Monthly Archives: November 2015

Pulling the plug on the medical brain drain – starts Tuesday

The junior doctors strike starts Tuesday. Thank god I have retired. The profession is split in it’s support despite the apparent unity of the BMA. Before you judge, remember that those threatening strikes are in the top 1% of the thinking elite of the country, have spent at least 5 years accumulating a minimum debt of £50K, and average debt of £70K. They work many more hours than they are paid for, and 80% of them are women. The temptation to delay having a family in order to complete training is set against the lower risk of having a child during those years when abnormal delivery is less likely. Having a second child is a major logistical exercise for a caring female doctor. Having a third might be a nightmare…

Pulling the plug on the medical brain drain starts on Tuesday this week, and the global marketplace for doctors, especially those without children free to travel, is wide open. Shortages in Australasia, Canada and many other countries mean those willing to take the exams, and if necessary learn another language, are free to apply. The drain will also be open for early retirement into motherhood, or a different career where night shifts are unknown… Unattached males may be more tempted by the overseas route, and females by either depending on their child status.

How we got into this position is well documented in NHSreality. We have had calls for graduate entry to medical school so that males perform equally to females. This would at least help to equalise the sexes within the profession… It would save money (more working life years) . The last time NHSreality looked it up it cost minimum £250K to train a doctor.. and yet 30% of A&E docs are leaving…

But even more important is the short termism of the political “rules of the game” in a first past the post plebiscite where the financial imperative is for less than 5 years.. Dictators would do better… Rationing of places for our own and cynically taking those form overseas does not inspire loyalty.. It does encourage overseas doctors to come even if their s=training standards and communication skills are suspect, and fosters a managed cultural decline. (Prolonged cultural disintegration and fear are now a fact. New deal risks junior doctor ‘brain drain’… )

The Sunday Times carries an article by Dominic Lawson 29th November 2015: Junior Doctors invoke patient safety, but this is a strike all about money.

NHSreality says that on an “immediate basis” (the only one appreciated by politicians and the media) he is correct, and the BMA’s invidious and disingenuous argument on patient safety is nonsense. However, in the longer term this is about feeling valued, and being valued by the public

Over 10 years, the solution is to train more of our own, but I have no short term solution other than paying up and accepting the junior doctors demands.. NHSreality wonders just how many will leave or retire or take a career break anyway.. NHSreality knows what it believes: what do politicians believe?

Here’s the rub: It’s about an exhausted, demoralised group of professionals who feel neither respected nor valued by their employer

Keep the moral high ground…. Do something but don’t go on strike. It’s the public support which matters..

“Medics admit they don’t act in patients’ best interests”… “Medical Profession in need of a morality injection”..

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

Medical Student debt – time for government to change policy on doctor recruitment

Disconnected from reality the politics of health is in “sound bites”. Universities have perverse incentives to appoint students from overseas. Who will be the first party to address health honestly?

A third of A&E doctors leaving NHS to work “in a non toxic environment” abroad

A new philosophy, what I believe: allow Trust Board members to use the language of rationing in media press releases


Another doctor suicide an angry response …. Time to campaign to Abolish or Reform the GMC ?

Is it time for the medical profession to grow some balls and campaign to abolish or significantly reform this STASI – esque organisation which has been associated with numerous suicides amongst doctors under investigation ?

Quite frankly the impositions made on this doctor ( see story below)  and the manner in which he was dealt with would have been intolerable in any other walk of life or profession , the answer is abolition of the GMC ( General Medical Council ) and replacement with a properly funded ( not by the profession ) independent board that is fully answerable to the law and properly regulated not a Quasi judicial kangaroo court as things presently stand. Following a recent review frankly moronic recommendations were made to the profession such as “resilience training” ( we are not combat troops preparing for Afghanistan ) quite frankly it is once again a case of  ” Lions led by donkeys”. this article does not call for a chaotic unregulated medical profession but one that is regulated with compassion and empathy not tyranny.

