Monthly Archives: May 2015

Gaming – a possible solution. A new business opportunity. For a big city in the UK to help rural Wales..

There is a great opportunity for a large city with a Tertiary Specialist centre to offer a lifesaving and creative solution for the people of rural Welsh areas. NHSreality suggests a building is divided into many millions of segments, and each is leased off to individuals at a small price. The price is to cover the cost of segmenting the utility bills, and forwarding copies as needed to the individuals who decide to purchase.

The advantage would be that citizens in rural areas, especially in Wales where there is no “choose and book” would be eligible for speedy access, without bureaucratic impediment, to the tertiary centre. Initial investigation and diagnosis in the rural area would be followed by changing registration to the city concerned.

Business Plan.

Capital costs: Assume at least 1000 people would take up the option and that the property costs £100,000. That is £100 each for a lease for say 10 years., reviewed as maintenance becomes problematic. But of course more patients might join the scheme..

Running Costs: The cost of would be about £100 per annum for overheads such as e-mailing scanned documents (appointments and copy letters to/from the GPs concerned).

What a great move for the Community Health Council. They would be representing their citizens and drawing attention to the inequalities of rural living…  By “reducing inequalities” they would be in tune with Welsh Government policy.

Meanwhile, there is a rumour that Seb Blatter will be offered Mark Drakeford’s job – no problem. It could not get worse.



The elderly are already less important in an ageing society. Why adopt a performance indicator to make it worse?

Oliver Moody reports in The Times 30th May 2015: Elderly at risk from ageist health targets, say experts – The elderly are already less important in an ageing society.  Why adopt a performance indicator to make it worse? (We know Caring for your elderly and continuous care can be impossible, and that Elderly get just five minutes of care) Rationing overtly and in advance would be acceptable, but unfortunately it will be knee jerk and sudden……

Pressure is mounting on the government to persuade the United Nations into a late U-turn on a global health target which critics say could lead to the “ageist” neglect of elderly patients.

Leading international development experts have warned that the proposals to cut premature deaths by a third worldwide within 15 years could lead to “institutionalised discrimination”.

The UN plans to make its member states pledge to reduce the number of premature deaths among under-70s from non-infectious diseases such as heart attacks, strokes, cancer and dementia by 2030.

In a letter to The Lancet, however, experts said that the target was “deeply troubling” in ethical terms and urged British officials to take the lead in fighting to extend it to cover the elderly.

Peter Lloyd-Sherlock, professor of social policy and development at the University of East Anglia, said it was unlikely that the NHS would be forced into the changes as it was forbidden by law from discriminating on age.

It could, however, lead health authorities to concentrate on treating younger people at the expense of over-70s and exacerbate the gaps that are already widening between the generations, he said.

The target is expected to be ratified by all UN member states in September. The Department for International Development, whose officials are representing Britain in the talks, is understood to see “little scope for renegotiation” at such a late hour.

Caring for your elderly and “continuous care”

NHSreality has already posted on my experience with my own parents. We are moving to a world where government will pay lip service to funding medical health care with many documents and guidelines, but reality will be refusal. Almost all my patients when I was a GP were refused “continuous care” , but those that did succeed did so after appeal, and perhaps re-application. There are several organisations/charities set up to help advise you. Also Care to be different. A legally based approach is at NHScare. Other sources are the Citizens Advice Bureau (CAB): Citizens Advice – When the NHS can pay for ongoing care, and The Alzheimer Society – NHS Continuing Healthcare – Information – Alzheimer’s Society and the Parkinson’s Association – Parkinson’s UK – Q&A: NHS continuing healthcare and … In Oxford NHS Continuing Care – Helping you to get full funding‎

The NHS choices site has Funding care – Care and support guide – NHS Choices which is not much help, and “How will I be assessed?” and your local commissioning group will have pages of advice based on the national guidelines. In Norwich you are reminded that you need to have more than £23,250 in capital and savings (Will I have to pay for care? – Norfolk County Council) and then the documentation – this consisted of 333 pages! The mionfield is so complex that inarticulate families need help, and charities are often overwhelmed. This will get worse. Thus private opportunists have appeared such as Kate Hurley, but I suspect that they will do no better than a well educated and determined family approach. The Kings Fund is pretending the problem is manageable.. A new settlement for health and social care interim report … Which Magazine produces Help With Continuing Care – and Money Are you eligible for NHS Continuing Care funding? – Money …

Children plan parents’ care from a distance – GP Closures will increase inequalities, and reducing trainee pay will add fuel to the fire.

