Monthly Archives: January 2017

For “prioritizing” read “rationing”. Billions needed to rescue unsafe NHS, doctors warn. The safety net is holed…

It is going to get worse and worse. The failure to care for the elderly and to fund the UK Health Services responsibly is evident. For prioritization read rationing: The safety net is holed… Those who fall through wont be voting on the future of their health service..


Chris Smyth reports in The Times 31st Jan 2017: Billions needed to rescue unsafe NHS, doctors warn

Thousands of senior doctors have told the prime minister that the NHS is unsafe and failing patients.

Doctors are “handcuffed and paralysed” by the limits of a health service that does not have enough money to do what patients ask of it, they said in a letter to Theresa May.

“We have reached unacceptable levels of safety concerns for our patients within the NHS and simply cannot continue,” more than 2,000 consultants and GPs said in the letter, published in The BMJ.

They urged Mrs May to pump billions more into the service to bring spending up to the levels in France and Germany. The intervention has focused attention again on the deepening rift between Downing Street and the NHS following a public spat on spending with the head of the health service this month. Simon Stevens, chief executive of NHS England, told MPs that Britain spent 30 per cent less per person on health than Germany and accused Mrs May of stretching the truth by saying that she had given the NHS more money than it needed.

A government spokesman said: “We have invested £10 billion in the NHS’s own plan to transform services and improve standards of care and recently announced almost £900 million of extra funding for adult social care over the next two years.”

More patients forced on to mixed wards

Heart failure patients face same death rate as 1998 (Heart failure is very difficult to treat effectively to secure better long term outcomes)

‘Loneliness’ commission launched in memory of Jo Cox

NHS patients are demeaned by mixed sex wards – Jane Merrick Opines

Cashstrapped councils leave families to care for the elderly – Chris Smyth

Families will have to step in as more older patients are denied help with washing and dressing, councils have warned. A cash crisis will leave local authorities unable to meet their legal duties to older people under reforms introduced three years ago, they said.

Ministers need to admit that older people will be given only limited help as there is no more money available, according to the Local Government Association (LGA). It fears legal challenges from people who say councils are not meeting an obligation to ensure their dignity and wellbeing.

Cuts to council budgets have meant hundreds of thousands of older people lacking help with everyday tasks and NHS leaders have complained that hospitals are filling up with elderly patients who have been allowed to fall ill and cannot go home safely.

Izzi Seccombe, of the LGA, said that pledges to the elderly were “in grave danger of falling apart and failing, unless new funding is announced by government for adult social care”.

She said councils would increasingly have to prioritise the least mobile people who could not cope without carers at the expense of those whose lives are improved by extra help…..

TRAIN WreckProtest while you can – Dead patients don’t vote. Rationing in action…  (Feb 2015 – 2 years ago!)

Is it irony? NHS birthplace hospital ‘should be knocked down’

In a possibly unintentional play on words, the BBC report could be seen as a parody of the ideology of the UK Health Services which has not been revisited since Aneurin Bevan’s time.

cropped-05-04-11-steve-bell-on-th-0041.jpgChris Wood for BBC News reports 28th Jan 2017: NHS birthplace hospital ‘should be knocked down’

A building key to the formation of the NHS is a dangerous eyesore and should be knocked down if no use can be found for it, some residents have said.

Tredegar General Hospital shut in 2010 and the health board that owns it is trying to find “the best way forward”.

Blaenau Gwent AM Alun Davies called it a key part of local history and said it must be saved.

Aneurin Bevan was its management committee’s chairman in 1928 – 20 years before founding the NHS…..

…The hospital opened in 1904, with construction paid for by wages of local iron and coal workers.

Its creation was the vision of what became the medical aid society – which was considered far in advance of any similar initiative as it gave sick pay, medical benefits and funeral expenses to its 3,000 members.

Between 1915 and 1933, Walter Conway – considered a mentor to Bevan – was its secretary.

By the time he finished, it was supplying the medical needs of 95% of the local population, employing five doctors, two dentists, pharmacy dispensers and a nurse.

In a nod to how it inspired him, when he set up the NHS, Bevan said: “All I am doing is extending to the entire population of Britain the benefits we have had in Tredegar for a generation or more.

“We are going to Tredegarise you.”

Fifth of new medicines to be rationed – NHS cost-cutting raises fears for patient safety

There are some services which are much better than drugs and medications. NHSreality has always advocated more psychologists, and if we have to choose between drugs and people treatments we should opt for the latter, except in overt psychoses. It is reasonable rationing, but it is covert, and it will increase the health divide if the rich buy private provision. NHSreality feels it would be better, fairer, and more honest, to ration the high volume cheaper drugs than the low volume high cost ones.

