Monthly Archives: November 2013

Medical negligence claims and human error

Here is an example of the type of advertising in local newspapers which is causing us to pay more, and the NHS to lose more money, and to become more and more inefficient.

OLYMPUS DIGITAL CAMERASource: Eastern Daily Press 27th Nov 2013

Michael Carter, a paediatric neurosurgeon, in The Times letters 27th November 2013 comments:

“Litigation extends now into every area of NHS medical practice, from negligence, criminal assault, benefit entitlements and child protection

Sir, Litigation involving the NHS is a targeted, calculated, multibillion- pound industry (letter, Nov 20). It is funded almost exclusively by the taxpayer, and genuinely deserving causes are often the smallest beneficiaries.

Regarding clinical negligence claims, John De Bono (letter, Nov 21) does not highlight the critical point that a poor outcome does not necessarily equate to bad practice. Neither does he point out that there are many perverse incentives that drive the development of a claim and its possible settlement. Not least of which is the fact that NHS trusts and the NHS Litigation Authority will almost always opt to settle a claim, however outrageous, rather than risk the immense costs of defending and possibly losing.

Litigation of some sort now extends into every conceivable area of NHS medical practice, encompassing scenarios as diverse as negligence, criminal assault, benefit entitlements and child protection. In many specialities the likelihood of it colours every single patient interaction.

Michael Carter

(Consultant Paediatric Neurosurgeon), Bristol

I agree. No fault compensation as delivered in New Zealand through the accident compensation commission is one answer, and this does not exclude litigating through tort law. One of the other problems is the advertising of litigation claims lawyers, and the “no win no fee” laws which encourage claims… It will take some time to reveal whether the new changes (below) alter the expense of litigation.

The new Legal Aid, Sentencing & Punishment of Offenders Act will change   the way in which “no win, no fee” cases are funded. (Emma Simon in The Telegraph comments March 2013)

“Supporters of the Act say it should put the brake on “ambulance-chasing   lawyers” who pursue spurious and exaggerated claims, often at inflated   legal costs.

But critics fear it could restrict access to the legal system for many   ordinary people. It will also mean that those who have legitimate injury   claims will have to use a significant part of any damages received to cover   their legal costs.

see also 28 Mar 2013 Number of ambulance-chasing firms falls by a third after change to ‘no-win, no-fee’ law

Bad News: Sixty per cent of girls obese by 16, says new waistline measure

Chris Smyth in The Times reports 26th November 2013: Sixty per cent of girls obese by 16, says new waistline measure

“The waist of the average 15-year-old girl has expanded nearly 13cm (5in) in  the past two decades, according to a study which finds that many children  are even fatter than previously thought.

Six out of ten girls are obese by the time they reach 16, according to a  measure that looks at waist size rather than body mass index (BMI). One in  ten girls at this is obese even by adult measurements, with waists larger  than 88cm (35in).

The average girl now has a waist of 76.5cm (30in) at the age of 15-16,  compared with 64.4cm in 1990, according to a study by Leeds Metropolitan  University. Among boys, the average waist has grown from 69.3cm to 77.7cm in  the same period, results published in the journal Public Health reveal……”


So who would support me in “deserts based rationing” in that free drugs for type 2 (maturity onset) diabetics with Body Mass Index over 30 (or commensurate waistlines) should pay for all their drugs in England (they are all free anyway in Wales and Scotland!)?



Neighbours urged to help elderly this winter as death rates soar

Chris Smyth in The Times 27th November 2013 reports:

Neighbours urged to help elderly this winter as death rates soar

“Health chiefs have issued an unprecedented plea for tens of thousands of  people to visit elderly neighbours this winter after official figures showed  a huge rise in deaths due to cold weather last winter.

NHS England  said an “army of Good Samaritans” could help protect the frail and ease pressure on  overstretched A&E units, as ministers promised more beds and extra staff  to tide hospitals over through the winter. Campaigners said it was “half-cooked” to rely on volunteers when the NHS and social services should  already be coming up with plans to look after elderly people.

Last winter saw 31,000 excess deaths linked to the cold, up 29 per cent from  the year before, with the Office  for National Statistics saying the rise was due to a longer winter that  dragged on into March. The figures have increased pressure on ministers to  help the elderly cope with soaring fuel bills this year.