The truth is spoken: “The NHS cannot last for ever”, but is an insurance based system better and fairer?


Patient co-payment for general practice services: slippery slope or a survival imperative for the NHS?

The JRCGP (Journal of the Royal College of GPs) June 2015 edition contains an article by the Editors, Les Toop and Claire Jackson, and opens for discussion a topic which is taboo for politicians NHSreality agrees with co-payments but only as one form of overt rationing. We will still need to know what is “not available”… or “not covered”.. and it will lead to two tiers – but then we already have this.

Patient co-payment for general (family) practice services occur in many countries. In both New Zealand and Australia the pros and cons of universal versus targeted co-payment are openly and robustly debated. It appears that much less public and professional debate is occurring in the UK, despite a widespread recognition of the increasingly unsustainable mismatch between supply and demand for primary care services. There is currently neither sufficient NHS funding nor personnel to meet this demand, and national surveys show the ever-increasing workload is causing burnout and demoralisation in general practice.1 While some policy discussion documents are now beginning to be considered,2 there appears to have been relatively little discussion, either in public, among the rank and file of the profession, or in the mainstream primary care literature, on the relative merits and harms of introducing targeted point-of-care co-payment. This seems odd, given the many co-payments already present in other parts of the NHS, for such things as sensory aids, dental care, and prescription medicines.

Is universal zero cost at point of general practice care a time-expired and unaffordable NHS sacred cow? Is it time to question the unquestionable?

International observers of the NHS note increasing despondency within the general practice workforce, with much talk of a broken system tracking an unsustainable trajectory. The increased patient demand is exacerbated and compounded by the burdensome opportunity and transaction costs of a powerful, centrally orchestrated, and financially-incentivised framework. This framework is designed to drive (or buy) ‘quality’ through a complicated and time-consuming matrix of accountability measurements. As the columns of this Journal and many others (both popular and academic) have detailed, the combination of increased demands from patients and an onerous system of accountability has led to widespread and serious workforce stress, demoralisation, and flight to early retirement.1 The Royal College of General Practitioners has done well to highlight this parlous situation3 and has placed the crisis front and centre of the party political debate. In election year, as might be expected, all political parties have reacted by promising thousands more GPs. Even if these could be magically spirited up tomorrow (and numbers exceeded those retiring early), will increased numbers alone, without changing the model of care rebalance the mismatch of demand and supply?


Both New Zealand and Australia face similar sustainability challenges and are currently reviewing the way general practice is funded. Both governments are firmly focused on best value for their publicly-funded contribution while preserving and improving equity in health outcomes. Co-payment, ‘value’ and targeting are central elements in the discourse and engender robust debate. It is unsurprising that across populations, access and use of services is ‘price sensitive’ and co-payments do influence use; for better and for worse.4

New Zealand

In New Zealand, patient co-payments are charged at the point of care. Patients enrol with practices, as in the UK. There is a partial capitation system worked out through a fairly unsophisticated formula with age, ethnicity, and historical frequency of use as proxies for increased need. Capitation payments account for approximately half of practice income. GPs mostly run small businesses and retain the right to set the levels of co-payment to fit their business models. In recent times, by ‘agreement’ with government and in exchange for increased capitation, co-payments, are generally (but not universally) waived for children <6 years of age (soon to be <13 years). For this age group attendance and access does seem to be price sensitive. Removing co-payments from the under 6s in (the late 1990s) led to an increase in attendances in the first year of between 5–11% across the country.5 For many worried parents with sick children this allowed additional free access to care. Inevitably this was accompanied by an increase of attendances for very minor ailments not requiring urgent medical review. The forthcoming effect of removing co-payments for those aged 6–13 years on appropriate demand is unknown and a likely further significant increase in such attendances is of concern to those GP organisations planning and providing after-hours care in particular.

