Monthly Archives: September 2015

The Nuffield Trust survey of health leaders – fails to ask the “ideology” questions and feel “managed decline” is inevitable

The Nuffield Trust survey of health leaders – fails to ask the “ideology” questions but feel “managed decline” is inevitable. There are no questions on “regional differences ” in philosophy and outcomes either

Since July 2014, the Nuffield Trust has regularly surveyed a panel of 100 health and social care leaders in England for their views on a range of issues including: finance, general practice and rationing.

Below we present the views of 100 health and care leaders on the pressures facing the NHS and social care ahead of the Comprehensive Spending Review.

Survey five: the state of the NHS and social care ahead of the Comprehensive Spending Review

An example is Q 11:

Q11. In April, former NHS Chief Executive David Nicholson expressed concern that financial pressures could mean “managed decline” for the NHS, for example patients waiting longer for treatment, new drugs not being made available straight away and it becoming more difficult to see a GP. To what extent do you agree with this view?

Managed Decline

More than four fifths (82.7%) of respondents agreed with Sir David’s view, with just 10.6% disagreeing. Those that agreed with the statement were asked to comment on which services or areas were at risk in their locality. Some respondents simply said all services were at risk. Of those that did specify, one of the most frequently mentioned examples was access to elective services, with many panellists highlighting concerns either over lengthening waiting times or raised thresholds for access to drugs or treatment.

One acute trust panellist said: “Waiting times for elective procedures are already lengthening according to ad hoc clinical prioritisation”, and another highlighted “access for elective care restricted by new filters (BMI [body mass index] etc.)”. A social care representative said there was an “increase in waiting times or raising of threshold for access to treatment in other areas, [and] more sophisticated rationing techniques – formal and informal – being used.”

Panellists also highlighted pressures on primary care, with many drawing a direct line between financial pressures and recruitment issues in general practice. One clinical commissioning group panellist said:

“There is a shortage of GPs and GP access is being affected”.


A social care representative said that GP services were at risk in their area “due to recruitment problems”. Other examples of managed decline mentioned included service reconfiguration, pressures on mental and community health services, and a reduction in coverage of specialist services.

Some panellists took the opportunity to comment more broadly on the policy implications of financial pressures. One respondent said:

“We are back to the bad old days of Thatcher and Major when waiting lists were up to two years, with deteriorating patient experience and quality.


An acute trust manager said that the ‘managed decline’ was “starting to happen in exactly the way Sir David predicted”, saying that the ‘Monitor letter’ “almost went as far as instructing us to do it” (referring to a letter sent by Monitor’s chief executive David Bennett asking trusts to revisit their financial plans due to ‘unaffordable’ financial forecasts).


West Wales needs a new Hospital – not improvements to Glangwili Hospital in Carmarthen. Failing to act in a utilitarian way may well lead to unrest..

Walesonline reports 22nd September: Maternity ward ‘not fit for purpose’ and increased numbers of patients ‘put pressure on staff’ after hospital reorganisation – The Royal College of Paediatrics and Child Health published the findings after looking at the NHS reorganisation in West Wales

West Wales needs a new Hospital – not improvements to Glangwili Hospital in Carmarthen. Failing to act in a utilitarian way may well lead to unrest.. The Post Code lottery where taxpayers pay the same for inferior services was never clearer than in West Wales.

Welsh Conservatives have called for an urgent statement from the Health Minister, after a report labelled Glangwili Hospital’s labour ward as “not fit for purpose”.

The Royal College of Paediatrics and Child Health has looked in depth at Labour’s NHS reorganisation in west Wales, including significant changes at Withybush, where care for the most premature and sick babies has been moved to Glangwili in Carmarthen.

It has concluded that the hospital’s maternity ward is “not fit for purpose; it is too small, with insufficient facilities and provides a poor environment for women and staff.”

The full report has been published on Hywel Dda University Health Board’s website, ahead of a board meeting on Thursday.

The report states: “The Glangwili labour ward is not fit for purpose; it is too small, with insufficient facilities and provides a poor environment for women and staff.

“The increased numbers of women using the unit, including those with high-risk pregnancies from Pembrokeshire has put additional pressure on the staff with two culturally very different teams learning to work together in cramped and difficult conditions.”

It continues: “Whilst senior midwives have strived to ensure that the service is safe, there has been insufficient priority given to the promised expansion of the facilities (Phase two) and the organisational development needs of the midwifery staff. These must be addressed as a matter of urgency.”