More than 25,000 of the deaths were among over-75s, prompting health service  bosses to call on 100,000 people to sign a pledge on the NHS  Choices website to “take time out this winter to look in on an elderly  friend or neighbour to make sure they are warm and coping well”….

….Mark Porter, chairman of the British Medical Association Council, said this  was only a “short-term fix” that did not address the acute funding pressures  facing the NHS.


Pneumonia is not necessarily an unpleasant way to pass on, and used to be called “the old man’s friend”. There are always more deaths in the winter months. Certainly the use of neighbours to check on infirm older folk with arthritis and incapacity is a good thing… Using the phone as well, but this wont give you the ambient temperature… It does reinforce another need: to have an advocate to attend you when in hospital…

Rise in ‘avoidable’ A&E admissions for over-75s

More than 500,000 over 65 admitted in emergency for conditions that should have been treated at home November 22 2013

Hunt shuns charity army of volunteers for elderly

Charity chiefs angry over health secretary’s rebuff of offer for extra care for elderly this winter November 22 2013

NHS volunteers offer to ease elderly winter crisis

Charity chiefs offer an army of volunteers to help to prevent elderly people blocking A&E departments and hospital… November 14 2013

Kings Llyn: New chief executive’s plea for GPs not to lose confidence in special measures hospital

The Eastern Daily Press reports 27th November 2013:

New chief executive’s plea for GPs not to lose confidence in special measures hospital

“Campaigners from the health union Unison said they feared services at the Queen Elizabeth Hospital (QEH) in King’s Lynn – including accident and emergency – could be closed if some people choose to use other NHS facilities because of worries about waiting times or the level of care.

Dr Manjit Obhrai said all services at the Gayton Road hospital would still be delivered and said categorically that the A&E would remain open and fully-staffed – but admitted there was a risk fewer people may use the hospital “if public confidence has been dented by what’s gone on before”.

He said: “We are saying to our GP colleagues, ‘Please don’t lose confidence in the hospital. We will work with you to improve the service.”

The patients of the English NHS have “choice” enshrined in their constitution. Not so in Wales ….The downgrading of peripheral hospitals inevitably means patients will choose to go to safer hospitals – as long as they are allowed…

How NHS reform goes around in circles

Was there ever a better case for de-politicizing the Health Services, and indeed, in order to achieve fairness and equality, for restoring the “National” part of the pre 2001 NHS? This would of course mean a review of the Scottish and Welsh assemblies. Non functional mutuals of 3 0r 6 million are much worse than a functioning one of 65 million, if we can achieve this.

Prof. John Oldham, of Imperial College has written an interesting summary of the last 30 years in the BMJ 2013; 347:f6716, and the evidence supports his contentions. The last time the title was used was in The Telegraph in 2007.


I have attempted to list these below and I attach a copy of the whole article. (Reform Reform Oldham J bmj.f6716) and then an interesting response….

Oldham adapts the change cycle to a (cynical) reform one:


1. A system built on body parts and top down – rather than holistically looking at the whole patient, and bottom up. (Not providong good transport links in deprived areas while there was the opportunity from Objective One and Community Fund monies meand that managers cannot sell the centralisation of expertise, even though it will save lives.)

2. Harm from competing demands. “Policy generating mechanisms unwittingly conspire to create a scenario of competing, and sometimes conflicting, demands on the NHS, at both the financial/managerial and the clinical level….”

3. Bias to status quo. “There are substantial stakeholders in the health-care system whose power and prestige is secured if things don’t change very much…” (not least Politicians who wont look at philosophy or agree to ration care, and are “gagged” by their central party structure. They always want change and nationalising care to centres of excellence, but never in their own patch.)

4. Death by research. Since advancement in most branches of academia depends on publication, bogus and duplicative, non-contributory, and micro-section research abounds. (Political nous achieves promotion, and often it is not medical talent or ability)

5. More effective reform: “physiology not anatomy”. (The focus on hospitals at the expense of primary care despite protestations to do the reverse for years… has meant that it is very difficult to sell the changes needed in rural areas. If General Practice had been stronger, and there were more GPs providing a greater variety of services, this would have been much easier.)

In has last two paragraphs, Prof Oldham says ”

My basic tenet is that  few reforms have truly transformed the delivery of healthcare as it is experienced by patients in the NHS in England.  They have often been the wrong sort of reform—focused on organisational structure not the way organisations work or what drives organisations to work that way—and do not reflect the multimorbid complex needs of most patients. Fundamental elements of the healthcare system not only remain untouched by reforms but create a self regenerative cycle that impedes true transformation. Although I have focused on the NHS, similar problems can be seen in the health systems of many other countries.

