Monthly Archives: April 2015

We are rationing the wrong way – and without a philosophical debate it will get worse

We are rationing the wrong way – and without a philosophical debate it will get worse. We should avoid rationing proven and effective therapies, especially if expensive, and ration out the cheap and cheerful ones. People are afraid of what they cannot afford or access… not of not having paracetamol, skin emollients, or nit treatment. If we get into deserts based rationing, then we might create incentives for mothers to breastfeed, and bigger disincentives than cost if they avoid it… The demographics demand a rational approach, as “Men near equality with women in life expectancy”..(Kat Lay in the Times 30th April 2015)……Calculate your own life expectancy by area… People should be encouraged to look after themselves more… Belgravia life expectancy 91 years, and Stockton on Tees 67 years…Smitha Mundasad for the BBC, 39th April 2015,  gives easier graphics.. see bottom page.

 opines 29th April in The Guardian “My plea to the NHS: decide whether or not my life is worth saving, and call me”. I have leukaemia. I’m a mum. A second bone marrow transplant is my only chance but the NHS must approve it. Six weeks on I’m still in the dark, waiting …


I had no idea. The day my GP phoned and asked me casually if I might be able to make my way up to King’s College hospital that afternoon for further tests, I had been on my way to the leisure centre. I continued on and swam 30 laps before I arrived [at the hospital].

When the doctors told me, the first words out of my mouth were: “But I don’t have life insurance.” I felt a dread, as if Death with his scythe lurked just behind me. “My children,” I thought over and over again. “My children.”…

Chris Smyth reports 29th April in The Times: Breastfeeding helps protect against return of cancer -Breast cancer patients who have previously breast-fed their babies are less likely to have the disease return and are less likely to die of it, research has found.

Dr Neil Barnard reports 24th August 2013 in The Times: Protect your brain at every age: Breast-fed babies have higher IQs than bottle-fed babies.

Nigel Hawkes on 20th May 2007 points out that overfeeding (and subsequent obesity) are linked to bottle feeding. Mothers who switched from breast to bottle ‘were misled’

Life expectancy is improving for both sexes

For what its worth “GP pledges are fantasy”…. Get Real ..

In The Times April 29th a small insert in page 6 (not on line) reads: GP pledges are fantasy.

Rising GP shortages mean that Labour and Tory promises on more convenient appointments are a “fantasy”. Vacancy rates at practices are at 9%, up from 2% four years ago, according to research by GP magazine Pulse. Nigel Praities, the editor, said that there were not enough doctors to staff current services and politicians “need to get real”. Even Pulse does not endorse rationing! (Pulse’s alternative election manifesto) (Fantasy vs reality – why election promises of more GPs don’t add up). NHSreality agrees. Some would ask “Why should GPs vote at all when it makes so little difference and supports dishonesty? ” Chris Ham (Kings Fund) and Nigel Edwards (Nuffield Trust) in The Guardian letters comment “Parties need a dose of realism over NHS funding promises”…

Orwell Quote1Sofia Lind and Eleanor Griffiths report in Pulse 29th April: Fantasy vs reality – why election promises of more GPs don’t add up

The 2015 general election has left a legacy of outlandish promises that politicians will come to regret.

From the Conservatives’ pledge of seven-day GP opening and same-day access for the over-75s, to Labour’s guarantee of a GP in every A&E and appointments within 48 hours, the commitments suggest all the party leaders have completely lost touch with reality.

And no matter which party wins, it will see its fantasy bubble pricked. Because all these promises rely on one thing: more GPs.

The Conservatives say they will supply 5,000 new GPs over the next Parliament. Labour and UKIP have topped this with 8,000. The Liberal Democrats made the extraordinary claim that they would be able to ‘fund 38,000 more GPs’ – although when challenged by Pulse they admitted this was just an ‘illustrative’ figure and 5,000 was more likely.

But all this is pure cloud cuckoo land. The number of GPs per head of population is falling and new data gathered by Pulse show that practices across the country are finding it almost impossible to recruit.

Morale and workload

One in 10 full-time-equivalent GP partner positions is vacant – up almost 50% since last year – and a fifth of practices are waiting a year or more to fill a vacancy. GPs say this is putting huge pressure on them, but the future looks even bleaker.

The results of a recent BMA survey suggested a third of GPs plan to retire within the next five years.