Welsh Conservative Shadow Minister for Health, Darren Millar AM, described the reports findings as “damning conclusions” that must now be dealt with urgently.

“For mums-to-be already being forced to travel further – this report will be extremely grim reading.

“Labour’s record-breaking NHS budget cuts have resulted in unwanted NHS reorganisation right across Wales.

“Despite the hard work of staff, it’s clear to me that changes to maternity services in west Wales continue to be dangerous and avoidable.”

However the report did say that despite the findings, survey data collected post-natally from 500 women who used the services at all three sites during the past year (since the changes) have shown overwhelmingly positive responses.

It adds: “The attention and care provided by the midwives to the women was particularly highlighted, and there were relatively few negative comments, which mainly related to environment and parking.”

‘Facilities completely inadequate’

Assembly Member for Preseli Pembrokeshire, Paul Davies, who recently visited Glangwili Hospital and raised concerns over the facilities available to staff and patients, said: “Despite the hard work of staff on the ward, the facilities at Glangwili are completely inadequate.

“Not only are Labour ministers forcing mothers in my constituency to travel further for treatment, they’re forcing them into a ward that’s not fit for purpose.

“Lives could be put at risk. The situation is that serious.

“I will continue to fight for the reintroduction of the special care baby unit at Withybush.”

Assembly Member for Carmarthen West and South Pembrokeshire, Angela Burns AM, said: “Like all those reading this report, I am extremely distressed at the services awaiting mums-to-be at Glangwili.

“No matter how hard our determined staff work, their efforts will continue to be hamstrung by the facilities available.

“It cannot continue and the special care baby unit at Withybush Hospital must be reinstated.”Hywel Dda University Health Board’s chief executive Steve Moore said: “This report, although only interim, provides us with an opportunity to assess where we are so we can do more of what is working well; and equally to address areas of concern.

Hywel Dda University Health Board’s chief executive Steve Moore said: “This report, although only interim, provides us with an opportunity to assess where we are so we can do more of what is working well; and equally to address areas of concern.

“I am grateful to the Royal College of Paediatrics and Child Health, other colleges and the lay member involved, for undertaking this work as it has been essential for us to be independently reviewed against the criteria we aimed to deliver. We committed earlier in the year to be open and transparent with staff and our public, so we are sharing this interim report, which will be discussed at full Health Board. I expect a clear action plan and timescale to be drawn up following this, including discussion with the Welsh Government and Health Minister, as well as clinicians and other staff and partners, including the Community Health Council, about any next steps.”

‘Distorted reading’

Health and Social Services Minister Mark Drakeford said the Conservatives’ response was a “distorted reading of an independent evaluation about the safety and sustainability of changes to maternity, neonatal and paediatric services in West Wales”.

He added: “It was commissioned by Hywel Dda University Health Board a year after consultant-led maternity care and neonatal services were concentrated at Glangwili Hospital in Carmarthen.

“It concludes that, despite all the persistent claims to the contrary, the changes are safe, sustainable in the long-term and have led to improved outcomes for mothers and babies.

“There is also better compliance with professional standards and more women are being cared for in the Hywel Dda area than under the previous arrangements. These findings will provide reassurance to people in Pembrokeshire and Carmarthenshire.

“It makes it clear that it would make no clinical sense to return to the previous arrangements. It makes a number of recommendations for the future, including the need for some improvements to the estate at Glangwili Hospital.”

BBC news report: Glangwili Hospital labour ward criticism accepted

The Neonatal debate and GP comment

Trust disintegration and a disintegration of trust.

More hook wriggling – and now trying to shake off the chains

Initially under the headline “Top Hospitals will run treatments across country”, Chris Smyth in The Times reports 25th September 2015: Specialist doctors will be sent into cottage hospitals

NHSreality wonders if this will include Addenbrooke’s whose latest headline was “Addenbrooke’s staff crisis put patient safety at risk” (chris Smyth 23rd September 2015). It was not chain link that won the wild west but barbed wire. We need to ration by many methods, but the main one is to reduce demand, and it will cause distress. Wales has plenty of barbed wire preventing the sheep from choosing/reaching England.

Specialist doctors will be sent to small local hospitals to “bring more world-class care to the patient’s doorstep” and cut travel time for those who need treatment, the head of the health service will say today.

Simon Stevens, chief executive of NHS England, will say that hospitals are to form chains and set up franchises around the country, marking the end of “go-it-alone” organisations. Local hospitals will be taken over by some of the country’s best or contract out services such as cancer care or neurosurgery to specialist centres. The Royal Free in London and Salford Royal are among leading institutions that plan to set up chains, while Moorfields eye hospital and the Royal National Orthopaedic Hospital will provide specialist treatment around the country.