Unfortunately the problem of physician suicide is not confined to the UK similar problems with a heavy handed regulator plagues doctors in the US too read the report from the US here .

“What’s most important is for depressed doctors and those thinking about suicide to know they are not alone. Doctors need permission to cry, to open up, to be emotional. There is a way out of the pain. And it’s not death………Compassion and empathy work wonders. More than once, a doctor has disclosed that a kind gesture by a patient has made life worth living again. So give your doctor a card, a flower, a hug. The life you save may one day save you.” ( July 14, 2014). Wible is an author and board-certified family physician in Eugene, Oregon.

'The new hidden cameras will allow us to see if anyone is violating our privacy policy by reading someone else's email.'

I have reproduced the article in full below from pulse magazine & credit to  Cavendish Press (Manchester)

GP trainee died by suicide after fearing GMC suspension

A newly-qualified GP voted ‘Trainee GP of the Year’ hanged himself after fearing he would be struck off by the GMC for failing an alcohol test, an inquest heard.Dr James Halcrow, 34, had been warned by the GMC not to drink after he self-referred for ‘other issues he was having’, which resulted in restrictions on his practice, the court heard.This included the GMC imposing a ban on drinking alcohol, but he worried that due to his socialising he might fail a blood test.His body was found by friends in his apartment in Manchester on 24 June alongside a note which said: ‘I’m sorry.

The coroner concluded that it was ’reasonable to rely on [a potential GMC suspension] as a factor in James taking his own life’Dr Halcrow was voted ’Trainee GP of the Year’ by fellow trainees at the North West Deanery, the court was told.The inquest heard that Dr Halcrow, who qualified as a GP in 2013, was deeply affected by the restrictions as the ban curbed his normally active social life.He attended two interviews with the GMC which went well, but on a third and final interview he said he would drink socially once the restriction was lifted.Dr Halcrow believed one interviewer had taken a dim view of this and he feared the restrictions wouldn’t be lifted.He had gone also out with friends and drunk ‘one or two drinks’ during the period of restriction, also knew he may fail an alcohol test because of the social drinking.After his death, his family learnt Dr Halcrow had been made ‘trainee GP of the year’.Shortly before his death, Dr Halcrow told his friend Paul Fleetwood, who owned the Manchester flat, that he was worried about the restrictions not being lifted, the hearing was told.He said that in his third interview a psychiatrist had taken a ‘very dim view’ of his admission that he would drink socially if they were lifted.Reaching a conclusion of suicide, coroner Jean Harkin described Dr Halcrow as a ‘remarkable young man’.

She said: ‘The GMC would have been aware he may have been consuming alcohol. That would have meant his restrictions would not have been lifted and James would have been aware of this.‘It is clear James was an excellent doctor, so much so he was given an award. He was very sociable and this restriction affected him deeply and affected the social side of his life also.‘It is clear James was looking forward to the restriction being lifted so he could partake in the consumption of alcohol if he wanted to. It is also clear he was deeply upset with his last interview with the GMC.‘It is also clear he would have known his alcohol consumption may have shown up in the last test he did and it seems reasonable to rely on that as a factor in James taking his own life.’It comes as the GMC is reviewing its fitness-to-practise procedures after finding that 28 doctors had died by suicide while under investigation between 2005 and 2013.

Niall Dickson, chief executive of the GMC, said: ‘Dr James Halcrow’s death is a terrible tragedy – he was a young doctor with a bright future in the profession.

‘It would be wrong for me to comment on the details of this extremely sad case. What I can say is we are determined to do everything we can to reduce the pressure and anxiety for doctors in our procedures. It will always be a stressful experience but we want to offer whatever support we can to help them through the process.

‘We have a duty to protect the public but we want to make sure that the procedures we have to follow in our investigations are as sensitive and compassionate as possible. Where there are concerns about the health of a doctor, our aim is to get them back to work as soon as it is safe to do so.’