At the other end of the scale, medical graduates are shunning general practice, due to concerns over morale and workload. This year, 30% of postgraduate GP training places are unfilled after the first round of recruitment, compared with only 9% at the same time in 2013.

And this situation has developed despite promises in 2010 from the then health secretary Andrew Lansley of a major boost to the number of GPs in training. This has patently failed to materialise and, in any case, new GPs take 10 years to train, so none of the promised new recruits will add to the tally being pledged by the main parties.

The various health spokespersons have mumbled that a focus on ‘personalised care’ and a boost to NHS funding will attract new GPs. But GP leaders point out that none of them has come up with any viable plan to boost GP numbers.

May cover story infographic

Funding shortfall

The promise of more NHS funding is an illusion. Labour has promised a £2.5bn cash injection every year, but this looks puny compared with the £8bn increase in funding demanded by NHS chief executive Simon Stevens in his Five Year Forward View.

Both the Conservatives and the Liberal Democrats have committed to the £8bn per year, but Mr Stevens’s calculations are predicated on the NHS itself delivering unprecedented ‘efficiency’ improvements of 2% to 3% a year.

But figures published recently by the Health Foundation show that crude productivity fell in the NHS by almost 1% a year in both 2012/13 and 2013/14. The kind of savings Mr Stevens wants are going to be a huge ask, even without the extended access to GPs promised by politicians.

NHS England has agreed a workforce plan with the GPC and the RCGP, but the £10m plan – including golden handshakes for new recruits into underdoctored areas and a simplified process to encourage retired GPs and expats to return to UK general practice – is widely regarded as a drop in the ocean.

GPC education and training subcommittee chair Dr Krishna Kasaraneni says the political parties must commit to fund GP services for the long term, rather than funding short-term political follies.

He says: ‘I have seen no pledges that have offered anything meaningful. To say “we will produce 5,000 or 8,000 extra GPs in five years” when it takes 10 years to put a person through foundation and GP training doesn’t add up. Unless somebody has a Back to the Future DeLorean they can use to manipulate time, I don’t see how they can create that many GPs in that short time. What is missing is detail. They are coming out with blank, high-level statements that are either a play on words or simply political games.’

Dr Kasaraneni adds: ‘What we need is not bailouts, but sustainable, long-term investment. How are we ever going to be able to provide seven-day access or appointments to everybody within 48 hours, without the workforce for it? This is nonsense and not the kind of promise they should be making.’

RCGP chair Dr Maureen Baker says a focus on returners and retainers is crucial: ‘We have a chronic shortage of GPs across the UK. Whichever government comes into power after the election needs to tackle this as a priority.

‘We have a plan – our joint 10-point plan that we launched with NHS England, Health Education England and the BMA – to build the GP workforce. Employing 8,000 more GPs by 2020 will undoubtedly be challenging, but our analyses suggest it will be possible with maximum effort to recruit, retain and return.’

The new induction and returner scheme, launched in late March, does make it easier for trained GPs who have taken a career break to return to front-line patient care in the UK – giving practices that take on returners an £8k annual grant.

May cover story infographic

Meaningless numbers

The RCGP has stepped up its efforts to sell general practice to trainees – although a YouTube video stating it was the ‘best time in a generation to become a GP’ proved controversial – and NHS England has even resorted to advertising in Australia to tempt GP expats to come back home.

But Dr Baker adds: ‘So far during the election campaign we have heard a lot of pledges from all political parties about how they will “tackle” general practice and provide more weekend and evening access to our services. These sound good, but without more GPs, more practice staff and significant investment in general practice, they are meaningless.’

And all of this is cold comfort for GPs struggling to recruit right now. Dr Raghunandan Vedapanakal, a GP in Whitehaven, Cumbria, said his practice had been two GPs short for two years, with 13 GPs covering 24,000 patients.

He says: ‘We are in a rural area and there is a lack of GPs because of a national crisis. GPs are taking early retirement due to pension reforms, work stress and too much meddling by CCGs and the Government. There is increasing demand from an ageing population, stagnant or decreasing income, GPs emigrating and 12-hour working days.’

GP Dr Imogen Bloor has had to close her practice in Islington, north London, after finding it impossible to recruit new GPs.

She says: ‘We have tried our utmost to find a way of continuing to provide high-quality care for our patients, but we feel unable to take the practice forward.’

If practices are to be expected to open longer, or guarantee appointments within two days, the new occupant of Richmond House will have to supply an awful lot more GPs – and soon.

