Monthly Archives: May 2014

Tories approach Labour MP Frank Field to help tackle NHS deficit

Toby Helm of The Observer reports Saturday 17th May: Tories approach Labour MP Frank Field to help tackle NHS deficit – A conjuring trick is proposed, to raise taxes calling it National Insurance, whilst failing to address the philosophy and the need to ration overtly. It does show how difficult it is to change and even harder for a conservative than a labour government. It was labour under Mr Muldoon, who achieved the change in NZ…

Field to meet health secretary Jeremy Hunt to discuss raising national insurance contributions

A Tory minister has asked Labour MP Frank Field to meet the health secretary, Jeremy Hunt, to discuss his ideas for raising national insurance contributions to pay for the NHS, in a sign that the Conservatives are considering radical options to plug the huge funding gap.

Field told the Observer that he was approached by the minister, who said the financial crisis in the NHS needed to be addressed and that he was right to be floating ideas on how the service could be maintained and put on a sound financial footing for future generations.

Field told the minister he would be willing to meet the health secretary, but not before he had held talks with shadow chancellor Ed Balls about his proposals, which he did last Tuesday.

According to Field, the minister also said that the financial crisis in the NHS had been the subject of discussions at high levels in government in recent weeks.

Field is drawing up proposals that he says will help to fill a looming £30bn a year “black hole” in NHS funding that will occur by 2020.

Without action, he says, a Labour or any other government would be faced with the prospect of having to make swingeing cuts across the other public services, far deeper than envisaged so far, to maintain the NHS in anything like its current form….

….

Field said the extra NI contributions should go into a dedicated fund that would be run as a mutual, with elected members negotiating each year’s level of contributions. “What we need is a new settlement for the NHS, an NHS mark two, that will reassure people that the most popular public service is safe for future generations.” He is now concerned that unless Labour moves on the issue, the Tories will steal the idea. Field proposed the sale of council houses in 1979, only to see Margaret Thatcher take up the idea and turn it into one of her most emblematic policies.

Labour is already committed to combining the budgets for health and social care but the party’s public position thus far has been that it will not look at a specific NHS tax.

Shadow health secretary Andy Burnham is wary of increasing NI in a way that would mean younger people in work having to pay the care costs of those already of pensionable age.

He favours other options, including a plan floated by Labour before the last election for a levy of 10% to 15% on people’s estates after death to pay care costs. To address Burnham’s concerns, Field proposes that those now over pension age would be asked to continue to pay NI, if they wanted free care. Otherwise, they would have to pay under the current system.

The Observer follows up with letters on Sunday 25th May 2014. Frank Field: would my ideas to save the NHS work under the Tories?

A reformed national insurance system is the way forward the fund the NHS – No it’s not!

Choice is not all it is made out to be – without overcapacity including GP recruitment

In “Bitter Medicine” on 24th April the Economist comments on the NHS (England) reforms.  The article uses selective use of information to support a political argument and belief. The benefits of “choice” and competition are only available to those well informed or assertive few in rural areas, and the citizens of large cities. Without “overcapacity”, choice remains an aspiration and a means to educate, rather than an objective..  Undercapacity, particularly of GPs in Wales, remains a more imprtant issue.. (Julia McWatt, Wales on line 24th May 2014)

Choice delusion

LIKE patients shrinking from needles, many doctors fear politicians pushing market-oriented health policies. For more than two decades governments of all shades have injected small doses of competition into England’s publicly funded health system. Reforms passed by the coalition government in 2012 provided the most recent jab. They have left many people feeling queasy.

David Cameron, the prime minister, had hoped to see nearly all of the NHS’s contracts awarded through competitive bidding. In the end, his new rules acknowledged that non-competitive contracting is sometimes the best choice if the process is transparent, unbiased, and clearly benefits patients. But the local groups responsible for purchasing care (known as Clinical Commissioning Groups, or CCGs) complain that they have received mixed messages. Some of the doctors that run CCGs say they fear legal challenges from health providers if they do not tender all of their contracts competitively. In February Andy Burnham, the shadow health secretary, said CCGs had spent £5m ($8.4m) on competition lawyers during the previous year. Sir David Nicholson, former head of the NHS, said that the service is “bogged down in a morass of competition law”.