There is ongoing and vigorous debate about smarter targeting of the capitation component of general practice funding69 and a review is planned. Any change to more targeted capitation will have differential effects on co-payments. There is a growing feeling among GPs in New Zealand that further more sophisticated mechanisms for targeting subsidies are needed, recognising that ability to co-pay is variable across the socioeconomic spectrum. There is strong support from general practice to retain co-payments both as a mechanism to manage demand and as a way to encourage self-management of minor ailments.

Politically there remains an unresolved tension between universality of subsidy (popular with voters but with the risk of increasing disparities) versus increased targeting of subsidy, aimed at increasing equity of outcome.


In Australia meanwhile, fierce debate currently rages around healthcare resourcing and sustainability, as the population ages and the proportion with complex chronic disease increases steeply. The 2014 Federal Budget provoked an outcry, with the announcement of a AUS$7 co-payment for all general practice Medicare-funded consulting, pathology, and radiology items, irrespective of the patient’s concessional status. By December, faced with a hostile Senate and lambasting by every health and social sector organisation and consumer group, the prime minister changed health minister and announced a commitment to co-payment for non-concessional patients only. By February 2015, Minister Sussan Ley had announced the government’s co-pay agenda to be ‘dead, buried, and cremated’ and committed to work with medical groups to find other system savings. That work is ongoing.

This outcome was influenced by a diverse set of events. The Australian community collectively voiced strong support for Medicare as a universal health insurance plan, allowing free-at-the-point of care support for those in need. In addition, the introduction of a co-pay on Commonwealth-funded GPs services seemed likely to result in an escalation of expensive and inappropriate state-funded emergency department utilisation. Medicare spending on general practice was demonstrated to be only slightly increasing; whereas hospital costs were increasing steeply.10 There was also concern for the viability of the general practice sector, with a profound and unpredictable sudden change to its business case likely to lead to the closure of many practices in rural or low socioeconomic areas. Finally, academics and medical leaders identified limited evidence of the community benefit of co-payment,11 and instead promoted a system-wide focus on improved care quality, efficiency, and coordination, particularly for the chronic disease care which accounts for nearly 40% of Australian health expenditure.12

While very damaging to the Federal government, the robust community discussion around the merits of co-pay has fuelled a wide-ranging and realistic national debate about healthcare sustainability, quality, delivery, and access. We do spend a vast amount on hospital solutions and far less on community capacity building, despite the obvious future needs of an ageing population. We also waste scarce resources in the ping-ponging of cost shift between state-funded and Commonwealth-funded care. Our funding models are now far too heavily weighted to fee for service (FFS) by international standards, and would benefit from bundled payments for episodes of chronic care or quality and access incentives. And we provide minimal incentives for non face-to-face care, despite the considerable opportunities offered by telehealth in a country of our vastness.

Healthcare systems internationally struggle to marry traditional service delivery models with changing community need. Healthcare dollars and human resources are scarce and contemporary models of care and funding drivers need to be aligned to encourage community engagement, personal responsibility, and partnership, and a coordinated all-of-system approach to the delivery of acceptable and accessible care. The decision to adopt or reject co-payment as a demand and supply tool should be made in this context: it is an element to be considered, not a stand-alone solution. Depending on the (often polarised) perspective and on the available funding for and capacity to meet demand, co-payment can drive both positive and negative outcomes. The secret lies in finding the best balance with other funding drivers and incentives, a balance that delivers net benefit to collective users, to providers and to funders, without perverse equity outcomes.

Given the imperative to better match demand and supply of general practice services in the UK (and it is patients and general practice teams who would be most affected) it seems both timely and critical for both groups to forcefully enter the debate on targeted, first point-of-care co-payments.

Dog attacks put 7,000 in hospital – bring back the license fee – and add obligatory insurance

Another reason for “deserts based” rationing of health care. All pets should be insured, all dogs should be licensed and muzzled. This toll of damaged people is too high to ignore. Co-payments are the answer.. Why not have a licence fee, increased for any owner, after his dog has had to be put down – as these people often buy another?

Oliver Moody in The Times May 29th 2015 reports: Dog attacks put 7,000 in hospital

The number of people being treated in hospital after dog attacks has risen three times faster than the rate of general hospital admissions.

Parents were warned never to leave their small children alone with the animals as it emerged that 1,159 under-nines had been admitted to hospital because of dog bites in the past year.