Additional reporting by Eleanor Bley Griffiths.

Sofia Lind reports the research: GP vacancy rate at highest ever, with 50% rise in empty posts

GP Magazine editorial “What the election means for GPs” – at the time it’s too close to call reads:

So far, perhaps the most interesting development is that Labour leader Ed Miliband has surprised many by performing better than anticipated.

The future of general practice is one of the issues on which the two main political parties differ. While the Tories would have GPs at the helm of CCGs controlling a large chunk of the NHS budget, Labour would pool budgets and link commissioners and providers under health and wellbeing boards to develop integrated care organisations.

Labour has been questioning the future of independent contractor status, but there are no indications yet that it would ring its death knell.

What might be more concerning for GPs is an area where the Conservatives and Labour agree: access. The Tories are pushing for 8am to 8pm access seven days a week for all patients by 2020, with Labour guaranteeing 48-hour access.

The Tories want 5,000 more GPs and Labour, 8,000. The question on many GPs’ lips will be, how will all this be possible?

With the possibility of the election of a minority government, there could even be a chance that the policies of minor parties (the SNP, Lib Dems, UKIP or the Greens) could prove crucial.

Our website, GPonline, will have live updates after 7 May on how GPs up for election fared, including Dr Louise Irvine, who is standing against health secretary Jeremy Hunt, and what the results mean for GPs.

The only predictable thing about this election is its unpredictability. Who will be in 10 Downing Street when your 18 May edition of GP is published?

Manifesto pledges: more money for the NHS… problem solved?

John Appleby from the Kings Fund opines: Manifesto pledges: more money for the NHS… problem solved? (BMJ 25th April and Kings fund) Everyone knows that overt rationing could solve the problem, but honest discussion is tactfully avoided in the most dishonest election, full of lies and half truths.

As Ipsos MORI has been reporting for some months now, the NHS is a big issue for the public, and now nearly half of all Britons surveyed (47 per cent) say the NHS and health care is their top concern when deciding how they’ll vote in the general election. The public’s concerns have been reflected in the political parties’ manifesto promises – a combination of more money and a long shopping list for how the extra cash will be spent (more doctors, more nurses…24/7 motherhood, and a free prescription for apple pie). But what do the promises add up to, and is the NHS safe in anyone’s hands? (And why is the politician’s favourite number 8,000,000,000?)

The manifestos’ focus on how much money should be spent on the NHS has been driven by a future funding scenario described by NHS England, Monitor, and other national NHS organisations in their joint forward look at how the NHS might fare over the next five years. Predicated on some upfront investment in infrastructure and operating investment (that is, keeping the business going), NHS England estimates that although the NHS needs a funding increase of £30 billion (€42 billion; $45 billion) over and above inflation by 2020/21, it could increase productivity by 2 per cent a year over the next few years and then by 3 per cent a year as the new ‘care models’ come on stream. In effect, this generates the equivalent spending power of £22 billion, leaving just £8 billion to be funded by the taxpayer. To get to such a real increase will require a cash increase of nearly £23 billion.

While there is nothing in the NHS national bodies’ Forward View that details the evidence or science behind the productivity assumptions (and hence the figure of £8 billion), both the Conservative and Liberal Democrat parties have signed up to NHS England’s funding scenario (Figure 1). This amounts to an average real increase of 1.1 per cent a year – similar to the increase over the last parliament. However, there is a lack of clarity about the Conservative promise, which could amount to a bit more than £8 billion depending on the period the pledge covers. Importantly, with no details on the path the Conservatives will take to reach their promise, there is a worry that the bulk of the increase could come in the later rather than (as needed) earlier years of the next parliament…..

Political parties’ NHS funding promises

Political parties' NHS funding promises

Data sources: NHS five year forward view, Conservative Party manifesto 2015, Labour Party manifesto 2015, Liberal Democrat Party manifesto

Gareth Iacobucci reports on the opinion of David Nicholson, former CEO of the English NHS. All main political parties’ pledges for NHS will prove inadequate, says former chief executive

The NHS faces a “substantial financial problem” this year that will require significant upfront investment to maintain current services, the former chief executive of the NHS in England has warned.

David Nicholson, who led the service from 2006 to 2014, said that it would be “helpful” for the NHS if Labour joined the Conservatives and Liberal Democrats in committing to his successor Simon Stevens’s call for an additional £8bn (€11.1bn; $11.8bn) of funding above inflation by 2020.

