Monthly Archives: January 2017

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.

Letters:

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 (www.bbc.co.uk/news/business-37341095), 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.

Waiting times and Waiting Lists are a problem in all G8 countries. Comparisons are not meaningful. Demographics are outstripping all systems abilities to cope…..

NHSreality thought to look up what was happening on waiting times and lists in all the G8 countries for comparison with the UK. Hip replacement is one of the most successful operations giving the greatest advance in Quality of Life Years. It is a duty of governments to ensure that it’s citizens have advanced knowledge of their options on how to avoid prolonged incapacity, which leads to early death. Whatever the system of health care, it seems that capacity is rarely sufficient, except where there is an insurance based private partnership. (Germany, Holland). In my own locality they have been rising since 2014. The Duthie report (1982) told us how to avoid this situation, but we have ignored it. The Times letters 21st Jan covers this rationing by undercapacity.

Image result for waiting time cartoon

In Ontario there is a “waiting times strategy” and this is here…. Possibly as a result of this openness the benchmark of 187 days wait is reached in 87% of patients. (2015). In the Okanagon region its over a year, but that is shorter than Wales. (Shelby Thom: Osoyoos man laments 56 week wait for hip replacement). In French speaking Quebec/Montreal the problem is the same: Gabrielle Fahmy 12th Jan 2017 – Surgery wait times in Moncton still too long – Health authorities have suggested province allow operating on nights and weekends

In 2013 Canadian Doctors for Medicare published paper no 41 (Viberg N, Forsberg): No. 41: How OECD countries measure and report wait times: an exercise in incomparability The comment is persuasive:

The analysis shows that it is difficult to make meaningful comparisons of officially published waiting times in the 15 countries studied, due to the many methodological differences in measuring waits.

It is not reasonable to conclude that if a country does not monitor waiting times, then waiting times are not a problem. In countries where waiting times are not registered and reported, accessibility may still be an issue, or it may not. We simply don’t know.

For example, France is often cited as a country has no waiting time problems, yet without a national monitoring system, this conclusion is suspect. Sweden has been identified as a country with relatively long waiting times, but this cannot be confirmed because the national statistics are incomparable.
Proponents of two-tier health care —advocates for allowing private payment to gain faster access to care — cite European countries as models for Canada, claiming their waiting times are shorter. Yet with no meaningful basis for wait time comparison, advocacy based on this polemic is spurious.

In England and Scotland the Nuffield trust publishes: Waiting time (referral to treatment) in Scotland and England

and the sub group for Hips is not as good as that for the average.

A private opportunist website advertises: An alternative to long
waiting lists for Knee & Hip Replacement Surgery  but this is outside their state system. As you can see from the 2013 report above they do not publish National Stats.

Germany on the other hand, with it’s mixed insurance model, obviously has capacity if the Daily Mail is to believed. Once again I suspect this is a private initiative. Beezy Marsh and Michael Woodhead report today Jan 23rd 2017 that “Germany offers to treat a million British patients”.

The latest OECD report comparing Hip Surgery is here but from 2011.

And opportunities exist abroad in India and Lithuania (Total Hip Replacement Abroad: Lithuania) (Hip replacement in India at low cost )

Australia has a waiting times publication., as does New Zealand

Big differences in waiting times for elective surgery

Karen Brown reports April 2016: Patients suffering because of surgery waits in NewZealandRadio

Waiting times for hip replacements set to go up again (Western Telegraph 2014)

Hip replacement patients in Wales ‘waiting twice as long …

NHSreality postings related:

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

Times letters 21st Jan: Services abroad as sick as NHS

groaned aloud when reading yet another article about how inefficient the NHS is and how much better things are managed overseas (“If I tumble from up here, I hope I land in the French health service . . .”, News Review, last week). Here in Catalonia, big hospitals have cancelled all scheduled surgery because of a shortage of staff, exacerbated by a flu outbreak. They also sent — it must be said — French nationals back over the border for surgery. The grass always appears greener . . .
Robin Flood, Catalonia, Spain

Stretcher case
How intriguing to read the cheerleader Kat Hind’s negative thoughts on the NHS, especially as the previous day a letter published in a British national newspaper was from a woman who had returned from a break in France and said that French television featured images of rows of people on stretchers in hospital corridors. Never mind fake news — let’s first agree on balanced reporting.
Huw Beynon, Llandeilo, Carmarthenshire

Private practice
The article highlighted exactly how to correct the problems in the NHS: charge everybody for any consultation and treatment, just as in France. I suggest that Hind takes out accident insurance so that next time she falls doing sport she can immediately be seen privately and not waste scarce NHS resources.
David Diprose, Thame, Oxfordshire

Waiting room
I was lucky enough to be transferred with my job from northeast England to Paris. While there I had a severe ear infection and made a GP appointment, costing €30 (£26). The doctor wanted to refer me to an ear, nose and throat specialist. On hearing I was due to leave for the UK, her receptionist spent 45 minutes ringing around and I was found a slot for the same day — at €65. The consultant prescribed antibiotics, painkillers and eardrops, adding a further €37.

