treacle” as Klein describes it, with morale sinking in many staff. Their career progress was often fossilised in the demise of  “agenda for change” as the only defence for trusts became to renegotiate contracts, and get most people to do the same work at a lower grade,

NHS ‘revolution’ demanded in new report into patient safety

Wales on line  reports: NHS ‘revolution’ demanded in new report into patient safety on 28th October 2013:

Report by Labour MP  Ann Clwyd calls for significant changes in how NHS handles complaints and deals with problems with patient safety

The NHS needs a “revolution” in the way it handles complaints, according to an independent report led by Cynon Valley Labour MP Ann Clwyd, whose husband died in “battery hen” conditions last year at a Welsh hospital.

Ms Clwyd today presented the findings of her review, launched amid deep concern about patient safety and in the wake of her own account of how her husband, Owen Roberts, was treated at the University Hospital of Wales in Cardiff.

Ms Clwyd said complaints should be regarded as “gold dust” and she “very much” hoped that the Welsh Government would adopt recommendations from her report.

She said: “When I made public the circumstances of my own husband’s death last year, I was shocked by the deluge of correspondence from people whose experience of hospitals was heart-breaking. It made me determined to do my best to get change in the system.

“We have given patients and their families a voice in this report, and their message to the NHS on complaints is clear. The days of delay, deny and defend must end, and hospitals must become open, learning organisations.

“Our proposals put patients firmly into the driving seat at every level as never before, and we now expect to see progress within 12 months time.”

Her report, which is focused on the English NHS, proposes that:

– Chief executives need to take responsibility for signing-off complaints……..”

BBC News said: “The culture of delay and denial over NHS complaints in England must come to an end, a review led by a Welsh MP finds. Listen to Anne Clewyd on the BBC.

Patients’ concerns should not be brushed aside, says Ann Clwyd MP 28 October 2013.
(Dec 2012)
Standards of care have not been high enough and the ability of the Trust Boards to respond whilst keeping waiting lists down, avoiding bed blocking and saving money is not there. Without overt rationing, where patients know what will and what will not be provided for, we are in for a future of covert post code rationing where only the well informed and the rich are able to gain access to the best services, Gaming of heathcare will become more prominent, and those living on “frontiers” of two regions, or having holiday homes or relatives who live with in areas with say “stroke centres” will be the winners.

Public health: how does the UK compare with Europe? Interactive map

The Guardian 30th October 2013 &  report:

Public health: how does the UK compare with Europe? Interactive map

“Women and children in the UK would have longer and healthier lives if they lived in Cyprus, Italy or Spain, according to a major piece of work by Sir Michael Marmot who warns that Britain is facing “a public health timebomb”……..

Public Health as a speciality has been under the financial hammer since well before the financial crisis. The idea that populations deserve good healthcare ahead of individuals, and that more health gain is achieved by aiming at the latter rather than the former, has not been well supported as it is a tacit admission of the need for individual rationing. We do have flu jabs, childhood vaccination campaigns etc, and will soon have shingles vaccinations – in some regions. (post code rationing) Despite the rhetoric on NHS choices, there is currently insufficient supply. If I was over 60 I would consider buying this vaccination as it is only available for the over 70s at present….  (Ageist rationing)

Health Service Anatomy – Administrative costs and overhead charges – Choice, Doctors and risk

The anatomy of the Health Service (In England) is explained by this graphic from 2010-11

Anatomy of Health Service

It is interesting that Aneurin Bevan boasted of a 3% annual administartion cost from 1948-1952. I am trying to find out what it is now but my estimate is over 25%

We and NZ have the highest reliance on doctors trained overseas.


Cancer survival rates have improved dramatically since 1994, when this graphic was produced.

Cancer Survival rates Europe

Women are outperforming men in all degrees and particularly in Mediciine

Class divide copy

And women are safer and have fewer referrals to the GMC

women safer

Choices are made by English patients on certain criteria – both choice, and the criteria to make a choice, are unot available to Weslh Health Service patients ot to their Doctors.

choosing hospitals

How many patients know they can choose?

which hospital

The “zero tolerance” policy towards violence may have reduced these figures from 2007

health battles

Waiting times (up-to-date)  for England are available on the Nuffield Trust website, but there are no similar graphics for the Health Services in N Ireland, Scotland and Wales.

All very sad, except the good news that cancer survival rates are improving…

Update 3rd November 2013 – Comment from John D:

Although the costs of administration in the NHS may be difficult to find, staff numbers show I think an interesting story.