Chris Smyth in The Times reports 19th Jan 2017: Fifth of new medicines to be rationed – NHS cost-cutting raises fears for patient safety

A fifth of new drugs will be rationed under tighter NHS cost-cutting plans, meaning that patients will suffer longer delays for medication.

Sufferers of cancer, diabetes and asthma could have to queue for treatment as health chiefs are handed powers to restrict access to medicines to save money, even if they have been ruled cost-effective by doctors.

Drug companies say that they will no longer launch drugs early in Britain if bureaucrats are given power to stop them from reaching patients for purely financial reasons. Campaigners warned that the plans would put Britain further behind the rest of Europe in offering cutting-edge therapies and more people would die while waiting for medicines.

At present patients have a legal right to be treated with drugs that have been ruled good value for money by the National Institute for Health and Care Excellence (Nice). Medicines that cost less than £30,000 for a year of good quality life are usually approved.

In the autumn The Times revealed plans to impose an extra affordability test on all medicines in an attempt to control NHS budgets that are under exceptional pressure. From April this year, even if Nice approves drugs, NHS England will be able to delay making them available or restrict who is eligible for treatment if the total cost to the health service is more than £20 million a year.

Analysis by Nice and the pharmaceutical industry shows that 20 per cent of newly approved drugs — expected to number about 12 a year — will fall into that category.

In recent years, for example, a cholesterol drug given to 160,000 people at risk of heart disease and a “breakthrough” prostate cancer treatment could have faced delays or restrictions. No drug to treat rarer diseases such as Duchenne muscular dystrophy would have been approved under the plans, the industry believes.

Phillip Anderson, of Prostate Cancer UK, demanded the scrapping of “catastrophic” changes that he said would mean patients dying while they waited for treatment to be made available. “A budget impact threshold has the potential to throw the brakes on the most effective new treatments and technologies just before they get to patients,” he said.

“It is unacceptable to put in place an open-ended ‘blank cheque’ for NHS England to request a very lengthy delay.”

Baroness Morgan of Drefelin, chief executive of Breast Cancer Now, said that the move would be devastating to cancer patients who were relying on new drugs to stay alive. “We are hugely concerned that the £20 million budget impact threshold would be a massive setback for access to new cancer drugs in England,” she said.

“With one in five new drugs set to be delayed by the proposed cap, we fear this country really could be left behind in access to the newest and best treatments.”

Patients can arrange to pay privately for drugs not available on the NHS but they must also meet staff costs and are told to go elsewhere to be treated.

NHS England says that the fifth of drugs caught by the new measure cost about £400 million a year compared with £125 million for new drugs below the threshold. Despite an existing £11 billion cap on the total NHS drugs bill, it argues that limiting who can receive new drugs will avoid the need to cut other services to pay for them.

The dispute comes after a rift over money opened up last week between Theresa May and Simon Stevens, the chief executive of NHS England. He publicly accused the prime minister of “stretching” the truth about NHS funding and “pretending” that cash shortages were not affecting patients.

Richard Torbett, of the Association of the British Pharmaceutical Industry, said that many patients would face delays of up to four years in getting common medicines. “Almost anything that’s in primary care — diabetes medicines, respiratory medicines, if there is anything for Alzheimer’s disease — would have a large number of patients even if the price is very low and it would trigger this new process,” he said.

Last year the NHS imposed caps on how many patients could be given transformative new drugs that can cure Hepatitis C to keep the annual cost to £200 million.

Mr Torbett said the industry was willing to negotiate phased introduction of medicines that would cost more than £100 million a year, but questioned the motivation for setting a £20 million figure. “For those really exceptional cases like Hepatitis C, where there’s an obvious challenge, then fair enough. But when it comes to one in five new medicines it starts to be another barrier for patients,” he said.

The change was partly motivated by fears that if a breakthrough dementia drug emerged, it could cost the NHS billions of pounds. George McNamara, of the Alzheimer’s Society, attacked the plan as a “short-sighted attempt to patch up a system that’s haemorrhaging cash”. It risked “cutting away the future hopes of people with dementia when they are most in need”.

He added: “There are potentially life-changing dementia drugs in the pipeline but they are likely to come in over the proposed threshold and the thought that they could still be rationed irrespective of whether they are cost-effective is really disturbing.”

NHS England declined to comment.