Credit: Cavendish Press (Manchester)

An Alaskan health model for the NHS ?

According to a report from the King’s Fund the “Nuka” model of health provision used in Alaska could be the way forward for the NHS . See below for the details

Nuka System of Care, Alaska

Southcentral Foundation is a non-profit health care organisation serving a population of around 60,000 Alaska Native and American Indian people in Southcentral Alaska, supporting the community through what is known as the Nuka System of Care (Nuka being an Alaska Native word meaning strong, giant structures and living things).

Nuka was developed in the late 1990s after legislation allowed Alaska Native people to take greater control over their health services, transforming the community’s role from ‘recipients of services’ to ‘owners’ of their health system, and giving them a role in designing and implementing services. Nuka is therefore built on partnership between Southcentral Foundation and the Alaska Native community, with the mission of ‘working together to achieve wellness through health and related services’. Southcentral Foundation provides the majority of the population’s health services on a prepaid basis.

Service features

The Nuka System of Care incorporates key elements of the patient-centred medical home model, with multidisciplinary teams providing integrated health and care services in primary care centres and the community, co-ordinating with a range of other services. This is combined with a broader approach to improving family and community wellbeing that extends well beyond the co-ordination of care services – for example, through initiatives like Nuka’s Family Wellness Warriors programme, which aims to tackle domestic violence, abuse and neglect across the population through education, training and community engagement.

Traditional Alaska Native healing is offered alongside other health and care services, and all of Nuka’s services aim to build on the culture of the Alaska Native community.

Community participation and collaboration

Alaska Native people are actively involved in the management of the Nuka System of Care in a number of ways. These include community participation in locality based advisory groups, the active involvement of Alaska Native ‘customer owners’ in Southcentral Foundation’s management and governance structure, and the use of surveys, focus groups and telephone hotlines to ensure that people can give feedback that is heard and acted on.

As well as building strong relationships with the population it serves, the Nuka System of Care depends on collaboration between Southcentral Foundation and a range of local, regional and national partners. New collaborations are being established each year as gaps in services are identified and filled.


Since it was established, the Nuka model of population-based care has achieved a number of positive results, including:

  • significantly improved access to primary care services
  • performance at the 75th percentile or better in 75 per cent of HEDIS measures
  • customer satisfaction, with respect for cultures and traditions at 94 per cent.

There have also been reductions in hospital activity, including:

  • 36 per cent reduction in hospital days
  • 42 per cent reduction in urgent and emergency care services
  • 58 per cent reduction in visits to specialist clinics.

Changing the rules of the game

In a post in Pulse magazine an experienced GP explains why the House of Cards that is General Practice in its current state is crumbling .


Changing the rules of the game

NHS hip operations and hysterectomies being RATIONED to save money, say family doctors (but covertly)

Alix Culbertson in The Express July 30th 2015 reports: NHS hip operations and hysterectomies being RATIONED to save money, say family doctors

Since there is no admission and this remains “unspoken” and post coded it is covert.

Funding Black Hole NHS

More than a third of GPs say the limiting of specialist treatments has increased since last year, a survey by GP magazine Pulse has revealed.

Doctors are now facing tighter restrictions on referring patients for specialist care, such as knee and hip operations, and are also having to deal with caps on the number of hysterectomies and the issuing of hearing aids, the research found.

The magazine said a total of 19 out of more than 200 NHS clinical commissioning groups (CCGs) – which organise and pay for the majority of health services in local areaa – were ordered by NHS England to cut their budgets to help the health service make £22 billion in savings by 2020.

Among the CCGs which have adopted restrictions are NHS Basildon and Brentwood, which capped the number of vasectomy referrals GP practices can make, and NHS Mid Essex, which has a “restriction policy” on acupuncture, spinal injections and hip and knee operations during 2015/16.According to Pulse, those with mild hearing loss in the NHS North Staffordshire area will no longer be provided with hearing aids, which campaigners have labelled as “cruel”.