The health regulator, Monitor, tacitly concedes that the rules could be clearer. It is busy tutoring CCGs on what they actually mean. If they honour common sense and put patients’ interests first “they’re 95% there”, says Andrew Taylor, former head of the NHS’s Co-operation and Competition panel.

And CCGs are probably wrong to believe that the coalition’s most recent reforms will mean their decisions get challenged more often through the courts. In truth, health providers have been growing more combative for years. In 2011 the Royal Brompton hospital in London went to court in the hope of reversing a plan to consolidate paediatric heart surgery in other hospitals. (It lost, but the case had a “signalling effect”, says Mr Taylor.) In fact by beefing up Monitor’s role, the government’s reforms have provided a means of resolving disputes outside the courts.

The reforms will probably have a bigger effect on hospital mergers. The government made it clear that the Competition Act—which prohibits anti-competitive agreements and the abuse of a dominant market position—should be applied to the NHS. In October two cash-strapped hospitals in Dorset were blocked from joining up on the grounds that it would give patients too few choices. This was controversial because the hospitals argued that their agreement would result in better care, a difficult thing to gauge. Some doubt the competition authorities can get the cost-benefit analysis right.

David Bennett of Monitor believes some of the hand-wringers are more interested in ending, not improving, the current competition regime. Mr Burnham admits as much, but his options are limited even if Labour wins the next election. His proposal to favour NHS hospitals and clinics for contracts may turn out to be illegal under European law.

The NHS’s new boss, Simon Stevens, seems keen on competition. Patients will benefit if he can convince critics of its merits. Two studies at English hospitals found that competition saved lives without increasing costs. Another study showed that family doctors located close to rival practices performed better. The medicine is working. Time to increase the dosage.

Centralising specialist health services does have some benefits

GPs’ emotive campaign claims they’re ‘teetering on brink’

STN250901_b_1070822aThe Sunday Times’ Sarah-Kate Templeton, reportgs 25th May: GPs’ emotive campaign claims they’re ‘teetering on brink’
GP LEADERS are to mount an emotive, politically charged poster campaign showing queues of patients waiting outside surgeries.

The Royal College of General Practitioners (RCGP) is sending the provocative images, reminiscent of the Labour Isn’t Working posters used by the Tories in the 1979 election campaign, to every surgery in the UK, asking doctors to place them in patient waiting rooms.

The poster could further sour relations between the RCGP, which has warned that general practice is “teetering on the brink of collapse”, and the main political parties, which are pressing for greater patient access to GPs.

David Cameron has pledged that an extra 1,147 surgeries will open between 8am and 8pm seven days a week and Ed Miliband has promised that if Labour gains power, all patients will be guaranteed an appointment with a GP within 48 hours.

The RCGP says the posters, carrying the message, ‘GP surgery, join the queue. The future of general practice?’, accurately reflects what could happen if more resources are not made available.

Dr Maureen Baker, chairwoman of the RCGP, said doctors at a small number of exceptionally busy surgeries had resorted to simply opening their doors and treating patients on a first come, first served basis.

The emotive, politically charged poster comes from the Royal College of General Practitioners

She said: “I have heard of some practices going back to the [system of] ‘We will open the doors at 8am and people will just turn up.’ “It is not what people want and it seems, in some instances, a pretty drastic solution [to] just not being able to cope with other alternatives.”

She said some patients with potentially serious conditions were waiting up to three weeks.

“If someone has had a cough for four weeks, they may feel unwell but they do not feel acutely ill so, when asked if it is urgent, they will say ‘No,’” she said.

“An appointment might be offered many weeks in advance — two to three weeks. If that cough is something serious, it could be tuberculosis, it could be lung cancer.”