Mr Stevens argues that this will help small hospitals stay open after a period in which NHS leaders often seemed to be determined to close them in the name of efficiency.

“Rather than patients routinely having to travel to specialist centres, we want to test the idea of bringing that expertise to their local hospital,” he will say in a speech to the Confederation of British Industry today.

“So key departments in smaller local hospitals are in some cases now going to be run by some of the best hospitals in Britain, such as Moorfields, the Royal Marsden or the Christie. This could help support a viable future for many smaller hospitals that are often so important to local communities, and improve the quality and range of services available, reducing the need to travel long distances.

“We’ve got some of the world’s best hospitals and specialists in this country, and it’s right they should be able to extend their reach more widely.”

Thirteen hospitals have been chosen to test the plan. Mr Stevens hopes the successful ones can then be imitated.

Just to remind readers of some of the facts and figures from the past (which will have changed) initially for Wales:

NHS workforce 2013


Where the money goes 2009

and for England

Health spend per head 2000 to 2013


Rationing hearing aids could cost you dear – “There is a perfectly good reason we have two ears…”

Jane Symonds in The Express 22nd Septemeber reports: Rationing hearing aids could cost you dear THE NHS has begun rationing hearing aids in the push to find £22billion in so-called ‘efficiency savings’ even though experts and charities warn the move is a false economy which will leave the health service and patients footing an even bigger bill.

“It’s lunacy on a level that I cannot get my head around,” says Dr Lorraine Gailey of the charity Hearing Link. “They will save a few hundred thousand pounds a year but will cost themselves 10 times that in managing the increase in people with hearing loss who become severely depressed or have falls and end up in Accident and Emergency.”

That may sound like an exaggeration but research confirms people with hearing loss are three times more likely to suffer a serious fall, while depression and anxiety are common. One study found that a third of people with hearing loss who did not have hearing aids experience prolonged bouts of depression.

More than 10 million people in the UK – one in six of us – have some form of hearing loss and experts predict that by 2030 adult-onset hearing loss will be so common it will cost the nation more than diabetes. Around two million people in the UK use hearing aids and another four million would benefit from aids but don’t have them.

Rationing audiology services and hearing aids can only compound the problem but it will also leave many patients out of pocket to the tune of thousands of pounds. Research has shown that a hearing problem can cut as much as £19,500 from annual earnings and the average pay cut is around £7,800 a year.

But seeking a solution can deliver an immediate pay rise. American studies show these shortfalls in earnings are eliminated when people with mild hearing loss are fitted with hearing aids and they are cut by three-quarters when those with severe to moderate impairment use hearing aids.

These findings are born out by a recent UK study which estimated lower employment rates among people with hearing problems costs the UK economy a staggering £24billion a year. The Ear Foundation estimates that if every opportunity was taken to improve the nation’s hearing, the savings would be at least £30billion – at a conservative estimate.

In a report by the charity, Andrew Dunlop, a GP who has a cochlear implant, argues: “To look at it as a single monetary measure is incredibly short-sighted.” He calculates he paid for his own implant in just two years and points out: “The alternative was that I would have been a burden to the NHS.” But this rationing has been extended with North Staffordshire becoming the latest area to stop providing free hearing aids for people with mild to moderate problems. The local clinical commissioning group, which made the decision, claims the move will affect only 500 patients.

But charity Action on Hearing Loss estimates up to 37,000 people will be hit. In other areas, including Sheffield and Medway, people are being offered only one hearing aid despite hearing loss in both ears. And Dr Gailey warns: “Where England goes, the other devolved countries tend to go.

Two Welsh health boards have already followed suit – Abertawe Bro Morgannwg University Health Board and Hywel Dda University Health Board are now offering patients with hearing loss in both ears single aids. Dr Andrew Meredith, a retired ear, nose and throat consultant, and adviser to Hearing Link said: “You wouldn’t give someone a pair of glasses with only one lens.

There is a perfectly good reason we have two ears.” Being able to hear in both ears is essential to locate the source of sounds and using a single aid can lead to head shadow effect – the head literally gets in the way of sound waves to the good ear and reduces their volume and clarity.

This is exacerbated by a tiny delay in sound waves reaching the good ear, enough to impair the brain’s ability to decode sound waves. Having only one aid when two are needed can even accelerate hearing problems because a lack of stimulus to the cochlea, the organ of hearing in the inner ear, undermines the brain’s ability to interpret sounds.