Two CCGs, NHS Luton and NHS Great Yarmouth and Waveney, require smokers to give up cigarettes and obese patients to lose weight before being referred for hip and knee replacement surgery.

And NHS North East Essex – which faces a £22m funding shortfall – is restricting vasectomies, female sterilisation and spinal physiotherapy.

Dr Gary Sweeney, chair of North East Essex, told the magazine: “We have no choice other than to stay within budget.

“If we do not implement these decisions we will have to select other services to restrict.”

Dr James Kingsland, president of the National Association of Primary Care, called the policies “unacceptable” but Dr Michael Dixon, chairman of NHS watchdog, NHS alliance, said CCGs “are caught between a rock and a hard place”.

Dr Richard Vautrey, deputy chair of the General Practioners Committee, said financial pressure is often hidden.

He added: “Where patients may have waited three months, they now wait six – this sort of thing is difficult to measure.

“Until we get new funding into the NHS we will continue to come under financial pressure and it will get worse.”

The survey asked family doctors if additional restrictions had been placed on their CCG in the last 12 months, with 36 per cent answering “yes”, 42 per cent responding “no” and a further 22 per cent saying they did not know.

Research by the King’s Fund think-tank found operations carried out as day surgery, as opposed to staying overnight, had saved the NHS about £2 billion.

Was you vote obtained under false pretences? All main political parties’ pledges for NHS will prove inadequate, says former chief executive. Only the Lib Dems can bring us to our senses..08993-images12

Saving the NHS – Political parties are in denial over how to fund the growing pressure on the health service. We need an honest debate about new means of paying for it
Saving the NHS – Political parties are in denial over how to fund the growing pressure on the health service. We need an honest debate about new means of paying for it

In Search of the Perfect Health System – a new book reviewed

Mark Britnell “In search of the perfect health system”, (published by Macmillan Education and Palgrave ISBN 978-1-137-49661-4)  2015 by Mark Britnell

In Search of the perfect Health system. Mark Britnell.

This is an important and timely book. It is more than good: it is pragmatic and excellent in its clarity. To describe the history and medical care system of 25 countries (after visiting 60!), and summarise the best and worst of each is an achievement in itself. To recommend different system virtues at different stages of a county’s development is even better, and to round the debate off with suggestions of the main drivers for future change is as good as readers could expect. It is very accessible for a work on health policy, and that in limiting the chapters to around 1800 words on average it clearly wasn’t possible to cover everything in global health.

Because National systems and ingrained and slow to change this book will stand for some time. If there is a country with low GDP spend and longevity that might also be included, it would be Ireland. The author avoids “rationing” as a possible solution, but he does seem to accept co-payments as a necessary evil (Australia, New Zealand).  There is no magic silver bullet, but then we all knew that.. He does not point out clearly that governments have a duty to populations, whereas doctors have a duty to individuals. This natural dissonance, and systemic perverse incentives, occurs in all health care systems.

For some years now doctors, especially public health planners, have been interested in different nations’ health systems. What a pity that the main readers are likely to be such doctors, nurses, and academics. The book should be compulsory reading for politicians, and recommended for Health Trust Board members, but I suspect they are unlikely to read it, let alone feel safe to comment. The benefits of patient autonomy, involvement in strategy, along with social solidarity and a reasonable percentage GDP spend are evident in just a few countries. If Russia and Mexico are ignored, universal coverage is best portrayed in Singapore and Hong Kong, but even these low spenders are struggling with projected demographics, the multiple morbidity of old age, and reduced birth rates… Insurance based systems seem to increase inequalities, which might be acceptable in Germany at present, but may not be once over 50% of people are over 60 years old….

Comprehensive and universal cover without competition between providers has economies in saving on transaction costs, but the author does not point out the different staff sickness and absenteeism rates when comparing systems.. Choice is not important since all systems are stretched to capacity (except Switzerland, and the fully insured or private parts of the USA).