Prostate cancer
Abiraterone, used by an estimated 2,000 men.
£43 million a year

Heart disease Ezetimibe, used by estimated 159,000 people.
£52 million a year

Diabetes Lucentis, treats vision loss caused by diabetes, used by 1,200.
£22 million a year

Skin cancer Pembrolizumab, thought to be used by just under 1,000 patients.
£48 million a year

Source: ABPI

Mental health now area of most public concern within NHS

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

We all know it’s going to get worse pending honest politicians willing to debate ideology with Mr Stevens and the Media. Meanwhile suggestions for better systems are being discussed in closet situations.. This suggestion is most welcome, and particularly in Wales where choice has disappeared, or Northern Ireland where abortion is so hard to access. The NHS crisis is spiralling out of control.. (Chris Ham in The Times 12 months ago) and The NHS desperately needs cash or it won’t survive, says former GP and Tory Health Minister Dan Poulter (The Sun 2w ago).

In The Times letters 30th Jan 2017: NHS EFFICIENCY

Sir, With the NHS under intolerable pressure, and many independent commentators ranking our system well below many others, we should examine what makes other systems fairer with better outcomes.

Many European countries have systems that are funded through hypothecated mandatory health insurance, but people ask, how does this differ from our own national insurance? The answer is that health insurance allows the insured to choose a provider, and the system reimburses that provider. With 70 per cent of healthcare costs being attributable to staff, reducing costs depends on using staff more efficiently.

In the UK, we have created the world’s biggest monopoly employer to provide 95 per cent of healthcare, and we feed that monopoly by largely barring all others providers regardless of their efficiency. As a consequence, the German healthcare system, which allows plural provision, employs many fewer staff for 80 million people that the NHS employs for 60 million.

The future of our healthcare system depends upon better use of limited resources. Cutting the number of hip operations (report, Jan 27) may save on the metal hip, but if all the staff remain in the expensive PFI building, little will be achieved.

Adam P Fitzpatrick Consultant cardiologist and electrophysiologist, Mottram-St-Andrew, Cheshire

An epidemic of nationwide bullying. In most dictatorships this precedes dissolution or breakdown….

Political collusion to neglect…? If the Regional Health services were companies they would be bust and run by the reciever

The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

This mismanagement of the NHS amounts to neglect

It’s nonsense. A £22Bn “black hole”! Management by incompetence.. Even a ghost could do it better.

Denial extends to the generic management solution – “Troubleshooters will be sent into struggling NHS regions”

Health services pay structures. Inequity and long-term mis management. Strikes and comparisons with politicians…

“Appalling care” in Gloucestershire hospitals due to mismanagement, warns whistleblower

Candour and Transparency? – what a farce

The NHS is being torn from those who have cherished it for decades

General Practice is “a house of cards….”

Changing the rules of the game

Trying to defuse some of the invective against NHS managers.



Doctors are open to change – given time to think about implications

It is not just doctors who need time, but also politicians and patients and media. Unfortunately they do not have the time… It’s going to get worse..

The Sheffield Telegraph Reports: Doctors are open to change – given time to think about implications

