Monthly Archives: May 2016

Panic Incentives are too late – “short termism trumping best practice”?

The bribe to work in a remote, deprived or unpopular area is interesting, and was suggested by NHSreality some months ago. But it is really too late, and this and the £12,000 “return to work” inducement are unlikely to make a difference. Let’s wait and see… but NHSreality sympathises with Stephanie Lis; It’s “short termism trumping best practice”. Nevertheless. pragmatism says you have to start somewhere.. The real problem is the long term rationing of medical school places, and the gender bias.

Sophie Borland on 26th May in the Mail reports: NHS to offer £8,000 to GPs… for school fees: Doctors to be offered ‘relocation allowances’ if they decide to move to areas that are short staffed

Zoie O’Brien on 27th May in the Express reports: GPs given £8K for children’s private school fees in desperate bid to fill remote surgeries – DOCTORS will be offered thousands of pounds to send their children to private boarding schools – if they take jobs in remote areas.

New plans to offer GPs £8,000 towards private education will be rolled out by the Government in a desperate attempt to fill severely short-staffed surgeries.

As demand for doctors rises with ageing and growing populations, the NHS is faced with a recruitment crisis.

Now, doctors will be handed one-off ‘relocation allowances’ for agreeing to take up posts in remote areas of England if a pilot scheme is successful.

Doctors only need to move 50 miles away to be eligible and they can work part-time – a minimum of two and a half days a week.

The pilot scheme will take off in areas such as the Lake District, the Isle of Wight, Lincolnshire and Lancashire.

Doctors will be offered a maximum of £10,000 of which £2,000 will cover education and training if they are returning to work after time off or maternity leave.

The remaining cash can be put towards ‘relocation expenses’ including estate agency fees, removal men, renting a flat or putting their child in boarding school if they don’t want to disrupt their education.

Boarding fees are on average £10,000 a year, a cost which rises at prestigious schools.

But plans have been met with anger from some.

NHS England will oversee the scheme mostly aimed at GPs who currently only work a few days a week, have moved abroad, or are taking a career break.

The payments are a one off and doctors must stay in the job for three years if they take the cash.

Supporters of the scheme say it is vital to offer incentive in a time some communities are facing real difficulty in getting community medical care.

In recent years young medical professionals have opted for hospital based careers while GPs are dropping their hours and retiring earlier – leaving a void in some practices.

Dr Maureen Baker, Chair of the Royal College of GPs, which helped draw up the scheme said: “Making it easier for trained GPs to return to frontline patient care after a career break or period working abroad is a priority for the College, and this scheme that targets returning doctors to work in areas most in need makes a lot of sense.

“It’s important that adequate safeguards remain in order to ensure patient safety, and that every GP who wants to return to practise in the UK is treated equally, but we need to cut through any unnecessary red tape, and working with NHS England, I’m pleased that we are making strides in this area.

“We hope this scheme will encourage returning GPs in hard to recruit areas in the best interests of providing safe care now and in the future, wherever our patients live.”

At a time when the NHS is rationing drugs and treatment, the Government has been accused of throwing cash at well paid GPs.

Jonathan Isaby, Chief Executive of the TaxPayers’ Alliance, said: “This will certainly raise eyebrows. We are forever hearing pleas for more money to be put into the NHS so taxpayers will be right to question if the authorities have got their priorities right.

“Hard-pressed families expect their taxes to pay for nurses and cancer drugs, not to be wasted on fees for expensive boarding schools which many cannot afford for their own children.”

Stephanie Lis from the Institute of Economic Affairs think-tank said: “This is yet another example of short-termism trumping best practice in the NHS.

“Throwing money at already very well-paid doctors will do nothing to fix the systemic problems with our centralised system of healthcare provision.”

GPs average salaries are around £100,000 a year and they soared by more than a quarter under a contract 10 years ago that also enabled them to give up out of hours work.


Fighting for the NHS’s moral life: There are 4 Chernobyl’s waiting for meltdown..

The only objection I have to the title is that there is no NHS. The content is correct, honesty has disappeared, fear rules and exit interviews are unknown. The author fails to grasp that we need honest rationing as well as culture before we can make the change, but over management and overuse of performance related pay have led to predictable outcomes. If the workforce was oversupplied Mr Hunt might have got away with it, but with undersupply over 30 years he will not. Chernobyl imploded because the reports given to the KGB were never fed through to politicians…. Something similar is happening to the health services. There are 4 Chernobyl’s (England, Scotland, Wales and Ireland) waiting for meltdown.. The post Chernobyl era led to the breakup of the soviet union..