I returned to the UK last April and needed to see my GP regarding a skin lesion. I was referred to a dermatologist for August and a biopsy was scheduled for October. Last November I was given a date for surgery this month.

I have the highest regard for clinical staff in the NHS but cannot understand why it should take 10 months from initial contact with a doctor to the actual surgical removal of a problem.
Stuart Leathes, Sunderland

Seven-day opening no remedy for lack of doctors
Surgeries opening seven days a week will not ensure more access to GPs; nor will it increase the number of weekday appointments available (“Don’t tell GPs how to treat patients”, Letters, last week). I am a recently retired GP and I cannot get seen for a potentially malignant skin lesion for five weeks. The doctors at my local practice work very hard; I know, I have appraised them in the past. So much for a two-week wait for cancer. We need more GPs, not open-all-hours surgeries.
Dr Steve Norman, by email

Out of contract
I do not have any time for the threats of Theresa May and the health secretary, Jeremy Hunt, directed at GPs over practice hours, but I have no doubt that the unsustainable pressures on A&Es are in large part a consequence of the last, misguided GP contract, which enabled doctors to opt out of out-of-hours care for a minimal loss of earnings. I qualified in 1973, and, having spent many years on call every third night and weekend, in addition to day work, my colleagues and I were very skilled in acute medicine in patients’ homes. Complex needs and care — usually blamed on the elderly such as me — did not begin with today’s cohort of doctors.
Derek R Pettit (retired GP), Henstridge, Somerset

Losing patients
I’m a doctor in my forties and work a minimum of 50 hours a week over four days. What keeps me going is providing for my family and helping my patients and the incalculable satisfaction this can give. GPs currently run their own businesses within the NHS, which means a degree of autonomy. Make us employees and we will be contractually gagged, like hospital consultants.

We all need to take responsibility for saving the NHS, which provides the best healthcare in the world despite continuing cuts. The need for a real-terms increase in funding is universally accepted outside Downing Street. If you cut the finances and increase the work, the warhorses will go. Up to a third of general practitioners are likely to retire within the next five years, and medical students perceive general practice as unstable, with uncontrollably long hours. I’ve never considered striking or emigrating before, but if I lose my right to manage and care for my personal list of patients, I’m off.
Ian Cockburn, Seaford, East Sussex

Double booked
At our GP surgery we book a double (20-minute) appointment if we need to discuss two medical issues. Problem solved.
Vic Brown, Morpeth, Northumberland

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Rationing by waiting, and insufficient staff. Wales is worst…

Full to capacity means stressful working conditions, delayed diagnosis, Surgeons having to do other work just to keep the hospitals going, and higher risk of cross infections. Waiting lists are increasing, but more so in Wales.. To cap it all there is a record undercapacity in nurses as reported in the Health Service Journal

Nick Servini for BBC Wales reports 19th Jan 2017: Welsh NHS patients still waiting longer than in England (Figures for Scotland here)

Waiting times in the Welsh NHS continue to lag behind the health service in England in most key categories for treatment and diagnosis, according to the latest statistics.

Directly comparable figures show the biggest gap was in the wait for hip operations, up by a fifth in 2015-16.

The average wait for hip operations in England was 76 days while in Wales it was 226 days.

But waiting times in Wales for heart by-pass surgery fell significantly.

In 2014-15 the average wait in Wales was 111 days. It fell to 43 days in 2015-16.

Overall, there were significantly longer waits in Wales in seven out of the 11 main indicators measured in Wales compared to the same indicators measured in England…..

Kat Lay describes the waiting times in A&E in The Times 20th Jan 2017: Hospitals’ beds full as ambulances are turned away

Twice as many hospitals turned ambulances away last week as they did in the same week last year, new figures show.

Health bosses warned the public that they should not add to pressures on the health service by going to A&E or their GP when suffering from the flu or norovirus and asked people to “do their bit” to check on vulnerable relatives and neighbours.

Hospital beds are essentially full, at 95.8 per cent, up from 94.8 per cent the week before and higher than in 2016. High levels of bed occupancy can disrupt the smooth flow of patients through treatment…., said: “Those who get infected with norovirus will usually make a full recovery within one to two days. However, it is important to drink plenty of fluids to prevent dehydration, especially in the very young or elderly. Good hygiene is essential to preventing infection, this includes thorough hand washing after using the toilet and before eating or preparing foods.”

Health chiefs also warned that the expected severe cold weather over the next few days could be dangerous and pose a health risk to vulnerable patients and people suffering chronic diseases.

Dr Thomas Waite, of the extreme events team at Public Health England, said: “The cold weather is forecast to continue for several more days, and in periods of cold people with long term health conditions, very young children and older people are at greatest risk of ill health….

HSJ:19 January, 2017 By

Revealed: The hospitals with the worst nurse staffing

Almost every NHS acute hospital in England is failing to meet its own nurse staffing targets, an investigation by HSJ has revealed.


