Monthly Archives: December 2016

Nursing degree applications fall by a fifth – a two tier service is evolving by neglect.. State basic, and Private enhanced.

Most of the doctors feel that Nursing took the wrong course when they tried to push through the degree increments and “Agenda for change” demands in the first decade (2004) of the century. GPs as self employed businesses resisted most as our funding was not future proofed. Those who capitulated are regretting it now. Stephanie Jones-Berry reports in “Primary Health Care”.and Greg Hurst reports in The Times 17th December: Nursing degree applications fall by a fifth despite the Agenda for change”  This decline is a disaster for those of us in our sixties and seventies who hoped for the quality of nursing care our parents received. Continuous neglect, rationing of training places in medicine, and over borrowed nurses-in-training, and Agenda for change has led to government preferring to hire nurses and doctors from abroad, at cheap rates of pay, rather than train our own, with whom patients have cultural affinity and good communication.

A two tier service is evolving in Medical and Nursing care, by neglect: state basic, and private enhanced. It would be better this change was managed and overt..

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Applications for nursing degrees have fallen sharply since the government withdrew their funding via bursaries and forced students to pay for their courses with loans.

Universities said last night that applications for nursing, midwifery and allied health courses were down by about 20 per cent compared with this stage last year. In some institutions applications have halved.

Shortfalls in applications were worse in London and the southeast, among mature candidates and in specialist fields such as learning disability nursing, occupational therapy and podiatry. There are fears that some small courses may become too expensive to run if numbers dip too low.

It is too soon to judge if the fall will mean fewer student nurses starting in September next year but universities are considering contingency plans to avert a shortfall in nursing graduates, including accelerated two-year postgraduate nursing courses.

Vice-chancellors are planning a campaign with health bodies to encourage more people to train as nurses, which is likely to run well beyond the normal deadline for university course applications next month to encourage candidates to make late submissions or apply through clearing in the summer.

Some caution is needed with the figures as the Universities and Colleges Admissions Service says year-on-year comparisons are complicated this year because calendar dates mean we are two or three working days behind last year’s cycle, and university applications generally are running behind last year’s figures. But the drop in applications for nursing, midwifery and allied health subjects is twice that of other courses, according to a survey by the vice-chancellors’ body Universities UK (UUK).

Ministers claimed that ending the bursaries would create 10,000 more training places, as costs are met by students taking out loans rather than direct government funding. It would be an embarrassment if numbers fell.

Janet Davies, head of the Royal College of Nursing, said her organisation had consistently raised concerns to the government that its decision would result in a drop in applications. “Our advice fell on deaf ears. The government went ahead in gambling on the future of the nursing workforce,” she said.

Steve West, vice-chancellor of the University of the West of England and chairman of UUK’s health policy network, said that the numbers were down. “We want to ensure . . . we get the right message out that there are fantastic career opportunities in nursing.”

Vice-chancellors say that mature students are likely to find it harder to take on a student loan of £27,000 to fund their degree and worry that potential student nurses may not fully understand that they will only start repaying once they earn above £21,000.

A Department of Health spokesman said that it was too early in the application process to predict reliable trends, adding: “We are committed to increasing the number of training places for homegrown nurses, as well as making sure there are more routes into nursing including through apprenticeships.”

The RCN is concerned the effects on the future workforce will be exacerbated by Brexit and an ageing population.

To date many midwives and nurses have not been able to “demonstrate they can communicate effectively”. Communication and cultural barriers in health acknowledged. Litigation results..

In an undercapacity market who can blame the nurses or doctors? £190m is “comeuppance” for politicians. NHS nurse recruitment from EU ‘too aggressive’!

Not enough nurses or doctors? Or are we just inefficient? The situation is a disgrace and a scandal, and needs a war like atmosphere of honesty to address it…

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

Not enough doctors – just keep lowering the bar & reducing the funding

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

 

Will you be more likely to die with a male doctor? Patients less likely to die if doctor is female…

The report by Kate Gibbons in in The Times and other newspapers on 20th December 2016 is an interesting read, and it has statistical power. “Patients less likely to die if doctor is female” is reprinted below. The study needs to be reproduced in the UK’s 4 services, where junior doctors are mainly female, and see if it applies. Justification of the bias in selection would be retrospective, and some consolation to those on waiting lists. If they do get admitted they are at least more likely to return home.