Margaret McCartney in the BMJ opines (BMJ 2016;353:i2822 ) : Fighting for the NHS’s moral life

Contracts are about to be rewritten, for GPs in England and for consultants. Junior doctors are getting a new one. Yawning gaps exist in out-of-hours GP and junior hospital rotas. Emergency department waits are increasing, as are complaints to the General Medical Council, and morale is disintegrating. Is this the NHS’s decline and fall?

Doctors used to have much autonomy, leading to innovation, excellent care, and high job satisfaction—but also to exhaustion and to a few doctors taking advantage of minimal oversight.

We now have bureaucracy, intrusive checking of often irrelevant “performance” data, and an entire (expensive) industry professing to regulate us. We no longer have a moral contract to practise medicine but instead have an angst ridden, nit picking one that assumes the worst and tries to find it.

I won’t resentfully add up the extra hours I worked this weekend or before my official start time, as long as I’m doing a useful job that’s valuable to patients and I retain some control over my working life. If my work feels crammed with conflict, if I’m routinely pleading for referrals to be accepted, or when organisations change without consultation or consideration, then clock watching and declaiming that “it’s not my job” will become natural.

In an emergency if a doctor can’t work a shift, then someone who doesn’t feel valued or part of a coherent service will feel no moral responsibility to help. Treat workers as mere disposable cogs in a corporate wheel, and they won’t imagine or invest their future as part of it. So, no one will innovate, create, or challenge. No one will feel ownership of a shared destiny.

All of this will have to come from external management consultancies with variously laughable grasps of medicine. We’re in a mess, pretending that we can do more with less, prioritising winning votes rather than fairness and without cognisance of opportunity costs—all inflamed by the recurrent misuse of statistics.

Patients are being told to expect more and to complain loudly when it’s not delivered. But in what warped universe can elective surgery at the weekend be more important to deliver than emergency overnight care?

If truth is the first casualty of war, the NHS is fighting for its moral life. Meeting the needs of everyone, free at the point of need: do this first, and then we can talk. We need an evidence based NHS, released from the stranglehold of party politics that causes so much waste and angst. But we also need to backtrack, to take advantage of professionalism and to allow staff to use it.

Insurer told to pay for unapproved knee surgery – Ombudsman sets an important precedent…

As more and more services are covertly rationed, and access is restricted, prioritised and post code denied, more and more of us will seek to have private medical insurance. This decision is important as it distinguished between NICE guidelines and rules. It puts the onus for judgement on the professionals looking after a patient in their particular circumstances. A victory for common sense but as the UK Health Services fail and fall further, and inequalities rise, it sets an important precedent. The ombudsman saw fit to override the perverse incentive of the insurer to refuse the claim…

Tom Whipple in the Times 30th May 2016 reports: Insurer told to pay for unapproved knee surgery

A health insurer has been ordered to pay compensation for refusing to pay for a woman’s knee operation.

Axa PPP had refused to cover a £6,000 knee operation for Michelle Booth, 47, despite her surgeon recommending it.

Although several hundred people have the operation in Britain every year, mostly on the NHS, they do so without the approval of the National Institute for Health and Care Excellence. Axa said this meant they were not prepared to offer it, forcing Mrs Booth to wait five months for the NHS.

The Financial Ombudsman Service said that the lack of Nice approval was not sufficient reason to refuse to pay for the treatment. Ms Booth told The Mail on Sunday: “Patients with private health insurance should be able to receive the treatment their doctor recommends, not the treatment the insurer recommends,” she said.

Ruth Lythe in The Mail reported 13th Feb 2013: ‘I paid insurance for 25 years then had to find £715 extra for knee surgery’: The tricks health insurers are using to cut costs

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Rationing numbers of pharmacies may be possible in cities, but it will be very inconvenient in rural areas, unless GP restrictions are lifted. The rural “on cost” is never clearer than in pharmacies. Our town has three, but technically one could do the job of all of them…( Lack of competition may then result in diminished service.?.). None of the links below gives an indication of the increased load that might result on GPs. Actually the evidence for this is very thin, and it may be more of a fear than a reality: but politicians need to be aware that an already creaking service might implode further. Like the poor retired major, Mr Hunt and his team might well be off their trolleys..