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More money needed… lets pour a little more into the holed bucket – and reduce the quality of care by rationing new treatments

The bucket of money for health spending has many holes in it, and the rate at which it leaks out the bottom, even with covert rationing is faster than we can print/put money in. Headlines such as Oliver Moody in the Times 18th Jan 2017: Extra £156 billion needed for healthcare, and 2 years earlier from Dennis Campbell in the Guardian: NHS will need extra £65bn by 2030, say analysts – Health Foundation says service is unlikely to meet unrealistic productivity targets and may have to ration access to treatment, show the inflationary nature of health costs. The OBR is rightly part of the department of justice…… The injustice of covert rationing is becoming evident. The good news is that rationing of new drugs is overt…

Image result for hole in bucked cash

The text of the Times article explains just how irresponsible the politicians are in their denial is:

Britain’s public finances are on an “unsustainable path” with an ageing population and the rising cost of healthcare, a watchdog warned.

A 50-year forecast from the Office for Budget Responsibility (OBR) said that chancellors would need to raise taxes or cut spending if the government were to stand any chance of fulfilling its pledge to balance Britain’s finances. It said an extra £156 billion would have to be found by 2066-67 to fund the gap in healthcare costs.

The OBR said that spending on both the NHS and the state pension were due to rise faster than economic growth and that, without policy action, public sector net debt would surge from 82 per cent of gross domestic product to 234 per cent in 50 years’ time.

Government borrowing would rise to 16.6 per cent of GDP and the annual budget deficit would widen from 0.7 per cent of GDP in 2021-22 to 1.8 per cent by 2025-26.

“Rising healthcare costs could make it harder for the chancellor to balance the budget in the next parliament and put the public finances on an unsustainable path over the longer term in the absence of further tax increases or cuts in other public spending,” it said.

Rosemary Bennett reports on a “little finger in one bucket hole” (social care) attempt: Tory council plans tax hike to fund social care as Surrey County Council does it’s best within the current rules of the game. It won’t be enough..

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

This is the type of “knee jerk” response which is irrational and which NHSreality has warned about. As new drugs come on line they are usually delayed in NICE approval until their patent has nearly expired. This was covert and unplanned. Now the announcement in the headline above makes it overt, but it denies British citizens access to drugs which other countries will have. Private Medical demand will increase, as will inequalities. A two tier system emerges by default, which increases fear in those excluded. One answer is to ration at the cheap high volume end of care, which encourages self reliance and autonomy.

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Going bust when it’s not allowed – all English Regions bar one.. The knee jerk response has yet to happen, as has the “honest debate”.

What is going to be excluded Mrs May? Please don’t be tempted by a knee jerk response..

 

Candour and Transparency? – what a farce

it’s a farce, and more like a permanent break – in both candour and transparency, and a permanent state of denial.

David Oliver opines in the BMJ 14th Jan 2017 (BMJ 2017;356:j146 ): David Oliver: Is NHS “candour” on a break for winter?

Winter seems more difficult each year in NHS acute care, and 2016-17 is no exception. Vocal public support from national leadership bodies would be a welcome New Year gift. It would certainly beat attempts at news management to limit reputational damage and appease politicians’ reported wishes to keep hospital crises out of the headlines.1

Looking at NHS performance statistics,2 media reports of clinicians’ tales from around the country,3 or statements from their medical colleges and societies,45 it’s been more like the Apocalypse than the Christmas story. Demand for urgent care is high, and hospitals are crammed, under extreme pressure to clear beds. An exit block continues,6 whereby stranded patients await overwhelmed community services that can’t match demand.

Trapped in the middle are frontline staff under almost unbearable pressure—the King’s Fund’s Chris Ham refers to them as “shock absorbers.”7 We’re forced to pick one uncomfortably risky option over another, as we juggle the system’s needs with those of individual patients.

Even more trapped are the patients themselves: on trolleys in corridors, stuck in ambulances outside emergency departments, diverted to other hospitals, or discharged earlier than they or staff would like, without enough chance for planning. When things go wrong it will be jobbing clinicians who face the complaints of patients and their families and attend inquests, not Whitehall officials.

The British Red Cross, one of several charities that do great work to support people leaving hospital or trying to remain at home, said last week that the situation in English hospitals in recent weeks had become a “humanitarian crisis.”8 It illustrated its claim with stories of patients discharged in haste without the right support at home.

On the same day, the Telegraph reported leaked memos from NHS England essentially instructing acute service managers to play down the extent of problems.9 The article reported a script containing lines for standard use to minimise public concern, “The most important thing” being to avoid negative language. NHS England then said that, as its winter planning was the best it had ever been, the Red Cross’s statement had no justification.

Another recent “leaked memo” story found NHS England telling supposedly locally owned sustainability and transformation plans how positive to make their public communications.10

The government’s response to the Francis report made the duties of candour and transparency statutory.11 This applies from frontline clinicians to board level NHS managers. In turn, this means a duty of transparency to the local patients, population, and press: transparency about unavailable beds, staffing gaps, funding crises, risks to safe care, and unavailable step-down care. It does not mean a “Crisis? What crisis?” denial of serious issues.

  1. References