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Yusuke Tsugawa was the original author in JAMA Internal Medicine October 13th 2016, and the article has free on line access. There were over 1.5 million patients analysed for nearly 60,000 physicians. The gender distribution of the physicians is not mentioned, but as they have graduate entry we can assume it is equal male to female, (unlike the UK where undergraduate entry results in 80% females).  The report is about internal medicine and there is a readmission rate of around 250K patients in 30 days. The potential total lives saved in the USA would be 32K if this is valid and reliable, and is accounted for by a difference of 4% in outcomes. It says nothing about quality of life, cost, or future care needs.

Elderly hospital patients treated by women doctors are less likely to die than those in the care of men, research has indicated.

A study found that people aged 65 and over who received hospital care from a male doctor had an increased risk of dying within 30 days.

Female doctors were less likely to flout national care guidelines and had better communication with patients.

The study, published in the journal JAMA Internal Medicine, was the first to examine how gender differences could affect mortality rates.

Analysis of more than a million patients aged 65 and over who had been in hospital for a variety of conditions, including diabetes, cancer and heart failure, found that those treated by a female doctor were on average 4 per cent less likely to die prematurely than those with a male doctor.

The researchers at Harvard University found that the differences were most significant for patients who had more severe conditions.

Yusuke Tsugawa, the study’s lead author, said: “The difference in mortality rates surprised us. The gender of the physician appears to be particularly significant for the sickest patients.”

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In a media led society, how do we tell the “hard truth” – Mr Fillon seems to have failed

A sensible pledge to “pledge to farm out minor health costs to private insurance “…… Readers might not think this is important but the lesson applies to the UK. Although we do not have layered insurance systems, we do have one universal system. In a media led society, how do we tell the “hard truths” such as on health. Rationing overtly is going to get harder, more punitive, more expensive and more regressive as the denial continues – Mr Fillon seems to have failed in persuading the French that they cannot have Everything for everyone for ever, and any ridicule would be better directed at the media and political opponents. Encouraging autonomy in minor health expenses is essential. The safety net should be there for the big, fearful, and expensive things..

In The Times 19th December Charles Bremner reports: Ridicule for Fillon after healthcare cuts retreat

François Fillon, the conservative favourite to win the French presidency, has been forced on the defensive after fumbling an attempt to retract a pledge to cut funding for basic healthcare.

The Republicans party candidate bowed to public outrage, deleted his pledge to farm out minor health costs to private insurance from his website and denied that he had ever made it.

“Never did I want to, or would I want to, ‘privatise health insurance’,” the former prime minister said. Until Tuesday, his campaign site said: “I propose focusing universal public insurance on serious and long-term illnesses, and focusing private insurance on the rest.”

The volte-face from the rural MP drew ridicule from his centre-left opponents and fuelled doubts about his credibility in a centre-right camp worried that his “Thatcherite” plans were alienating voters.“It’s hard to fathom just what he is saying at this stage,” said Marine Le Pen, the National Front candidate, who mocked Mr Fillon’s U-turn and said that his plans for cutting social security cover made her feel sick. “I hope it will pass quickly because I’m told digestive troubles are among the ‘small ailments’ that would no longer be covered.”

An Odoxa survey showed that nine out of ten respondents opposed cutting public spending on health.

“This programme is worrying, intimidating and confusing,” said Marisol Touraine, the health minister.

Mr Fillon has also been criticised for his support for President Putin.

Manuel Valls, the former prime minister, who is likely to become the Socialist candidate next month, said that Mr Fillon’s move was a cynical one. “Mr Fillon’s manifesto consists of less independence for France in the face of Russia and hard prospects for the French with the basics of our social model cast into doubt.”

Polls suggest that Mr Fillon is best placed to win the election against the far right and a fractured and discredited left-wing camp, but a survey yesterday showed that he was not liked by a majority of the public.

An Ifop poll for Le Journal du Dimanche suggested that 55 per cent believed that he would win the election but only 28 per cent wantedhim as president. His biggest support comes from the over-65s, who are 50 per cent behind him. Of the respondents, 62 per cent were worried by his promise to cut welfare cover.

Many voters, including many from Mr Fillon’s own party, described him as an out-of-touch, upper- middle-class country dweller who did not understand their problems.

Mr Fillon has spent the past two weeks trying to rally support from his former rivals, Alain Juppé and Nicolas Sarkozy, but they have not given him full backing. “The start of Fillon’s campaign has been a struggle. There’s no clear direction,” said one of Mr Juppé’s lieutenants. “The winning strategy can’t just consist of sitting on your favourite’s laurels.”