The next iteration of reform must not focus on structures but begin the rebalancing needed: rewarding longitudinal population care, prioritising and narrowing the focus of system-wide demands, creating equivalent generalist and multidisciplinary input to policy generation, and placing as much emphasis and reward on implementation as there is on research, in both training and career advancement.

Most importantly, the health and social care system experienced by citizens will be bettered by a deeper understanding of the nature and holistic needs of the patients and users that are the main drivers of activity. Professions and organisations should reform their functioning around those whole people, and not around body parts. Multimorbidity and complex patients and their needs are the new frontier of healthcare.

one of the BMJ responses

Why aren’t patients at the centre of health care?

A theme running through the print edition of the BMJ of 23rd November was how patients are not, despite the rhetoric, at the centre of health care. In addition to the professional factors,including those described by Oldham(1), three powerful trends in the last thirty years have made this less, not more, likely.

The first is the neo-liberal ideology of competition, that health systems will work best if made to behave like competing businesses. A major fallacy in this is that to a business, customer service is a means to the end of profit, not, as it should be in a health system, the end in itself. Businesses cannot be expected to do things that do not contribute, directly or indirectly, to profit. If healthcare organizations are to behave like businesses, they too will first look after their own interests, not necessarily those of patients.

The second is the cult of management that has dominated us since the 1980s, entering the National Health Service with the Griffiths Report, with its creed that all problems have generic managerial solutions. This has given us our never-ending stream of reorganizations: to a man with a hammer, every problem looks like a nail.

The third is the abuse of industrial analogies for health care. While industrial models of defined processes can be applied to some healthcare activities such as elective surgery in fit people, such processes depend on standardized and quality-controlled raw materials – the very reverse of the raw material of medical care, people in all their variety and increasing complexity as they age, with freewill and feelings of their own.

Reference: Oldham J. How NHS reforms go round in circles. BMJ 2013:347;f6716

Competing interests:None declared

Edmund J Dunstan, Locum Consultant Physician

Royal Orthopaedic Hospital, Birmingham,

Good News: Boost for cancer treatment services at Norfolk and Norwich University Hospital

Eastern Daily Press reports 26th November 2013: Boost for cancer treatment services at Norfolk and Norwich University Hospital

“Cancer patients are set to benefit from quicker radiotherapy treatments when a £4.5m extension at the Norfolk and Norwich University Hospital opens next year.”

Throughout the country, more and more people are waiting longer and longer for Radiotherapy. The standard is set at 31 days which would never be accepted in a private or insurance based system. There are no private providers outside of London as the capital needed is so large.

As long ago as Monday 8 August 2011 Cancer News (Cancer Research UK) reported: Shorter radiotherapy waiting times ‘saving 2,500 lives a year’

cuts to radiotherapy waiting times are saving around 2,500 lives annually in England, according to a letter published online in the British Medical Journal.

Things are much better than they were in 2000 when The Daily Mail reported:

Deadly wait for cancer treatment

Thousands of cancer patients are dying as they wait for treatment, it was  revealed yesterday.

The number waiting a ‘dangerously long time’ has doubled in two years,  according to a report from the Royal College of Radiologists.

Two-thirds of people face a delay of longer than four weeks, during which  time many tumours spread and become incurable.

In some cases, patients are having to wait up to eight months for  radiotherapy. The Government target is for treatment to begin within four weeks  of a referral by a consultant.

The study found the number of patients receiving medical attention within the  target time fell from 68 per cent in 1998 to 32 per cent in 2000. Britons are  less likely to survive cancer than residents of almost every other country in  Europe.

The demographics mean the demand will rise across the country. In rural areas there is a real risk of serious delays as budget cuts hit.

Ambulance Watch: Report calls for 400 extra front-line staff at under-fire 999 trust

Eastern Daily Press reports Tuesday 26th November:

Ambulance Watch: Report calls for 400 extra front-line staff at under-fire 999 trust

The challenges facing the region’s under-fire ambulance service have been laid bare by a new report which reveals that the organisation will need more than 400 extra front-line staff over the next four years to meet demand.

More employees of the state, needing pensions and salaries, without co-payments means more balance of payments deficit! The poor manpower planning considering the demographics facing us is stunning..