 In the Royal Surrey County Hospital – a Foundation Trust – their website shows the most recent annual report and accounts.  The attached (Full Time staff equivalent Royal Surrey County Hospital) shows the Full Time Equivalent Staff numbers from the report.

 What business could operate with nearly 18% of its staff working in Administration and Estates?

 The report can be found here.



The real cost of Health Care exposed – on Cruises

The Telegraph 30th October 2013 reports: Cruise passengers warned over medical bills

Inadequate insurance could cost cruise passengers thousands in medical bills,   the consumer magazine Which? Travel has warned

The Times 30th October 2013 reports (not on line)

Cruise Doctors charge up to £233 a visit.

This is a reminder that the NHS is a mutual for us all. This is what happens to costs when the safety net is removed, (and fear returns). When Insurance companies charge individuals they make money easily. When they charge groups they make less money per capita…. Surely the cruise liners should offer a joint mutual policy option…



The NHS is a club for managers. Collect £200,000 every time they pass Go

In the next two weeks the final accounts of the 161 primary care trusts and strategic health authorities that were abolished in April under Andrew Lansley’s controversial reforms will be published…

NHS payoff scandal could cost David Cameron dear – Rachel Sylvester in The Times 29th October 2013

Charlotte Leslie, a Tory member of the Commons Health Select Committee, believes that despite all the changes the Government has failed to get a grip on the NHS  culture. “There’s a powerful cabal within the Department of Health that will hijack any reform to make sure it’s still jobs for the boys and girls,” she says. “The NHS is a club for managers. It’s a completely unaccountable system with people merrily waltzing around the merry-go-round picking up £200,000 every time they pass Go.”

To read the full article and the threat to Mr Cameron when the full NHS accounts are published read here.NHS payoff scandal could cost David Cameron dear. I just wonder if they all signed a gagging “disclaimer”…..? It doesn’t sound as if many managers became depressed..

“It’s a recession when your neighbour loses his job; it’s a depression when you lose your own.”
―     Harry S. Truman

Addendum 1st November 2013:

The Times’ Chris Smyth, Lucy Bannerman, & Kathryn Nave 1st November 2013 report: £1m payoff, then NHS brings back managers

“A married couple who were both NHS managers received redundancy money of almost £1 million before being taken back on by the health service a few months later.

They are among dozens of senior staff given payoffs of more than £100,000 after 161 NHS bodies were abolished under health reforms this year, according to accounts published yesterday. Many found new jobs in the NHS….”

GDP and GVA differences across the UK – a threat from Scottish Independance

I appreciate these map diagrams are from 2011, 2010 and 2007/8 and that the report from Wales is from 2005. But they do imply that there may be a problem if Scotland leaves the United Kingdom. An area with higher than average GDP and 5.3m people may be leaving the mutual pool of 65m people. Assuming budgets are static, the subsidy for the poorer regions that remain in the UK would be proportionately higher from the remaining affluent areas. This might cause some resentment… It certainly needs discussion. See post on Deprivation differences..

To see a map of regional differences in GDP as a % of Europe GDP average look here.



Report: Wales Government compares GDP with Europe April 2005. This reports claims Wales has 90.2% of the average GDP per capita of Europe.

for reference: The economy of Scotland  The economy of Northern Ireland The economy of Wales The economy of England The economy of the UK

GVA (Gross Value Added) in the UK shows the following table:

The Countries of the United Kingdom by GVA per capita sets out the Gross Value Added per capita (as of 2011) for each of the countries of the United Kingdom as well as separate figures for the nine English regions.[1]

Rank Country (and English Regions) GVA per capita Total GVA
1 England £21,349 £1.12 trillion
Greater London South East East South West East Midlands North West West Midlands Yorkshire and the Humber North East £35,638 £22,369 £19,355 £19,093 £18,083 £17,754 £17,486 £17,073 £15,842 £283 billion £192.3 billion £114.1 billion £101.5 billion £81.6 billion £123.9 billion £95.8 billion £91 billion £41.6 billion
2[note 1] Scotland[note 1] £20,571[note 1] £108.1 billion[note 1]
3 Northern Ireland £16,531 £29.9 billion
4 Wales £15,696 £47.3 billion
United Kingdom £20,873 £1.34 trillion


  1. Revenues from North Sea oil and gas are not included in these figures. If it was, Scotland would have a greater GVA per capita output than that of both England and the United Kingdom as a whole, although it would still be behind the Greater London region.

Update 6th November: Gavurin-GDP-England--Wales

Source: Gavurin Geographic Data Intelligence.