Baker added: “The RCGP is about standards of care for patients. We are seeing the consequences of the increasing funding constraints and we do feel that general practice is teetering on the brink.”

Baker suggested the prime minister’s pledge would actually result in fewer appointments during traditional opening times.

“It [the service] is spread as thinly as it can be, any thinner and I do feel that we will see general practice falling over.”

Andy Burnham, the shadow health secretary, said: “This is a mess of David Cameron’s own making. He raided the GP budget to pay for an NHS reorganisation no one wanted and no one voted for. Cameron’s cuts have made it harder for people to get an appointment and left GPs working under intolerable pressure.”

The posters are part of the RCGP’s Put Patients First: Back General Practice campaign designed to highlight its claim that up to 100 practices, serving 700,000 patients across Britain, are facing closure.

The RCGP says that, despite dealing with 90% of patient contacts in the NHS, GPs receive just 8.4% of the NHS budget. The number of GP patient consultations is estimated to rise from 338m in 2013-14 to 441m by 2017-18.

A Department of Health spokesman said the GP patient survey showed the vast majority were satisfied with the service, adding: “There are over 1,000 more GPs since 2010.”

It’s the truth.

 

Top insurers under fire for medical snooping

Ali Hussein in The SUnday Times 25th May 2014 reports:

Top insurers under fire for medical snooping

Watchdog orders inquiry after unwitting customers give L&G and Aviva access to their entire records

SOME of Britain’s biggest life insurers face an inquiry into claims that they are gathering unnecessary medical information about customers from GPs — including details about contraception, mental health and relationship problems.

The Information Commissioner’s Office (ICO) is to investigate growing concerns about the number of personal details requested for life insurance applications.

The move follows a Sunday Times investigation, which found that some insurers, including Aviva and Legal & General (L&G), routinely make “subject access requests” under the Data Protection Act to access all records held by GPs, rather than bespoke medical reports highlighting only relevant information.

John Canning of the British Medical Association expressed “grave concern”, saying: “A GP will hold all your medical history, containing details such as contraception use, termination of pregnancies and relationship issues that would have no bearing on an insurance policy.

“Our concern is that the consent obtained by insurers isn’t always understood by the person applying for a policy. Our belief is that this is a misuse of the Data Protection Act.”

How often is it that patients records are “not available” in the different Regional Health Services – which have failed to computerise, an act that would solve the problem? The opposite side of the coin of having too little information is giving away too much…

 

YOU could die on the waiting list: Patients kept waiting for months to start cancer treatment

Hannah Devlin reports in The Times 24th May 2014: Patients kept waiting for months to start cancer treatment

If there is one area where inequality of access and rationing will lead to more fear than any other it is in the treatment of cancer. This can be either palliative or curative, but in either case, along with delays in diagnosis (by imaging waiting lists) and treatments as above, there is a real risk of anger in the population. It is also wrong of any party to try to blame the other. This situation is the result of decades of neglect, undercapacity in staff, worn out plant, and out of date philosophy (everythig for everyone for ever). YOU could die on the waiting list.. The good news is that “Cancer no longer a death sentence as half of victims survive a decade“.. So we must be doing something right. It’s just that there is a system being covertly rationed – if it is to be rationed then we all have a right to know how, and to be treated equally.

Cancer patients are being made to wait longer before starting treatment, official figures show.

The health watchdog Monitor has found that an increasing number of foundation trusts are failing to begin treating people with cancer within 62 days of their being referred by a GP.

In the latest quarter, 26 trusts failed to meet a target of diagnosing cancer and treating 85 per cent of patients within two months, compared with 16 in the same period last year. In part, hospitals are struggling to meet the targets owing to a 3 per cent increase in referrals, linked to public awareness campaigns. The Midlands performed worst on cancer waiting times, while London hospitals performed best.

Finances are also suffering at many of the country’s 147 trusts, with the average financial surplus being one third of the size of last year. The number of trusts in deficit has doubled to 40 since last year, with the combined value of deficits running at £307 million.