Natalie Huet reports on politico.eu 19th December 2016: Lessons from François Fillon: How not to reform health insurance in France – François Fillon proposed dramatic reform for an overstretched health care system but has retreated bit by bit.

Jerome Chartier said ““One thing that got in the way is that we started to focus on details rather than on the most important … that social security is in deficit,””…

The Mailonline reports that the Fillon website was changed to delete the suggestion that healthcare insurance should be partly privatised.

 

…political “unsayables”. Behind closed doors nearly every politician admits that the current system for paying for health and social care is decades out of date.

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Its one of the political “unsayables”. Behind closed doors nearly every politician admits that the current system for paying for health and social care is decades out of date.

But very few of them are willing to say publicly that reform is long overdue.

Even though the government is this Thursday expected to announce that councils will be able to raise a bit more cash from their taxpayers towards paying to care for our elderly with dignity, few in Westminster would pretend that’s anything like a long-term solution.

So what is? Sources say the Cabinet Office is looking at various mechanisms to find some answers.

But whatever they come up with, it won’t be easy to get other political parties to buy in, especially with a small majority. So maybe it requires a different kind of fix.

The BBC has been told that Number 10 was considering plans for a cross-party commission to look at the costs of health and social care, before the referendum.

After three former health ministers – Norman Lamb, the Liberal Democrat, Stephen Dorrell, a Conservative, and Labour’s Alan Milburn – launched a bid for a national review to find consensus, David Cameron’s team invited the three to present their plan to the government, in a seeming acknowledgement that the current system is not sustainable.

Norman Lamb told me: “We went in and talked to them and presented them with a paper and then the whole run-up to the referendum took over and we never got any response from that and then of course there’s been a change of government but the need for this government to engage in this and for all parties to stand up to their responsibilities as well, to join a process, to ensure that we reach a one in a generation settlement for the health and care settlement I think is absolutely fundamental.”

When asked what he would say to Theresa May’s team, Mr Lamb replied: “Engage. Talk to us now.

“There is an urgency about this. If you keep sleepwalking towards the edge of the precipice, real people up and down our country will suffer.”

Baroness Cavendish, who held the talks in Number 10 said: “I was very attracted to the idea that we might be able to get cross-party air cover for a solution….. we all know that the 1948 NHS created a system that is now not fit for purpose because it doesn’t address the new challenges.”

She said she did not think the “impasse” could be solved without a process that involves all political parties.

Some ministers are known to be encouraging Theresa May’s government to consider the idea of a commission. One of its supporters in government told me “there is a recognition that as a civilised society we need to spend more”.

But another minister said there also had to be a conversation about how much families had to contribute and that maybe “people’s expectations” had to be modified.

Changes in our society make this one of the hardest questions ministers need to answer. There have certainly been plenty of attempts before.

But the reality of what many councils – and more importantly, thousands of families – are now experiencing in their lives, makes it day by day harder to ignore.

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Simon Johnson reports in the Telegraph (Scotland) 12th December 2016: Scottish breast cancer patients denied drug approved for English NHS 

Julie Anne Barnes reports from Scotland: Breast cancer test which could spare patients chemotherapy available on NHS … except in parts of Scotland – The genetic test, which is not available in three NHS Scotland areas, gives sufferers the option of avoiding chemo when it’s not needed.

Helen Puttick in the Times 15th December reports: Patients still suffer from NHS drugs rationing whilst “Shona Robison, the health secretary, announced fresh reforms which she said would give people better access to the latest drugs”, to try to mitigate the situation.

BBC news reports 17th December 2016: Breast cancer drug Perjeta refused for use in Scotland

The Economist opines: Taxes will rise to fund care for Britain’s elderly: A “sticking plaster” solution for a system that “needs a quadruple bypass”

 

Growing old without dignity – The middle classes and the ‘left behind’ will unite in anger if the government can’t devise a way to pay for social care

Rachel Sylvester in The Times 16th December 2016 reports: It’s time to face up to the cost of growing old – The middle classes and the ‘left behind’ will unite in anger if the government can’t devise a way to pay for social care – The reality of growing old, living and dying alone, and without dignity is something we all have to face up to…

I grow old… I grow old…

I shall wear the bottoms of my trousers rolled.

Shall I part my hair behind? Do I dare to eat a peach?”

Like TS Eliot’s J Alfred Prufrock, we hate the idea of ageing. We want to imagine ourselves for ever young rather than admitting that we could one day become frail and fragile, incontinent and incoherent, losing our mobility or our mind. In the era of individuality we can’t bear to think that we might end up completely dependent on others. We fetishise youth and vigour, ignoring the elderly.