The author does not answer his implied titular question, except to say it is spurious… He does make it clear that politicians drive the system, and that where countries have tried reform and integration, they have sometimes failed if there are tensions between National and State providers. (Australia)

In considering the UK the author points out there are now 4 different systems and focuses on England. He is critical of the UK’s inability to integrate primary and secondary care especially after ignoring the Griffiths report, and of the general lack of consistent leadership, with ministerial change every 2 years. He does not refer to the covert rationing and obfuscation, and the obtuse language used – prioritisation and restriction being examples. He does not point out the lack of “exit interviews” which could help to bring back an honest culture, and the absence of the open discussion of perverse incentives before a change is initiated. Also, the lead that well designed GP information systems could make to cultural change is not recognised.. The absence of suggestion on how to deal with SIPGs, and a sensationalist media, is an omission in the chapter in “patients as partners”. This chapter ends with “As the greatest untapped resource in healthcare, patient power will increasingly be the factor that makes our health systems sustainable.”

Several countries have moved away from comprehensive universal free at the point of access, cradle to grave and without reference to means, provision; notably New Zealand and Scandinavia, but they were only able to do this with the agreement of the people, and when they were persuaded by left wing administrations. This seems to exclude right wing parties from designing the pragmatic changes needed to be sustainable. The progress of true patient representation is promoted, and as honesty becomes evident any changes will obviously need social persuasion and democratic approval. The author sees a general weakness in all current systems – they need to be flexible enough to be able to change speedily, when necessary,

Update 1st December 2015: Chris Ham: Learning from others—devolved governance in the Australian state of Victoria BMJ 30th Nov 2015


What the Spending Review really means for the NHS

The Nuffield Trust: What the Spending Review really means for the NHS

27 Nov 2015 (NHSreality agrees with this, but there is more than this – no progress without overt rationing.Scheerder's Sieves

“The NHS will receive an additional £10 billion a year above inflation by 2020, delivering in full the Five Year Forward View,” the Treasury announced a day ahead of this week’s Spending Review.

Other versions of The Truth were also available, however.

Chancellor George Osborne attempted to steal a march on those competing versions by announcing partial details of NHS England’s element of the Department of Health’s settlement a day early.

That announcement included reference to an annual £10bn real terms increase to NHS’s England’s budget by 2020–21. This first version of The Truth relies on the strange – but not unfamiliar – tactic of reporting an increase against an out-of-date baseline; in this case, NHS England’s spend for 2014–15, allowing Mr Osborne to include the £2bn additional spending already included in the current year’s budget.

Version two took that into account, bringing the reported real terms annual growth down to £8bn by 2020–21, leading the Chancellor to claim the funding request set out in the Five Year Forward View had been met, with a modest front-loading of the extra cash and average annual real terms increases over the five years of 1.5 per cent.

It is after this that things get sticky.

A redefined NHS ringfence

As we feared, a significant portion – just under £3.5bn – of the £8bn extra for NHS England will be funded through very significant cash reductions to the £15bn worth of the Department of Health’s total £116.4bn spending that lies outside of NHS England.

Although characterised as ‘Whitehall’ budgets by the Chancellor, that spending comprises almost £5bn in NHS-wide capital investment, with the same again in clinical education and training, including the salary costs of doctors who train on the job. It also covers over £3.5bn in public health spending, a similar amount in central and local NHS administration costs, and £0.8bn in arm’s length bodies such as NICE, NHS Blood and Transplant, those overseeing medical and health research and development and the Care Quality Commission.cropped-orwell-quote11.jpg

Those budgets will now be slashed by over 20 per cent in real terms over the next five years, with the most severe cut front-loaded to the next financial year, when an immediate cash reduction of £1.5bn will be made – 12 per cent in real terms.