Jason Dorsett, finance and reporting director at Monitor, said: “The majority of patients attending foundation trusts are receiving quality services in very difficult financial circumstances. Times are tough and hard decisions will have to be made to ensure patients continue to get the services they need at an affordable cost to the taxpayer.”

Richard Murray, director of policy at the King’s Fund think-tank, described the worsening of waiting times for cancer patients as “grim” and the overall finances of hospitals as “quite scary”. He added: “You really shouldn’t delay treatments for some cancers and the anxiety for patients is enormous.”

The report noted that many foundation trusts increased staffing after the Stafford Hospital scandal, making it harder to balance the books. Overall, staff numbers had increased by 24,000 (4 per cent) since last year.

A Department of Health official said that NHS staff would look into the causes of dips in performance on cancer waiting times, and added that trust chief executives needed to keep a tight grip on their finances. “The Government has made tough decisions on the economy but at the same time we have increased the NHS budget in real terms,” the official said.

Andy Burnham, the shadow health secretary, said: “David Cameron has to accept responsibility for this serious deterioration in the performance of the NHS.”

The report also found that trusts narrowly missed an A&E target as 94.7 per cent of patients were seen within four hours, below the required 95 per cent.

Update 25th May 2014: Letter in The Sunday Times from Prof. Andrew Jones

Give radiotherapy the cancer funds it needs

YOUR campaign to improve access to innovative radiotherapy is vital and could be addressed by broadening the £200m annual Cancer Drugs Fund. Despite a highly effective £25m, one-off investment in 2012-13, supporting a growth in delivery of the most advanced forms of radiotherapy across England, there is no regular investment for radiotherapy equivalent to the Cancer Drugs Fund.

This stark contrast in funding for new developments is worthy of public debate to ensure innovative radiotherapy techniques continue to be exploited.

The King’s Fund 2011 report How to Improve Cancer Survival: Explaining England’s Relatively Poor Rates states: “It is more important to improve access to surgery and radiotherapy than access to cancer drugs … this suggests that the contribution of the Cancer Drugs Fund to improving overall outcomes will be very limited.” Nevertheless, the Cancer Drugs Fund continues to have strong political support and has been extended to 2016.

This fund should be increased by about £50m a year to provide improved access to innovative radiotherapy techniques and the effective training of the workforce.

This would produce a significant boost to the most cost-effective cancer treatment available for patients.
Professor Andrew Jones, President, the British Institute of Radiology

 

Devolution and health: data and democracy. Any differences will be because of tribalism and a smaller mutual

Sott L Greer writing in the BMJ in 2008 (Analysis BMJ2008;337:a2616 Devolution and divergence in UK health policies) explores how political variation in the UK has led to differences between the health systems of its four nations since devolutionDAPC05GCC

Devolution and spending will probably be the two main health legacies of Tony Blair’s Labour government. Spending, because the historically low cost NHS received one of the greatest bursts of funding in history, with long term consequences for workforce, infrastructure, and patients; and devolution, because it created four distinct health systems just as that spending started. The politics and policy debates of the four systems are very different, and their leaders have used autonomy to pursue different values with, increasingly, different success.

Autonomy and diversity

Devolution gave the Northern Ireland Assembly, Scottish Parliament, and National Assembly for Wales great power over health services and public health. Under the 1998 legislation they are highly autonomous and not subject to any law of shared standards or values. They receive block grants that are not related to need but can be spent as they choose. Some regard them as overfunded, especially relative to English regions outside London (fig 1⇓); questions arise as to whether their worse statistics with respect to health and other issues (fig 2⇓) justify their higher rates of funding.