Sean Poulter in The Mail reports 30th May 2016: Local Chemists threatened by supermarkets and Sophie Borland reports 28th May 2016: £170m cuts could kill off a QUARTER of our chemists – prompting warning of even more pressure on A&Es
Previously on 4th May Ian Strachan in the Huffington Post, opines: Why the Government Plans for Pharmacy Make No Sense

Despite the uproar BBC news reported 23rd May: Thousands of pharmacies in England ‘at risk of closure’

and Mark Whitehead in Local Government News 23rd May opines: Closure of local pharmacies would be ‘catastrophic’ for public health

Chris Sloggett in Pulse reported 23rd March: RCGP launches new initiative for pharmacists to work in GP surgeries, but this implies an expansion. Mr Hunt really wants to save money somehow, without co-payments and overt rationing. A bit on honesty might help..





Don’t have narcolepsy in the wrong Post Code. “…end the postcode lottery and apply some common sense.”

John S Watts writes in the BMJ: ( BMJ 2016;353:i2881 ) Prescribing sodium oxybate for narcolepsy: end the postcode lottery and apply some common sense

Yes, don’t have narcolepsy and remain living in the wrong post code.


Zeman and Zaiwalla’s call to end the irrational and inconsistent rationing of sodium oxybate for the treatment of narcolepsy should be welcomed.1

Of note, a recent case in the High Court, reported in the Telegraph, quoted the judge as describing the decision by NHS England to decline funding of this drug for a 17 year old girl with the condition as a “thoroughly bad decision,” “totally irrational,” and “disastrous.”2 The judge accepted the fact that her condition was deteriorating, and that this was the most effective treatment, a position that was not disputed by NHS England. He decreed that the case was exceptional and fell within the current policy of funding the treatment for such cases. The brief report made clear the devastating effect the condition had on the girl’s life and functioning, and the relatively small cost of the treatment that could have helped improve her symptoms. It is striking that the cost of legal proceedings must have dwarfed the cost of supplying the drug.

It was also disappointing to learn, yet again, of the postcode lottery that still exists for patients from the same country and who pay the same taxes. The NHS was set up to be a national service for health. Instead, it is now a series of local companies, increasingly being run for profit.

“..a brutal and potentially fatal form of healthcare rationing”. It should be the politicians with “an inability to face the outside world” rather than the patients..

The Times leader refers to “..a brutal and potentially fatal form of healthcare rationing”. It should be the politicians with “an inability to face the outside world” rather than the patients.. We can raise as much money as is needed for cancer, which is also rationed (Viz: there are hospices in richer areas, but not in poorer ones), and children normally evoke much sympathy. Unfortunately the children with mental health needs come from families that are seen as least deserving. If we wish to have fewer children in care as offending as teenagers, we need to challenge the right to parent badly, and this would also help prevent some of the psychiatric problems. At the same time we do need to provide more child psychiatry services and if this means co-payments for other services – so be it. Without reference to means is meaningless…

NHS Perverse Incentives

Rosemary Bennett reports 28th May 2016: NHS refuses to treat children with life-threatening mental illnesses

Children who attempt suicide, suffer from psychosis, severe anorexia and other life-threatening mental illnesses are being refused specialist treatment by the NHS despite being referred by their GP, a report by the Children’s Commissioner for England has disclosed.

Anne Longfield called the situation desperate and described services as unresponsive as she revealed that one in eight classified as having a “life-threatening condition” was turned away by their mental health trust last year. Even those with the most serious illnesses who did secure treatment faced long delays, with the average waiting time 110 days for children in this category…..

The Times leader of the same day reads: Mind the Gap – Promises to improve mental healthcare for young people are not being kept

There is a “gaping black hole” in mental health services for young people. These were the words of John Partridge’s parents at an inquest into his death last month. He took his life after discharging himself from hospital without being seen by specialists whose help he clearly needed. His parents’ blunt analysis is borne out today by the Children’s Commissioner’s finding that one in eight children with life-threatening mental illness are being denied specialist treatment even after being referred for it by their GPs.

Overall, more than a quarter of youngsters referred to the overstretched Children and Adolescent Mental Health Services (CAMHS) do not get the help it is supposed to provide. The average waiting time for those who do get it is 110 days.