Christine Larson, an account manager for a large distribution company, is living proof that resolving hearing problems can pay off. After a series of operations failed to repair damage from a perforated eardrum, Christine, 43, from Bristol, put up with impaired hearing for more than 15 years.

She admits: “I struggled a lot at work. I relied on lip-reading to piece together sentences and it could be quite embarrassing at times. I excluded myself from conversations with colleagues and customers because I struggled to hear them.” Dr Gailey says this is a very common response to hearing loss. “People become withdrawn from families and the workplace.

They become less positive. With an ageing population and people having to stay in work for longer, it’s going to be a huge problem.” But Christine finally sought help and now wears a state-of-the-art invisible hearing aid. “It’s made a massive difference to my life,” she says.

“I was recently promoted and I think having my hearing aid gave me the confidence to step up.” Hearing deteriorates gradually, so many are not aware they’ve a problem until there is significant hearing loss. On average it takes 10 years for someone to address their hearing problem and when they do ask for help, almost half aren’t referred to an audiologist.

The Socialist Worker: Rationing NHS hearing aids will punish people for being deaf

Britain throws open its doors to foreign medics

As if it was new news Rosemary Bennett reports 23rd September in The Times: Britain throws open its doors to foreign medics  This has always been the case, ever since the service began in 1950. We could have trained enough but we chose to train undergraduates instead of graduates, which resulted in more women than men, and a higher drop out rate.

Britain experienced one of the largest jumps in immigration among the world’s leading economies last year, according to an international report.

A total of 558,000 people came to Britain, a rise of almost a quarter (24 per cent) compared with 2013. Of the 27 other nations analysed in the report, only Israel and the Czech Republic recorded larger annual rises.

Germany and America had more immigrants but lower annual increases.

The data was compiled by the Organisation for Economic Co-operation and Development (OECD), an influential Paris-based think tank that evaluates the economic performances of leading countries.

Its findings illustrate the scale of the challenge faced by ministers to meet a pledge to cut net migration.

Last month, figures published by the Office for National Statistics showed that net long-term migration to Britain, the most reliable indicator, reached a record 330,000 in the year to March.

David Cameron promised to cut net migration to the “tens of thousands” during the 2010 election. A spokesman for the OECD, at the launch of the report, said Europe was facing “an unprecedented refugee crisis” and predicted that applications for asylum could reach a million by the end of the year. The latest figures suggest that refugees have lodged 572,520 applications so far.

José Ángel Gurría, the OECD secretary general, said the numbers were manageable. He called on European leaders to “step up to the challenge”.

“Europe has the experience and the capacity to respond,” he said. “The human cost of this refugee crisis is appalling and countries need to quickly agree a fair allocation of refugees within Europe and ensure that such vast numbers of troubled people receive food, shelter and support. An emerging challenge will be the integration of the many new refugees who will remain in European host countries.

“We need to scale up and adapt programmes so that refugees can integrate as quickly as possible in their new homes and make best use of their skills. We should all remember that migration is not a liability, but an asset.”

Britain has opposed quotas imposed across Europe for migrants from Syria and has instead announced that the country will accept 20,000 asylum seekers from the war-torn country over the next five years.

The 380-page study on migration included an in-depth analysis of foreign-born doctors and nurses in each country. It found that apart from the US, Britain was the most popular destination for foreign-born medics.

“The United Kingdom is the second country of destination for doctors, receiving 14 per cent of all foreign-born doctors who practise in OECD countries, followed by Germany [nine per cent],” it said.

Britain also saw the “greatest swing” in the number of foreign-born doctors working here in the first ten years of the century. The report states that about 2.7 million doctors in the OECD nations last year were trained in foreign countries. They accounted for more than one in four doctors in Britain and America and more than one in three in Ireland, Israel, New Zealand and Norway. A third of all doctors originating from low-income countries were expatriates in an OECD country.

The NHS has always relied on overseas doctors.

Not enough Doctors or Nurses?

Not enough capacity? We are approaching an internal war with not enough beds or people..

We need capacity

Medical Student Debt. Time for a change in policy on recruitment.

Update 25th September 2015: Below shows the number of overseas doctors 2 years ago and where they came from… The NHS confederation figures put these in perspective and they say:

  • In 2014 the NHS employed 150,273 doctors, 377,191 qualified nursing staff, 155,960 qualified scientific, therapeutic and technical staff and 37,078 managers.
  • There were 32,467 additional doctors employed in the NHS in 2014 compared to 2004. The number has increased by an annual average of 2.5 per cent over that time.