Ninety per cent of NHS patient contacts are said to occur in primary care. GPs manage the tasks of being physician/healer, friend/advocate, resource-finder, and gatekeeper. That is why we value them although we know that different GPs will prefer some roles to others. But in 10 years time the GP and primary care systems may look very different. How will this be decided?
Many politicians, both national and local, seem unaware of how deeply the NHS crisis affects general practice. Indeed some consider that since Labour’s 2004 GP contract upped GPs’ pay and conditions and exempted them from routine out-of-hours duty, GPs have been sitting pretty, with many able to afford to go part time. That contract helped to improve GP recruitment, especially among women doctors, but it also contributed to the increasing difficulty of seeing the GP of one’s choice and led to a steady decline in public satisfaction in the NHS GP patient survey (though satisfaction remains high). However Downing Street’s suggestion that the crisis in NHS hospitals is down to GPs not offering a Sunday service smacks of ignorance and desperation. Recent trials (including in Sheffield) suggest lowish demand for Saturday afternoon surgeries and even less for Sundays. The truth is that we’ve actually been going to see our GPs much more often in the last 15 years and recent research suggests a 15 per cent increase in consultations between 2010/11 and 2014/15. GP numbers grew by only 4.75 per cent (much less than hospital doctors) and practice nurses by 2.85 per cent. Funding for primary care as a share of the NHS overall budget fell from 10.6 per cent in 2005/6 to 7.2 per cent this year but the costs of maintaining a practice and keeping to regulations have risen. Last year some practices, including those working in the most deprived areas, had their income reduced. The small increase offered by Hunt by 2020 will barely make up for this. Pressure on GPs and their staff is also fuelled by generally higher expectations, by having to keep up to date with new developments and technologies, by the erosion of other sources of patient support, particularly through cuts to local authority services and the benefit system, plus the administrative failures of Capita’s newly privatised support services. Overall GP job satisfaction is at its lowest since 2001. GPs are leaving the service or retiring. Few current GP trainees contemplate working full time. Practice staff are becoming harder to recruit. In Sheffield 30 per cent of practice nurses and other support staff are over 55 and the ratio per patient is the lowest in South Yorkshire. Good patient care is further complicated by difficulties in liaising with other services, including hospitals and social care. Last year’s Challenge Fund initiatives in Sheffield found that lack of liaison caused significant problems for both GPs and patients and a promising improvement scheme was abandoned because the private sector social care partner could not adjust its structure to meet the flexibility required. Most GPs in Sheffield are said to be genuinely enthusiastic for changing working practices to provide a better NHS service – provided they can find the time to think about it! Sheffield’s developing primary care strategy seeks radically to change the way we seek help for health problems, relying on our willingness to see other health care professionals rather than going first to the GP. It casts GPs both as medical generalists and clinical leaders for neighbourhoods. By getting services to work together, it hopes to help tackle demand for health care and significantly to reduce hospital admissions. We’ve heard such overly hopeful NHS-speak before, going back at least to 1996. Changes like this will only happen after an open and public renegotiation of the balance of the key elements of NHS care (including some transfer of funding from hospitals). No politician or party has yet felt confident about taking this on, not least because both efficacy and public acceptability have yet to be tested. Moreover, at the moment there just isn’t the right level or mix of staff. Some important local proposals depend on gaining transformation funding from NHS England. But much will depend on exactly how primary care is organised in the future. But more radical moves may be under way. The local Sustainability and Transformation Plan (STP) talks of running most local health care under an Accountable Care Organisation. This proposal is problematic in itself, but the ACO, probably hospital-centred, could easily decide to subcontract neighbourhood care not to GPs directly but to organisations which employ GPs – just like the contracts Virgin Care has elsewhere. So most if not all GPs would become salaried employees and indeed nationally 27 per cent already are. This would be a very different type of service. General practice matters to us all; its future needs discussion. The CCG and Sheffield Healthwatch need to take this on, as well as political parties. We need to join in too, as well as keeping up pressure on the Government to protect the NHS as a whole. Try joining your surgery’s patient participation group – and check it’s linked with the new CCG-sponsored network of similar groups.

SSONHS will also be supporting the national march for the NHS organised by Health Campaigns Together in London on March 4. Visit Our NHS and Sheffield Save Our NHS for details.

Image result for just in time cartoonImage result for just in time cartoon

Dont say we didn’t warn you… Nursing levels are going to get worse….

Chris Smyth reports in The Times 27th Jan 2017: Staff crisis grows as foreign nurses abandon the NHSDon’t say we didn’t warn you… Nursing levels have led to a locum bonanza, and are going to get worse…. We are undercapacity – whether it’s for your lawn or an operation…

European nurses are giving up on the NHS, with the number arriving to work in Britain down more than 90 per cent since the Brexit vote.

A total of 101 EU nurses registered last month, down from 1,304 in July, according to figures from the Nursing and Midwifery Council (NMC).

More European nurses are also leaving, prompting fears that Britain may be seeing the start of an exodus of the staff who have kept hospitals running in recent years.

Hospitals are already struggling to find enough qualified nurses, with tens of thousands of vacancies and many wards dangerously understaffed.

Hospitals turned to the EU after a damning report into the Mid Staffordshire scandal four years ago warned against cutting staff to save money. Recruiting missions were dispatched to Spain, Greece and other countries to increase the numbers of their citizens working in the NHS.

There are now 38,661 EU and European Economic Area (EEA) nurses registered to work in Britain, up from 16,798 in 2013.

However, since the referendum last June and with the introduction of tougher language tests last year, there has been a dramatic fall in new arrivals. In 2015-16 9,388 EU nurses came to work in Britain but the number arriving has fallen every month since July.

Janet Davies, chief executive of the Royal College of Nursing, said: “If this is the beginning of a long-term drop in the number of nurses coming to the UK from other parts of the EU, that’s a serious concern at a time when we’re already facing a crisis in nurse staffing numbers. With 24,000 nursing vacancies across the UK, the NHS simply could not cope without the contribution from EU nurses.

“We need a guarantee that EU nationals working in the NHS can remain. Without that, it will be much harder to retain and recruit staff from the EU, and patient care will suffer as a result.”

In December 318 EU staff left the nursing register, up from 177 last June, meaning 331 fewer working in Britain than in September.

Jackie Smith, chief executive of the NMC, said: “This is the first sign of a change following the EU referendum and it is our responsibility as the regulator to share these figures with the public.”

English language tests were toughened last year for newly arriving nurses. Only 453 application packs were requested last month compared with 3,697 in January 2016, the month before test requirements were raised.