Now in 2014 Scott Greer writes again and says: Devolution and health: data and democracy (BMJ2014;348:g3096) He calls it “about as good a natural policy experiment as you could imagine.” He says that “rather than UK politicians planning to learn from the experiment, the Nuffield Trust and the Health Foundation are amongst the few organisations that have tried to learn from this experiment. Their fourth report on devolution and health is ingenious and thorough, required reading for anyone wanting to understand health policies in the UK.”

darwins-devolution-theory

There is no mention of the benefits of being in a larger mutual, and the disadvantages of tribalism.  The Professor does say that “there is scarcely an idea that couldn’t benefit from comparative data and learning across borders”. To most of the profession it appears deliberate that Wales cannot compare outcomes and data with England. Only after sufficient years have passed for WHO approved data: perinatal and maternal mortality, will it be evident which regional decisions were best. Even then, those decisions might have been appropriate if made from the point of view of the size of the mutual concerned.

Only now are the important frontier issues becoming noticed (Infertility post code inequality) and it is evident that access to Stroke treatment centres cannot be eqitably speedy to ensure universally good outcomes… I wonder how many PCT and LHB members have actually read and digested the Nuffield document on quality of care? About as many as have read In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear. Any differences will be because of tribalism and a smaller mutual…

Update 15th July 2014. The Economist July 12th in “A Costly Solitude” on Scottish Independence: Wales GVA (Gross Value Added, or output per person) which explains why there is more pressure to ration more in Wales..

 

Too many checks are “planned” – they should all be spot and random – including educational ones

BBC News reported 13th May 2014: Spot checks into OAP hospital care

Failings in patient care at two Welsh hospitals have been criticised in an independent report.

The Trusted To Care review was held after concerns at Neath Port Talbot Hospital and the Princess of Wales Hospital in south Wales.

It followed the neglect of patient Lilian Williams, 82, who died after being treated at both hospitals.

Her family complained and it led to the review, they are now calling for a public inquiry.

Mrs Williams, from Porthcawl, had been admitted to both hospitals a total of four times between August 2010 and November 2012, when she died.

Her family claimed she suffered “appalling” neglect.

The ombudsman who investigated her family’s complaint was highly critical of her care, and called the case tragic.

Abertawe Bro Morgannwg University (ABMU) Health Board subsequently apologised and admitted the case had been “completely unacceptable”.

Since then, campaigners have called for a public review and the resignation of the board’s chief executive. They claim “hundreds” of examples of poor care have come to light.

A review was ordered by Health Minister Mark Drakeford into levels of care offered by both hospitals.

It catalogued a series of failings at the two hospitals, describing “a sense of hopelessness” in its care for frail and elderly patients. It found “poor professional behaviour” and a “lack of suitably qualified, educated and motivated staff.” One patient told the review team: “I am in Hell.”

Others said elderly patients were instructed to go to the toilet in their beds, medicines had been recorded as given when they were not, and staff tolerated dangerous practice.

The report also found there was:

  • Variable or poor professional behaviour and practice in the care of frail older people
  • Deficiencies in elements of a culture of care based on proper respect and involvement of patients and relatives
  • Unacceptable limitations in essential 24/7 services leading to unnecessary delay to treatment and care
  • Lack of suitably qualified, educated and motivated staff particularly at night
  • Adversarial and slow complaints management
  • Disconnection between front-line staff and managers and confusion over leadership responsibilities and accountabilities
  • Problems with organisational strategies on quality and patient safety, capacity development and workforce planning
  • The report also says some staff felt ill equipped to meet the needs of patients with dementia

The report said: “There are aspects of the care of frail older people which are simply unacceptable and must be addressed as a matter of urgency.

“ABMU has not at any point been ‘another Stafford’. But no one should be in any doubt that there are aspects of the care of frail older people which are simply unacceptable and must be addressed as a matter of urgency through action by the Board of ABMU and by the Welsh government.”

Health Minister Mark Drakeford apologised to those patients affected.

Too many checks are “planned” – they should all be spot and random – including educational ones

22nd May Princess of Wales Hospital wait ‘did not cause death’

19th May Apology over failings at Singleton hospital, Swansea

19th March South Wales NHS: Health bosses agree shake-up recommendation