Global Recruits on the wards


Do we really believe these figures? Even if all the recruits are doctors it’s only 10,000 out of 150,000 or about 7%!

NHS losing billions to ‘fraud by doctors and dentists’

A sad story.. How does the cost of fraud compare to the neglect by politicians?


NHS losing billions to ‘fraud by doctors and dentists’ – GPs create ‘ghost patients’, dentists claim for false work and pharmacists fail to declare charges paid, report says as it claims £5.7bn lost to fraud

Up to £5.7 billion a year could be lost by the NHS to fraud by patients and staff, a new report has claimed.

A review led by Jim Gee, a former director of NHS Counter Fraud Services, suggested fraud was taking place across areas such as general practice, dentistry, prescriptions and payroll.

Among examples of fraud cited in the report were GPs creating “ghost patients”, dentists claiming for more work than was carried out and pharmacists failing to declare prescription charges that have been paid.

 Mr Gee and co-author Professor Mark Button, director of the Centre for Counter Fraud Studies at Portsmouth University, said they hoped the research “focusses attention” on the issue, adding the NHS needed to improve how it measured fraud losses.

The authors of the report, published by PKF Littlejohn accountants, said: “Fraud has negative consequences in all sectors, but in healthcare the impact of fraud is even more pernicious.

Quite simply it has a direct, negative impact on human life as the quality, quantity and speed of patient care is diminished.”

The area with the highest estimated losses to fraud and error was payroll, at between £555 million and £1.49 billion – where scams included false allowance claims.

Procurement scams, such as under-providing goods and services, was estimated to cost between £1 billion and £1.27 billion, while between £304 million was lost to fraud by patients through false claims for free prescriptions, dental care and optical services.

The overall level of fraud, based on an analysis of loss measurement data from the UK and around the world, was said to cost between £3.7 billion and £5.7 billion of the £110 billion NHS budget in 2013-2014.

Mr Gee told the BBC: “There is a vast, honest majority who find fraud against the NHS to be completely unacceptable. However, there is also a dishonest minority who can cause significant financial damage.

“The best way of stopping this is not to wait for fraud to happen and then act after losses have been incurred, but to proactively deter and prevent them. Fraud is a cost to be measured, managed and minimised like any other.”

Making doctors stay….. in a neglected NHS. Letters in the Telegraph. Altruism destroyed early..

On Saturday the Junior Doctors meet. Their decision on whether or not to strike is important to all of us: Junior doctors threaten strike over new contracts – The BMA’s junior doctors committee will meet on Saturday to discuss its plans to attempt to block a deal (Laura Donelly in The Telegraph 18th September 2015). What a shame to have destroyed their altruism so early in their careers. Normally it takes 5 or 10 years, but the government plan to cut their wages makes it instantaneous. Their absence will certainly be felt.

Letters in The Telegraph 24th September 2015:

We can’t make doctors stay in a neglected NHS

SIR – Tom Tugendhat, the Conservative MP, suggests that junior doctors should spend a period of time working for the NHS before they are allowed to move abroad, given the high cost of their training.

It is wrong to hold our graduates captive in a chronically underfunded system when nearly 40 per cent of our medical workforce has qualified overseas. We can’t criticise those who emigrate while we rely on immigration for skilled workers, which suppresses wages.

We must accept that a truly world-class health system will cost more than we are currently willing to pay.

Duncan Scorgie

SIR – Tom Tugendhat compares the idea of making doctors provide return of service to the NHS to the requirement for Army doctors to serve for six years after qualifying. Members of the Armed Forces make up a significant proportion of the medical staff in hospitals across the country and therefore act as an easy comparator.

The Navy’s current medical student cadetship programme pays back tuition fees (£9,000 a year) and purports to provide further benefits of up to £15,379 a year, including a salary at medical school.

The salary of a newly qualified Navy doctor is a competitive £40,728, compared with £22,636 in the NHS. I have worked alongside Navy doctors and, although hard-working, they do an identical job to NHS doctors.

Moreover, military staff have subsidised accommodation on base and, if this is unavailable, are given an allowance to enable the renting of alternative accommodation.

Therefore, before Mr Tugendhat compares the NHS with the military, perhaps he should consider why so many doctors wish to leave the NHS. A medical degree should not be turned into a form of bonded labour.

Daniel Leslie