Old age is too close to death, the last taboo. Politicians kiss babies rather than hugging dementia patients on the campaign trail. They promise to save the NHS, which cures people, rather than pledging to salvage social care, which manages declining health. On television, older people are crotchety Victor Meldrews or imperious Lady Granthams. There is a level of cruelty and neglect in residential care homes that would never be tolerated in schools or hospitals.

Andrea Sutcliffe, the chief inspector of social care, believes it is ageism that makes us turn a blind eye to the elderly — but the truth is that we are looking away because we don’t want to catch a glimpse of our older selves. We lock the ageing process away in a corner of our brains that has no connection with the present. We are in denial about the future — which means we are failing to prepare for the looming cost of care, as individuals or as a society.

The ageing population will have a much greater impact on the country than immigration. In 20 years’ time, a quarter of the UK population will be over 65. The number of people over 85 is set to more than double by 2039. Yet nobody has unveiled a “Breaking Point” poster to highlight the political importance of this demographic time bomb. In fact the Conservatives cynically exploited cross-party attempts to find a funding solution before the 2010 election by running a campaign against Labour’s “death tax”. One of the first decisions the Tories made after winning an overall majority was to shelve their manifesto pledge to implement the Dilnot Commission recommendation for a cap on care costs that would have given families much-needed reassurance.

Social care reform doesn’t seem like a vote-winner, but it should be. The potential financial implications of our lengthening lives are terrifying. One in ten of us will have care costs of more than £100,000, but half will end up spending less than £20,000. People who would never dream of sending their children to private school because they think they could not afford it can end up spending more than the fees for Eton in a nursing home. Others, however, will pay absolutely nothing. It’s completely unpredictable which way it will go.

There is a condition lottery in place that is even more pernicious than a postcode lottery: if you get cancer, you will be treated for free on the NHS, but if you have Alzheimer’s you have to fund everything yourself. It’s deeply unfair but it’s also disempowering. This is a life-changing risk that is impossible to manage and against which you cannot take out any insurance.

It’s not only the wealthy who are affected. Anyone with savings or assets worth more than £23,500 has to pay for their own care. That’s the price of a family car or 20 pairs of Theresa May’s favourite leather trousers. There are many of the prime minister’s favoured “just about managing” families who will have squirrelled that much away in a savings account for their children over the years.

These self-funders also find themselves subsidising care home places for state-funded residents because councils are not paying the true cost of care. In a nation that is already deeply divided on social and geographical grounds, that is only going to create more resentment among those struggling to make ends meet. Meanwhile, some of the most deprived parts of the country are becoming care blackspots as providers either go bust or hand back local authority contracts because they cannot make them pay. There could be mass care home closures as the market fails and it will be northern towns and cities as well as rural areas in the southwest that will be hardest hit. Those too poor to pay for their own care are increasingly being asked to pay “top-up” fees they cannot afford. There is little social justice in that. Elderly care is an issue that unites “left behind” voters and leafy suburbia in anxiety that will soon build to anger.

This is not just about cash, it is also about control. The Brexit vote revealed the growing frustration that many people feel about being unable to shape their own lives but there are few issues over which we have less power than the cost of getting old. In her speech to the Tory conference, Theresa May argued: “The state exists to provide what individual people, communities and markets cannot. We should employ the power of government for the good of the people.” It’s hard to think of a conundrum that more perfectly fits her criteria than social care. Families cannot pay the rising costs. The risk is so variable that it needs to be pooled among as many people as possible. Yet the government has no solution to the problem.

The prime minister is planning to let local authorities increase the amount they raise in council tax to pay for social care but this is a short-term fix that risks deepening divisions, since wealthy areas will be able to get more funds than poorer areas, where the need is greatest. It does not remotely confront the scale of the long-term challenge.

The Treasury must find more money to plug the immediate gap in funding to pay for state provision and the government should also implement the recommendations of the Dilnot Commission as soon as possible. But even that will not be enough. It is rare to hear Tory MPs calling for tax rises but a growing number are now doing so to deal with the social care crisis. They are correct in thinking that it would be morally right, as well as practically important, to create a level playing field between the funding arrangements for the NHS and social care, even if that involves increasing national insurance to pay for improvements to elderly care.

It is time to open our eyes to the reality of an ageing population and start planning for reality. Otherwise we will end up nervously shuffling towards the future echoing Prufrock’s lament that “I have measured out my life with coffee spoons”.