Paul Myatt, of the hospitals’ group NHS Providers, said: “This is an early warning sign and needs to be monitored closely. There is already a high nursing vacancy rate in many parts of the country so if this drop-off continues over the next few months it would definitely be concerning.

“Members are saying to us that Brexit has created uncertainly for staff who are already here at the same time as trusts are finding that the EEA pool of nurses is increasingly depleted.”

Jeremy Hunt, the health secretary, told MPs earlier this week that it was a priority to guarantee the right of European NHS staff to work in Britain “forever”, but Theresa May has refused to offer assurances pending a deal on the status of Britons living in Europe.

Earlier this month official figures revealed that almost every NHS hospital has too few nurses on the wards, with warnings that patients were going unwashed, unfed and untreated because of a lack of staff. Analysis found that 96 per cent of 214 hospitals failed to meet their planned level of nurses during October day shifts, up from 85 per cent two years ago.

Efforts to replace them with home-grown nurses were dealt a blow last month when universities said applications for nursing degrees fell 20 per cent last year. Ministers scrapped bursaries and required nursing students to take out loans for their courses, arguing that this would lead to 10,000 more places.

Recruiting foreign nurses ‘frustrating and expensive’: British Nurses should cash in on the bonanza

How to cause disenchantment with those who are badly needed – Brexit will make things even worse for staffing levels..

Health services failure will make Brexit look cheap….

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


There is no rationing.. ? !!

The Telegraph 267th Jan 2017:

The Telegraph September 2016:
The Telegraph 9th Aug 2016:
The Express 12 days ago:
The Daily Mail:
The Standard 6 days ago:
The Times today:

Patients will be refused hip and knee replacements unless they are in so much pain that they cannot sleep or go about their daily lives, under the latest NHS rationing plans.

Health chiefs in the West Midlands are using a scoring system designed to assess patients’ illness to reduce hip operations by 12 per cent and knee replacements by 19 per cent. The move is intended to save £2.1 million a year.

Very obese patients would be refused surgery unless they could show that they had lost 10 per cent of their body weight or were in danger of losing their independence, the Health Service Journal revealed.

The Royal College of Surgeons (RCS) said yesterday that the “alarming” cost-cutting plans would inflict needless suffering on patients. It said that thousands of people were falling victim to arbitrary denial of treatment.

About 160,000 hip and knee replacements a year are carried out by the NHS in England and Wales and the figure is rising by about 8 per cent annually as the population ages. The prostheses replace joints worn by age or damaged by conditions such as arthritis.

Most patients are elderly but the number of replacements provided in people aged under 60 has increased by 76 per cent to 18,000 during the past decade. Better surgical results and more durable implants mean that joints can be replaced in younger people without the need for operations to be redone after 15 years. Doctors also say that younger patients are less willing to wait for surgery than in the past.

Stephen Cannon, vice-president of the RCS, said that the decision to restrict access to NHS care, based on arbitrary pain and disability thresholds, was alarming.

“It is another example of how the huge financial strains the NHS is under are directly affecting patients. It is right to look at alternatives to surgery but this decision should be based on surgical assessment, not financial pressures.”

He added that the savings estimate “overlooks the longer-term impact on patients of delayed treatment, prolonged pain and potentially higher costs of treatment. For example, patients affected by these changes may require additional pain relief medication and may still require surgery further down the line.”

Redditch and Bromsgrove, South Worcestershire, and Wyre Forest, the three local health groups implementing the plans, hope to avoid 350 operations a year. Paul Green, from Saga, said: “To suggest that it is acceptable for people to have to wait until they are unable to sleep before they are eligible for an operation is an outrage. How would these people feel if that was their mother or father or grandparent?”

Three years ago the RCS found that 44 per cent of local clinical commissioning groups required patients to be in various degrees of pain before surgery, against advice from the National Institute for Health and Care Excellence.

NHS Redditch and Bromsgrove Clinical Commissioning Group said: “The Oxford scoring system is a guidance for clinicians and they recognise that many patients will benefit from physiotherapy and weight loss before considering surgery. If a patient feels that they require this surgery but do not meet these criteria, there is a clear appeals system via individual funding requests.”

It would be more equitable to ration out certain cheap drugs and services… than for GPs to offer private weekend work

From my understanding of the current GP contract partners would be breaking their contract terms to see patients in their own partnership as individuals. However, if they form a company and the company sees the patient, the work being contracted out to the GP principals, I am unsure of the state of the contract. It may have to be tested in law. This is the thin edge of a wedge that leads to a two tier service… and evenings during the week may end up similarly private. Overt rationing would be preferable.. Interesting “imbalance of supply and demand” in a profession whose training numbers have been almost entirely controlled / rationed by governments..