A charity urged ministers to overhaul “ineffective” new laws intended to control dangerous dogs following the figures showing that there had bad been 7,227 hospital admissions linked to dog attacks in the past 12 months.

This was a 7.7 per cent increase on the previous year and up 76 per cent in a decade, during which time the overall number of people admitted to hospital rose by 25 per cent, according to statistics released yesterday by the Health and Social Care Information Centre.

The most common wounds were to the wrists, hands and forearms, although young children were most likely to be bitten on the head. Boys aged between five and nine are most at risk.

Merseyside was the most dangerous area, with 322 cases of people being treated after dog attacks, followed by Durham, Darlington and Tees, and Thames Valley. The safest places were London, Kent and Medway, Surrey and Sussex.

Trevor Cooper, the legal specialist at the Dogs Trust, said the charity had been frustrated by changes to the law controlling dangerous dogs brought in by the government last year.

However, Caroline Kisko, secretary of the Kennel Club, said the rise in hospitalisations because of dog attacks was more likely to reflect changes in the way they were recorded and an increase in dog ownership.

A spokeswoman for the Department for Environment Food and Rural Affairs said it was working with vets and groups representing dog owners to “promote dog welfare and responsible ownership”.

“Changes to the Dangerous Dogs Act introduced last year have enabled the police and local councils to take stronger action and we are working closely with them on enforcement issues such as giving warning notices to owners if their dogs are not under proper control,” she said.

Cyclists, disability wheelchairs, and all dog, cat and exotic pet owners should be insured, licensed and registered

Signs of Desperation in the media and in the conservative party – The Health service and the politicians are “Blowin’ in the wind”

Nobody seems to know how to proceed with the Health debate. I was listening to Bob Dylan again after a number of years. Politicians could do well to listen again. The lyrics might have been written for the war, but could equally apply to the Health Service you happen to be in within the UK. When will the politicians “man up”? When will they ASK TEMSELVES “How many times can a man turn his head, and pretend that he just doesn’t see?” Rationing has to be overt in the information age… Listen to the music again?

“Blowin’ In The Wind”

How many roads must a man walk down
Before you call him a man?
How many seas must a white dove sail
Before she sleeps in the sand?
Yes, and how many times must the cannon balls fly
Before they’re forever banned?

The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind.

Yes, and how many years can a mountain exist
Before it is washed to the sea?
Yes, and how many years can some people exist
Before they’re allowed to be free?
Yes, and how many times can a man turn his head
And pretend that he just doesn’t see?

The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind.

Yes, and how many times must a man look up
Before he can see the sky?
Yes, and how many ears must one man have
Before he can hear people cry?
Yes, and how many deaths will it take ’til he knows
That too many people have died?

The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind.

The dam’s about to burst on the right to die – but politicians and administrators are either fearful or have their hands tied, or both.

David Aaronovich opines in the Times 28th May 2015: The dam’s about to burst on the right to die

The official line is contrary to David’s and NHSreality’s opinion, but in this respect the politicians are following rather than leading. It’s really the same reasoning as for NHS rationing. They fear more votes to be lost by having an honest debate… than won by supporting change. Whether it’s facilitating a good death and patient autonomy and choice, or fostering these beliefs with regard to the Welsh Health service as a whole, our politicians and administrators are either fearful or have their hands tied, or both. Meanwhile inequalities increase, as those with the means and the information take advantage of a foreign service…

As with abortion and divorce, politicians are terrified of letting us make our own decisions. Make no mistake, change is coming

The water is rising and pressing and this dam too will break; in my lifetime we will achieve a “right to die”. If I wasn’t certain of it before the suicide of Jeffrey Spector this week in Switzerland, I am now. Where once the reaction to his decision to go to the Dignitas clinic might have been uncomprehending, horrified even (he was not ancient, nor was he terminally ill, and — like me — had three beautiful daughters), it has in fact been understanding and sympathetic.

Jeffrey Spector is me and he is almost every single person I have spoken to in recent months about how they envisage their own deaths. Just the day before the photographs appeared of Mr Spector’s “last supper” I met an old friend walking down the sunny road in Hay-on-Wye. I can’t remember how we got on to the subject — absent friends, I suppose — but we began discussing old age and then, almost inevitably, what we would consider the minimum standard of life worth sticking around for. It was an abstract discussion, of course, and we both knew that we might change our minds when faced with the reality of incapacity or misery. But at the heart of it was one simple proposition: we wanted the right — and hoped for the ability — to be able to decide for ourselves.