The government has rightly set itself the target of putting mental healthcare on the same footing as physical, but the goal remains elusive. Money has been earmarked for young people’s mental health, but not enough of it is being spent. The number committing suicide is rising and the number being hospitalised is rising faster.

There is a widening gap between ministers’ rhetoric on this most distressing of public health emergencies, and concrete action to tackle it. The former reflects a growing awareness of the problem thanks partly to efforts such as this newspaper’s Time to Mind campaign. The latter is in- adequate, and children are paying with their lives.

The latest official figures show 201 suicides by people aged 10-19 in 2014, a 10 per cent increase in a year. Each is a tragedy. Together they are the tip of an iceberg. According to the YoungMinds charity, three children per classroom have a diagnosed mental illness and the number admitted to hospital for self-harm or eating disorders has doubled in three years.

In all, 248,000 young people were referred to CAMHS last year. Some GPs are quicker to refer than they were, but this counts for little when specialist clinics are so swamped that waiting times in four areas average more than 100 days. In the West Midlands it is double that. In several, the Children’s Commissioner reports that specialist treatment is being withdrawn if a child misses a single appointment. This is a brutal and potentially fatal form of healthcare rationing that ignores a common symptom of acute anxiety or depression — an inability to face the outside world.

Shortly before John Partridge’s death he was admitted to hospital in Devon with a history of mental illness and with blood on his clothes having cut himself with a razor blade. In a comparable case Edward Mallen, 18, took his own life after being referred to mental health services as an acute suicide risk but receiving, in his father’s words, “a strip of pills and couple of website addresses”.

The system failed them both. An extra £1.25 billion has been put aside in principle for mental healthcare for young people for the five years to 2020. In practice £143 million has been allocated for this year. The money is not ringfenced and there are fears it is being funnelled elsewhere because of budgetary pressures. Such fears are compounded by the fate of Natasha Devon, the first children’s mental health “tsar”, sacked after singling out exam stress as a cause of depression. Ministers must examine the origins of this epidemic more dispassionately, and tackle its symptoms more aggressively. When young people are contemplating suicide, there is no time to wait.

Children in care six times more likely to have a criminal record



A deserts based approach to bed blocking and obesity? How could we encourage families to take their relatives home?

Do we need a deserts based approach to bed blocking and obesity? How could we encourage families to take their relatives home? The “£820m cost of bed blocking” described by Chris Smyth has been known for some time. At any one moment a “point survey” reveals that many, sometimes up to 80% of patients, might be at home in an ideal world. (Where Social Services and / or family were helping the discharge). We need sticks as well as carrots… but what would be acceptable to one family would be anathema and impossible for another. NOW is when political leadership and open discussion of ideology needs to take place.

Dr Tim Rimmer (ophthalmologist) in The Times letters 26th May 2015 says “As our politicians will never dare to end the NHS as we know it, they will have to think outside the box and make some bold decisions about obesity management and dietary advice now.”

Bed-blocking costs NHS £820m a year by Chris Smyth

Bed-blocking costs the NHS £820 million a year and the problem is more than twice as bad as official figures show, the spending watchdog has found.

Delays in moving fit patients out of hospital are growing at an “alarming rate” as the population ages and cuts to social care bite, the National Audit Office warns. In a report released today, it says that better co-ordination in the care of elderly patients is crucial to the future of the NHS. Hospitals reported a record £2.45 billion deficit in 2015-16.

Hospitals must get better at organising help for vulnerable patients to go home, the NAO warns after more than half of trusts were found to start planning too late. Two thirds of hospital beds were occupied by people over 65. Official figures show that hospitals lost 1.15 million bed days to delays in transferring patients who were medically fit to leave, a rise of 31 per cent in two years. The NAO’s survey of hospitals suggested that the true figure was 2.7 million bed days at a cost of £820 million a year.

A spokeswoman for the Department of Health said: “Elderly patients should never be stuck in hospital unnecessarily and we are determined to make health and social care more integrated.”

GPs will be offered £10,000 to move to unpopular parts of the country under a pilot scheme to tempt doctors back to the NHS. Foreign doctors who have left the NHS, British GPs who have emigrated and those who have taken time out to raise a family are being targeted.

Alex Matthews King in Pulse 25th May reports: NHS offers £12,000 for GP returners to work in struggling practices