Kat Lay reports in The Times 26th Jan 2017: Growing band of GPs back patient fees

GPs are preparing for a showdown with Whitehall over charging patients for appointments as more family doctors broke ranks yesterday to back the idea.

Doctors warned they would not back down after condemnation from MPs, insisting that they face a choice between charging patients and shutting surgeries.

GPs have also privately lobbied ministers over plans to sidestep NHS rules and charge for seeing patients at evening and weekends. While health chiefs insisted that the idea was not valid, it is not clear how GPs could be prevented from going ahead.

Doctors have said that they cannot provide the seven-day services…..

The Times leader:  If the NHS is the nearest thing Britain has to a national religion, some devotees are starting to lose their faith. This year’s winter crisis in hospitals is among the worst in memory. With shrinking resources, general practice is struggling to pick up the slack. We reported yesterday that some GPs have responded with proposals to charge patients for out-of-hours appointments. The idea will be controversial, but it is worth considering.

The proposals do not involve charges for consultations that take place in normal GP opening hours. Instead, patients would pay a fee if they wanted to see their own doctor in the evening or at weekends. They could also have to pay for discretionary procedures such as vasectomies.

The effect would be three-fold. First, this is simply a way of offering more appointments. Second, it would raise cash. With the number of GPs falling, that would help to pay for new doctors. Third, it would manage demand. Patients who worked during normal office hours and with non-urgent complaints would be more inclined to pay for an evening slot, freeing up emergency services and daytime appointments for more pressing cases.

This model would bring Britain into line with most other developed nations. Even western countries considered paragons of social democracy share some of the cost of care with patients. In France and Japan, patients contribute about 30 per cent of the cost of appointments. In Germany, the contribution is capped at 2 per cent of the patient’s income. In Sweden, a visit to the GP costs about £30.

It is not heretical, therefore, to float the idea for the NHS. It is already clear that the right to care “free at the point of delivery” cannot be absolute. Most people pay for their prescriptions, and 1.2 per cent of NHS funding already comes from patient charges. The King’s Fund, a think tank, estimates that the percentage of health service funding raised by national insurance and general taxation is at an all-time high.

The truth is that pouring yet more public money into the NHS is not sustainable. We know that demand will keep growing, partly as a result of an ageing population and partly because expensive new treatments and drugs are constantly becoming available. The state can pick up the tab only by borrowing more or raising taxes. Either option would be bad economics or worse politics.

There are some helpful improvements available at the margins. NHS England plans to train up 1,000 pharmacists to do some of GPs’ simpler jobs, such as blood-pressure checks and medicine reviews. That will relieve pressure if patients are willing to accept a pharmacist’s view. Another proposal under consideration is to fine people who do not turn up for appointments. According to some estimates, there are 14 million missed GP appointments every year. Penalties would help to unclog the system and raise some money.

These are interesting ideas but they will not address the long-term imbalance between supply and demand. Patient charges could. Any new arrangement would have to prevent GPs from using the extra money to supplement their already adequate salaries. Safeguards would also be needed to ensure that a sick person is always seen, regardless of their bank balance. Treating the sick should remain the NHS’s first priority. Unless new sources of revenue are found, however, it will get more strained every year until it finally snaps.


Sir, One cannot blame GPs for considering levying patient charges for out-of-hours cover in the face of wholly inadequate funding (“GPs draw up plans for patient charging”, Jan 25). However, the lessons from NHS dental charges must be learnt. Charges discourage patients who need care — indeed, that is precisely why the government introduced them in the early days of the NHS.

Today dental charges are increasingly putting more pressure on an already overstretched health system, as hundreds of thousands of our patients head to A&E — and to GPs themselves — for free treatment that our medical colleagues were never trained to provide. Anyone who thinks that GP charges could serve as a “top-up” for derisory direct funding can also expect disappointment. As dentists know from experience, ministers will just keep asking patients to put in more so that the government can pay less.

Henrik Overgaard-Nielsen

Chairman of General Dental Practice, British Dental Association

Sir, Am I the only retired GP who remembers providing a 24-hour service to patients, performing minor surgery, carrying out home visits, looking after patients in community hospitals, running minor injuries sessions and a host of other services that were convenient to patients and not all directly remunerated? Luckily, there are still some practices which do provide excellent care for their flock, and I am fortunate enough to be cared for by one. Many, I fear, are cared for by clock-watchers, who have forgotten that they are following a vocation, not just a job. Despite a handsome salary, their limited remit forces local A&E departments to attempt to fill in the gaps, which is both inappropriate and a waste of precious resources.