But he said that the current pledges from all main political parties would prove inadequate …

Cartoons about creative problem solving, avoiding problems, taking action, avoidance, dealing with stress, stress management, avoiding stress.

Only genuine understanding from politicians can save the NHS “…it’s clear that they don’t understand our reality.”

Katya Certic reports 27th April in The Guardian: Only genuine understanding from politicians can save the NHS and is supported by Ashley Kirk “Paramedics take 40,000 days off sick with stress as strain on NHS takes toll” (Still the worst organisation in the world for absenteeism)..

NHSreality understands and supports this view wholeheartedly. That’s why I chose the title for the website… And much as NHSreality appreciates it will be unpopular, overt rationing and reducing demand is better than covert rationing and the pretence that we can cover and provide for everything, for everyone, for ever.

One of my local parliamentary candidates knocked on my door recently and asked me what she could do to win my vote. This is what I told her.

My husband is a GP and I’m a paediatric registrar. The NHS is the number one issue affecting us in the coming election (and I say that as an immigrant and new mother who is in the process of buying her first home). If you want to win my vote, you need to show me that you understand our reality.

My husband is a partner in an inner city GP practice. Today, he’s duty doctor, responsible for all the acutely unwell patients who contact the surgery and need a same-day appointment. He left for work at 7.20am for an 8am start and I don’t expect him to be home before 9pm. On Monday, he worked extended hours and was seeing patients until 7.30pm. After he finishes seeing patients tomorrow evening, he’ll be catching up on the paperwork that built up during today’s on-call, which means another 8pm finish, at the earliest. He spent last Saturday doing an extra surgery too.

When we see friends leaving their partnerships because of early burnout and then hear politicians promise to increase GP recruitment by the thousands in the next five years, I can see that they don’t understand our reality. When I see a consultant cry with exhaustion after a 24-hour weekend shift and then see journalists reporting on senior doctors not working weekends, it’s clear that they don’t understand our reality.

The NHS, like every healthcare system in the world, is imperfect, but it is full of passionate, hardworking people who do their utmost every day to provide the best care possible for their patients. There’s plenty about it that could and should be improved, but the people tasked with making those improvements need to have a real understanding of how it works instead of making grand but ultimately empty promises to win votes.

So if you want to win my vote, go out and talk to the people on the frontline. Listen to their concerns and discuss your ideas with them. Show that you’re committed to learning about the issues before legislating on them. The NHS is in trouble and it needs your help, but until you understand our reality, you can’t possibly know how to save it.



Update 26th April:

Margaret McCartney: General practice is still the best job in the world (BMJ 2015;350:h1721 )

Despite political inference, wasteful awareness campaigns, misleading advertisements, poor evidence, and ridiculous media stories, general practice is still the best job in the world. GPs witness the life stories of individuals and families unfolding in real time.

Often you’re a port in a storm; sometimes you offer a hand on the rudder, helping to steer the ship. You don’t perform complex surgery, and the work isn’t glamorous. But it is complex, requiring incisive intelligence—and, if you want glamour, you can wear whatever shoes you like.

Even though you may think you have little to offer, you may be surprised when, years later, your words are quoted back to you with gratitude. You may do home visits on foot in the snow and slip over, and another patient may come outside to offer you his arm…..

Rebecca Jones in the JCPGP opines: Institutional snobbery prevents general practice from being a desirable career choice (10.3399/bjgp15X684937 )

I have to admit that I only considered a career in general practice with reluctance. This now seems ridiculous, as embarking on GP training has been the best decision I have ever made. Throughout medical school and foundation training I was convinced that my career path lay in surgery, however, a last-minute decision, involving the consideration of lifestyle and career progression, meant that I ended up training as a radiologist. But after merely 3 months in the programme I resigned, primarily because of the lack of patient contact as well as my need to engage in meaningful relationships and daily interactions with patients and other healthcare professionals.

So, I was left with a decision. What area of medicine would allow me to fulfil this yearning for patient contact combined with my love of a clinical conundrum? There …

Charities say letting people die at home could save millions for NHS

The Press Association reports in the Guardian 27th April 2015: Charities say letting people die at home could save millions for NHS Marie Curie says many people with a terminal illness are in hospital unnecessarily, and not by choice, at the end of their lives 

In the richer areas and more densely populated areas of the country hospices are well funded. They will therefore continue, and the health divide between the rich and the poor will be enhanced… the suggestion makes good sense, but if funding is not given disproportionately it could be regressive. It is however, an example of rational rationing of resources. It will not save a lot f money but could free up plenty of beds…

The NHS could save millions of pounds if the majority of people who died of a terminal illness in hospital did so at home as most wished to do, charities have said.