Few details have been provided as to where the £3.5bn Department of Health axe will fall, although the Spending Review Blue Book announced average annual real terms reductions to local authority public health grants (currently around £3bn) of 3.9 per cent. That would suggest in the region of £600m of the NHS England’s ‘extra’ £8bn will be funded through cuts from public health – a move which sits uncomfortably with the Chancellor’s claims to have delivered “in full” the Forward View, which had at the centre of its plans to ensure the sustainability of the NHS a “radical upgrade in prevention and public health”.

The knock-on effects of ending nursing bursaries

The Spending Review also announced plans to end NHS bursaries for student nurses – switching these instead to the Student Loan Company. If successful in expanding student nurse numbers, the switch could be cost saving to the Department of Health, representing an annual saving to the Health Education England (HEE) budget of around £1.2bn. However, the need to honour existing commitments means this saving will not transpire until the end of the five-year period, with only £650m saved per year by 2018–19. (Net savings will be lower to the NHS, of course, if personal debt liabilities for newly qualified nurses translate into pressure on NHS pay rates.)

In the meantime – and following HEE’s indication that its budget for next year is likely to be frozen – there is a risk of stealth cuts to NHS hospitals if HEE is forced to respond by reducing or freezing the subsidies it currently pays to NHS providers to cover part of the salary costs of junior doctors and placement expenses for undergraduate medical trainees.

Will the urgency of budget cuts cause panic sale of NHS assets?

But one of the biggest dangers is the sheer size of the cut to the Department of Health’s budget needed by next April. With just four months to find £1.5bn in cash, the risk of a short-sighted fire sale of NHS assets is perhaps greater than ever.

The scale of these reductions to the Department of Health’s wider budget means that while NHS England’s budget will grow at an annual average 1.5 percent in real terms over the next five years, the rate of growth for health spending as a whole will be just half that.

This third version of The Truth is one the Treasury is almost as happy to convey as the first and second. However, in the context of continued austerity and severe spending reductions elsewhere in the public sector, the Department of Health will continue to receive real terms annual increases – just – when measured against economy-wide inflation.

All smoke and mirrors?

The Treasury is less keen to trumpet what that means for health spending as a proportion of GDP: it is left to the Office for Budget Responsibility to set out in its accompanying analysis to the Blue Book that spending plans for health will translate into a 0.2 per cent decrease in NHS spending as a share of GDP between 2015–16 and 2020–21, and a 0.3 per cent decrease after adjusting for our ageing population – continuing the same downward trajectory started in 2010–11.

These figures are a sobering antidote to the headline 3.7 per cent real terms increase to NHS England’s budget next year. However, that ‘frontloaded’ increase itself risks feeling substantially lower if – as seems likely – NHS England’s total spending this year is higher than planned as a result of the hospital overspend optimistically projected at a net £2.2bn. That will perhaps require NHS England’s net spending this year to be raised above the Chancellor’s baseline by around £1bn – most likely funded through a cut to the Department of Health’s capital spending programme – reducing the real terms increase for NHS England next year to something closer to 2.7 per cent.

Yet even without that risk, the planned profile of the £8bn (a 3.7 per cent at best increase next year, followed by much lower increases down to less than half a per cent in real terms by 2018–19) indicate that the spending of this ‘transformation fund’ – intended to help the NHS deliver new models of care and invest to save – will need to be tightly managed. There will be little room for double-running costs (and therefore additional permanent staff) to run beyond 12 months as the tolerance for recurrent additional spending is minimal.

The NHS isn’t out of the woods yet

These pressures exist even before considering those brought by additional commitments explicitly referenced in the Spending Review’s Autumn Statement – such as seven-day working – as well as those that are not – such as new pension costs for NHS employers. And as my colleague Mark Dayan will explain in his blog later today, the continued underfunding of council adult social care services can be expected to have ongoing repercussions across the health service.

Big decisions such as Spending Reviews always throw up many versions of The Truth. But public and politicians alike should not walk away from this Autumn Statement believing the NHS has been taken care of, with no more legitimate reason for concern. As cuts to supporting services and continued pressure roll on, the health service experience may be of a very different reality indeed.