Dr John Drewer Newton Ferrers, Devon

Sir, GPs charging patients for weekend care stems entirely from Jeremy Hunt’s determination to ram through a seven-day-a-week NHS without putting in the money to pay for it. The government should listen to cross-party voices calling for an NHS and Care Convention with the aim of delivering a sustainable, long term settlement for the NHS and care.

Norman Lamb MP Lib Dem health spokesman, and health minister 2012-15

Sir, Dr Prit Buttar, the Oxfordshire GP leading the initiative to offer enhanced access to certain GP services for payments, says that GPs may decide that their time at weekends and in the evening is more valuable, and that therefore charges are justified. However, might the fact that Dr Buttar has retired at 56 offer us some clues to the pressure on GP resources? In most industries and professions, retirement at 56 is impossible. Are the conditions of GP pensions unsustainably generous, and does this in part explain the shortage of GPs?

Lesley Viner Frampton Mansell, Glos

Sir, Perhaps the time has come for us to reassess our spending priorities. A visit to a beauty parlour, football matches and foreign holidays are affordable to many in all income groups. The NHS budget will always to be overstretched, so maybe those who can pay should pay a contribution towards a consultation, in the same way as one does for NHS dental care, however politically uncomfortable this may be.

Pennie Holt Thornton Cleveleys, Lancs

Sir, The huge reduction in the use of single-use plastic bags since the introduction of the 5p charge shows how behaviour can be changed by the introduction of small fees. One wonders what the impact would be of a £1 charge to see a GP and £5 to go to A&E.

Richard Tweed Croydon

A fearful anonymous consultant tells it as it is… “the NHS is in crisis”.

Metro newspaper (freebie) reports 23rd Jan 2017: As a doctor working in a major trauma centre, I can definitely say the NHS is in crisis

A fearful anonymous consultant tells it as it is… Is this whistleblowing? Would he be punished if his name was known? Of course it would… Please note the comment on the perverse incentives. It is the rules of the game as defined by the politicians which have been destroying the large mutual that we used to know as the NHS – and which is now becoming the No Hope Service. When doctors seeing patients are not experienced enough many rarer diagnoses are missed until too late or until treatment is expensive… We need more experience at the front line and this means, for the next decade, GPs retraining in A&E and out of hours care, and the abandonment of “QOF”, the system of performance related pay for GPs. As in most crises, the rich will do relatively better.

There is a lot of talk currently about the NHS being in a state of crisis.

I’m not an expert on healthcare policy but I do, however, have 21 years experience of working across emergency departments – the last 12 of them as a consultant in a major trauma centre.

With emergency departments so close to breaking point I can confidently say that the NHS is most definitely in crisis.

It has been a relatively mild winter with no flu epidemic (yet) but the figures paint a different picture.

The NHS has a target to see 95% of emergency patients within four hours, but that figure was 78.5% on average last week.

How does the government choose to respond? By denying that there is a crisis and instead redefining who the four-hour target applies to.

Jeremy Hunt has said that the four-hour target should only apply to ‘urgent health problems’, as opposed to everyone who comes into an A&E.

The figures are one thing but what is happening on the ground is even more disturbing.

Emergency departments are overcrowded with care being delivered in corridors because there are no cubicles, and patients are waiting unacceptable lengths on trolleys as there are no beds available within hospitals.

I can assure you that this is not because of any lack of effort or commitment from nurses and doctors on the front line who are working tirelessly around the clock.

Indeed, the situation is incredibly frustrating as we are left to face the day-to-day reality of inadequate funding and resources.

We are happy go the extra mile – it comes with the territory.

When this happens every shift for months on end, however, and your workload is double what your department is equipped for, it becomes unsustainable.

Staff become ill, stressed and eventually burn out.

Despite an enthusiastic start, many junior doctors have left frontline specialties such as emergency medicine as, despite offering one of the most rewarding and interesting careers, the constant battle to deliver high quality care with inadequate resources is taking its toll.

Stabilising emergencies by leading the care of the critically ill and injured in those initial vital hours is a core role of an emergency department doctor.

I suspect that few enter the job thinking that they will spend their time searching for trolleys when there are none left, shuffling patients into any space that they can find to examine them and having to repeatedly apologise for the long wait and lack of beds.

Doctors and nurses working in an emergency department want to deliver high quality emergency care in a timely fashion and to maintain dignity for their patients.

Overcrowded emergency departments make this impossible to achieve.

Even worse than that, there is evidence that overcrowding leads to avoidable deaths.

The reason that overcrowding has become such a problem is not, as the politicians might have you believe, because too many people are attending A&E unnecessarily.

Yes there are a small proportion of patients whose needs may be better served via another route but simply telling people not to go to A&E unless they have a ‘true emergency’ does not work.