Figures from the latest Office for National Statistics (ONS) survey of bereaved people found that 85% of those who died in hospital in 2013 had expressed a desire to die at home.

Marie Curie, which provides care and support to people with terminal illness, said patients were being denied the choice because of factors including a lack of 24/7 community support, poor coordination between services and the failure to provide fast and free social care support for people at the end of life.

But the charity said there was scope for efficiency savings to be made by helping those who wanted to spend their final days at home to do so.

With access to high-quality nursing care in the community, total care costs could be as much as £500 lower per person.

All the main political parties have made some kind of commitment to improve choice at the end of life, but Marie Curie – representing a coalition of other charities – said whichever party came into power in the next parliament needed to set out how it would do this.

Dr Jane Collins, chief executive of Marie Curie, said: “It’s time to change the way we care for people with a terminal illness.

“Fewer than 5% of people say they want to be in hospital at the end of their lives, yet around 50% of people who die do so in hospital, often with no clinical need to be there.

“Pressure is increasing on NHS budgets and A&E departments are already over-stretched.

“The evidence shows that it makes financial sense for the NHS to support people to be cared for at home in their last weeks and days. This is also what the majority of people with a terminal illness would prefer.

“Together, we are calling on all parties and the next government to set out how they will introduce fast and free social care for everyone nearing the end of their lives to reduce pressure on hospitals and deliver genuine choice.”

Marie Curie has been working with charities that support people at the end of their lives. These are Cicely Saunders International, Hospice UK, Macmillan Cancer Support, the Motor Neurone Disease Association, the National Council for Palliative Care and Sue Ryder.

Rationing care is a fact of life for the NHS

Richard Vize reports in the Guardian 24th April 2015: Rationing care is a fact of life for the NHS , but the average patient does not know this, until they need a service. It’s one of the toughest issues the health service has to face, but it should be debated openly, honestly and without political interference.

This week’s survey by HSJ revealing that 39% of clinical commissioning groups it contacted were considering rationing care to save money in the coming year highlights one of the murkier areas of health policy and raises a number of difficult questions.

Rationing is nothing new, of course. When waiting lists stretched to many months and even years, treatment was often rationed simply by the patient dying before they reach the operating table. Heart surgery was a striking example of this. The long waits in A&E departments acted as another form of rationing.

Labour’s all-out assault on waiting lists and eventual introduction of the 18 weeks referral-to-treatment target ended this backdoor workload management system. Now the NHS Constitution gives the impression that clinical need and conformity with Nice guidelines are all that stand between the patient and treatment, while the purchasing decisions of commissioners should ensure that any rationing is open to public scrutiny.

Agency and Locum fees reveal the extent of the undercapacity, and the political denial

Agency and Locum fees reveal the extent of the undercapacity, and the political denial. Sarah Kate-Templeton reports 9th April in The Times: Consultants double pay with overtime at overstretched NHS And it’s worse where there are fewer wishing to come!

NHS consultants are doubling their salaries by doing extra operations as the health service struggles to cope with a record number of patients waiting too long for treatment.

In addition to the extra payments to consultants, trusts are spending up to £10m a year having NHS patients treated privately in an effort to cut the waiting lists. The spending comes as NHS leaders warn that funding shortages are more severe than previously thought…..

Jonathan Morris for BBC news 24th April reports: Cost of agency nurses soars for NHS South West

Spending on agency nurses in the South West has soared from about £12m to more than £59m in the last four years, it has emerged.

The Royal College of Nursing, which made Freedom of Information requests to 27 NHS trusts, said the NHS was being “crippled” by a shortage of nurses.

The biggest rise was at the Royal Devon and Exeter Hospital, which spent £6.1m in 2014, up from £390,000 in 2010.

The hospital trust said it only used agency nurses “when necessary”.

The Royal College of Nursing (RCN) said there were fewer nurses than in 2010, so NHS organisations have had to look for ways to address the shortfall.

As a result, trusts have been paying high rates to agencies to supply temporary staff and recruiting nurses from abroad…..