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Gagging continues: NHS ‘fails to learn from fatal errors’

Chris Smyth reports in The Times Dec 13th 2016: NHS ‘fails to learn from fatal errors’

342_gaggingPatients are dying because of a “defensive wall” over fatal errors in the NHS, a watchdog has said.

Deadly mistakes are repeated because hospitals lack guidance on reviewing deaths and fail to follow the rules, according to “absolutely shocking” findings by the Care Quality Commission.

It found that families were being shut out of investigations that were too often poor quality and failed to uncover the truth. Six in ten of the investigations analysed left important questions unanswered and only one in 14 gave a proper answer to the bereaved families.

Inspectors carried out a nationwide investigation after the death of a teenager under the care of the Southern Health trust, which investigated less than 1 per cent of deaths of patients with mental health problems and learning disabilities.

The family of Connor Sparrowhawk, 18, refused to accept the trust’s assurances after he drowned in a bath having suffered an epileptic seizure at a learning disability unit in Oxford. An inquest found that care failures and neglect contributed to his death.

Professor Sir Mike Richards, chief inspector of hospitals, said: “Opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening . . . There is not a single NHS trust that is getting it completely right. An agreed framework needs to be established that sets out exactly what the NHS should do when someone dies and ensures that families are fully involved.”

Almost 300,000 people a year die in hospitals and care services, yet there is “confusion and inconsistency” about which deaths should trigger an investigation, the report found. A third of hospitals did not know how many patients died soon after leaving their care and staff lacked training in looking into deaths, inspectors found after surveying all hospitals, inspecting 12 and analysing dozens of investigation reports.

Family involvement was “tokenistic” with less than 10 per cent saying they were properly involved, inspectors found. Bereaved parents said that they were seen as a “pain in the neck” and had experienced “more courtesy at the supermarket checkout” than in the NHS.

Professor Dame Sue Bailey, chairwoman of the Academy of Medical Royal Colleges, said: “This landmark review reveals in stark detail what many in healthcare have suspected for a long time. Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care.”

Deborah Coles, director of the contentious death charity Inquest, who advised the commission on the report, said: “There is a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients.”

Peter Walsh, chief executive of the charity Action Against Medical Accidents, said the “absolutely shocking” report “goes further than any other in exposing the dire quality and inconsistency of many NHS investigations”.

He said that the commission had to take some responsibility, however. “There is a responsibility on the CQC itself and NHS England to be more robust in insisting [that hospitals] conduct investigations,” he said.

Geery Peev reports in The Mailonline 7th December 2016: Cancer patients waiting longer than 2 months has doubled in 5 years.

A A Gill exposes the covert rationing he was unaware of – until he became ill..

NHSreality is content that Nivolumab (Bristol-Myers Squibb) is not yet approved for the UK Health Services by NICE. NHSreality is not happy that it is covertly rationed, and that some people will be covered for it either by their wealth, or by Private Medical Insurance. The Drug Data sheet is complicated but clear. Survival at 12 months is improved, and the relative chance of being alive compared with no treatment at 12 months is 3 fold. However the absolute chance of survival is low… and it looks very much as if it merely delays the inevitable, and with a low quality of life.

 

Despite the cost of over £100,000 per annum it has been approved for some conditions. Giles Sheldrick and Olivia Lerche report in The Express 7th December 2016: Blood cancer breakthrough: New immunotherapy treatment nivolumab approved for use (In lymphoma). This is good news. However, if we are going to ration health at the expensive (fearful because none of us can afford it) pole, we need to do it overtly rather than covertly. My personal preference would be the ration high volume low cost treatments, and be able to afford the new technologies, but still feel that there is “Too much chemotherapy”…. This is an area where the greatest savings and improvement in quality of life could be made.

A A Gill rightly exposes the covert rationing he was unaware of – until he became ill.. But proper end of life care would be better value..

BBC News 10th December – AA Gill: Sunday Times critic dies after cancer diagnosis and AA Gill: Final article describes cancer fight: The Full English

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BBC News 20th November 2016: Writer AA Gill diagnosed with ‘the full English’ of cancer

Lucy Bannerman in The Times December 12th reports: AA Gill was denied £100,000 ‘weapon of choice’ cancer therapy

Dead people don’t vote… End-of-life care ‘deeply concerning’

“Too much chemotherapy”…. This is an area where the greatest savings and improvement in quality of life could be made.

Child cancer results improving. In a “cradle to grave” Health Service we are not doing badly at cradles.. but we are doing badly as patients approach their grave.

The NHS and reckless election promises. How about posthumous voting?