The water is rising. There is a fissure, a disconnect between the law and what a growing number of people regard as their own most basic fundamental right — to decide how, optimally, to leave this life. This fissure also divides the ordinary, moral person from those religious and secular figures supposedly leading any discussion on ethics and morality.

Put in the most simple terms, they fear our use of our own discretion about dying. They do not trust us to do the right thing. They are scared — as they almost always are — about the consequences of an extension of our personal autonomy.

It was this way on divorce. On women’s marital rights. As late as 1984 the Criminal Law Revision Committee (the forerunner of the Law Commission) was arguing against the idea that a married woman had the right not to have sex with her husband.

Up to 1967 women who found themselves to be pregnant had no right to decide on a termination. In 2010, after 50 years of struggle for gay rights, the Labour equalities minister, Harriet Harman, was not prepared to risk supporting gay marriage. It was, she said, “a developing area”. Within four years the first gay couples in Britain were legally wed.

And now they will be in Ireland following last week’s vote, yet the irony there is that women may not enjoy the physical autonomy that a gay man may. Abortion is severely restricted — even the latest law provides a right to a termination only where a woman’s life can be shown to be at risk. One result, of course, is the constant flow of young Irish women to Britain for terminations, their numbers a statistical representation of Irish social hypocrisy.

Which is exactly what Jeffrey Spector was for us — a representation of our hypocrisy. Our law will not be enforced to the extent of stopping him going to Switzerland or prosecuting those who helped him get there, and no one is seeking new laws to criminalise the Swiss citizens who provided the means. Instead we wash our legal hands of him. It was in Switzerland, there’s nothing we need to do. Not us, guv.

Mr Spector’s family issued a gentle statement. “While this was a difficult and painful time,” it said, “as a family we supported and respected his decision 100 per cent.” Ask yourself this question: if his family respected his decision, why wouldn’t the law? Who was affected more than they? Who had greater right to complain?

There are several arguments used against any move, however minimal, towards a right to die. And of course, as with abortion, divorce, gay rights and any other extension of autonomy, there will be some unwanted consequences. Even so, these arguments need dispatching for the bad logic and poor morality that they contain.

I will spend no more time on the dishonest “better palliative care, not killing people” trope than to point out that no such binary choice exists. In fact I am reasonably certain that a demand for better palliative care would be one result of a system where people thought harder about how they wanted to end their lives.

Then there’s the “bad relatives will elbow their elderly family members towards the exit” argument. Maybe a few will. Maybe a few already do. But we can frame laws about that, and in any case that putative danger cannot override the concrete right of the majority to ownership of their own lives.

Finally there’s the “burden” argument. This word is, I think, a sincere mental roadblock laid down in front of synaptic traffic. It seems to mean one thing but in fact connotes another. If I say I do not want to be a burden, I mean “I may not wish to be a person who — whatever the moral character it supposedly builds in others — has to have his faeces cleaned from him twice a day.” It is the effect on me (not just on the burdened) of being the burden that is intolerable. It isn’t how I wish to live.

This is not a column about the law, but about the principle. Yet it illustrates my point that Mr Spector would not have qualified for an assisted suicide in this country even under Lord Falconer’s Assisted Dying Bill, whose uncertain progress was interrupted by the election. In fact that bill as now amended resembles nothing so much as the latest Irish abortion law. You have to be practically dead already before you can be allowed to die.

No, I’m talking not about assisted dying, but about the right to die. If I feel my life is not worth living, and I can demonstrate that this is my settled will and not some whim, and if it seems reasonable to suppose that I will not change my mind or that my circumstances will not alter radically, then I must (and eventually will) have the right to do it. And if doctors are unwilling to help, as many were over abortion, then hopefully there will be a cadre who — wanting the same rights for themselves — will assist.

Mr Spector haunts me. “I am a proud person,” he wrote, “a dignified person, independent and self-motivated. It is me who is doing this.” Amen, Jeffrey. The sound you hear is not just weeping; it is the dam creaking.