The fact is that departments are overcrowded with patients waiting to be admitted to wards, patients who are deemed too unwell to be discharged home.

This is unsurprising given that our hospitals are being run at excessively high occupancy rates, which reached 95% in the first weeks of 2017.

The chronic underfunding across all facets of health care – and social care in particular – has led to a situation whereby there is nowhere to send these patients to once they have recovered from their illness or injury.

Underfunding coupled with a perverse system of financial incentives for trusts means that there are not enough beds available for emergency admissions.

This so called ‘exit block’ is what paralyses emergency departments, and in recent years the winter crisis has lengthened to cover much of the year.

Healthcare workers are driven to the point of exasperation being told ‘you need to be more efficient’.

We continually strive for more efficient ways of working and we do make marginal gains in some areas.

But any efficiency gains become insignificant when our departments are gridlocked with dozens of patients waiting for beds.

In addition, cost savings that we make are dwarfed by the hundreds of millions that the NHS spends paying locum staff to fill the gaps left by burnt out and disillusioned staff.

When demand and expectation increases year on year but resources and funding do not, what you get is a crisis.

I genuinely fear for what lies ahead. You know you’re in trouble when even the Chief Executive of NHS England, Simon Stevens, says that the government is not funding the NHS adequately.

Those of us that remain on the frontline will continue to do our best to maintain a safe, high quality emergency service but the real solution lies at the hands of the government, who must act now to address this sorry situation.

This blog was put together with the help of the British Medical Association, the voice of doctors and medical students in the UK.

In a nutshell – at risk of a No Hope Service

Kill the QOF (Quality Outcomes Framework) for GPs

Making rural hospitals sustainable – It is both quality hospital doctors and GPs we are short of… Please don’t be tempted to reduce standards..




Don’t let May trample on the NHS – In the absence of more money, the NHS will need more imagination.

Fiona Goodlee (Editor) writes in the BMJ 19th Jan 2017: (BMJ 2017;356:j305)  Don’t let May trample on the NHS. As the Economist opines in “No more money for the NHS, says Philip Hammond “- ” – and Britain’s doctors revolt against plans for a seven-day service  – In the absence of more money, the NHS will need more imagination.

News that Theresa May will feature in US Vogue magazine has added to what Martin McKee calls “the uncomfortable disconnect between her words and actions” (doi:10.1136/bmj.j213). Her homily on the steps of 10 Downing Street six months ago, including sentiments that she repeated in a speech last week, suggests deep concern about people who are struggling to get by—the “just about managing.” Her actions as home secretary and now as prime minister give no such comfort.

The United Kingdom is one of the most unequal societies in the developed world (, and despite it also being one of the world’s richest countries, its health spending is below the European average, and its health and social care system is near to collapse. Both McKee and Chris Ham in his editorial (doi:10.1136/bmj.j218) point out that governments in which May has served have either contributed to this sorry state or repeatedly failed to tackle the underlying causes.

The result, unflinchingly documented by the BBC’s fly on the wall documentary Hospital, is senior surgeons and their teams standing idle (doi:10.1136/bmj.j281) and their seriously ill patients sent home because of a lack of intensive care beds, while inadequate social care means that medically recovered patients are stuck in hospital. Outside hospitals GPs are struggling to get patients admitted, patients wait in ambulances parked outside casualty, and, for the first time in several years, waiting lists are growing and even cancer treatments are being delayed.

May’s response has been deplorable, justifying the horror expressed in BMA chairman Mark Porter’s letter to her (doi:10.1136/bmj.j296). She has, he says, downplayed the crisis in the NHS in England and deliberately scapegoated GPs (doi:10.1136/bmj.j259) to distract from what’s happening in the NHS. She has also picked a damaging fight with Simon Stevens, who as NHS England’s chief executive understands how the NHS works and what it needs to move forward and is one of the few in the NHS who has “spoken truth unto power,” as David Lock describes (doi:10.1136/bmj.j256).

As Margaret McCartney says in her column this week, May’s intervention represents “the kind of policy making that’s serially disastrous for the NHS” (doi:10.1136/bmj.j246). Such knee jerk political interference, without reference to even the most superficial evidence, causes harm and waste and further demoralises the professionals on whom the service depends.

Yes, there are things clinicians and managers can and should be doing to eliminate unwarranted variation and improve the quality of care. Gareth Iacobucci describes many of these in his latest article (doi:10.1136/bmj.j204), and Jennifer Dixon calls for clinicians to find ways to work better, not harder (doi:10.1136/bmj.j216). But this doesn’t let the government off the hook. The UK needs a proper financial settlement for its health and social care, one that reflects its wealth and its claims to be a just and socially progressive society.