Monthly Archives: January 2017

Remedies for the desperate plight of the NHS

 

Lord Desai writes to the Times 14th Jan 2017: Remedies for the desperate plight of the NHS

Sir, The NHS has been in crisis almost every year for the past 51 years I have lived here. It used to be the nurses’ morale and now it is A&E. A partial answer, as Philip Collins suggests (“Desperate NHS needs a desperate remedy”, Jan 13) is an explicit system of rationing. But there is also a need to explain to the users that free care has a “resource” price, only they don’t pay it directly. Every individual should receive an “Oyster” card” preloaded with so many points, and each treatment should have a declared price that would be deducted from the card when used. The card would be refilled as necessary, but at least patients would be made aware that each time they use the NHS there is a price paid somewhere in the system by someone else who is thereby being kept out.

Lord Desai House of Lords

Reply: ‘OYSTER’ HEALTH CARD (letters 17th Jan 2017)

Sir, Lord Desai’s Trojan horse proposal to achieve pay-as-you-go in the NHS is excellent, apart from its rather London-centric “Oyster card” allusion (letter, Jan 14). Having been in Milan helping to build the European Institute of Oncology, I would add in a chip with each patient’s entire medical record, as used throughout Italy’s health service. This must be better than the NHS’s failed IT scheme. Moreover, it’s high time patients were empowered with the responsibility to hold their own data. Whose data is it anyway?

Professor Gordon McVie Division of Cancer Studies, KCL, and clinical adviser, Institute of Molecular Oncology, Milan

Patients should pay to see their GP…?

Limiting access by payment for the majority is a simple and knee-jerk solution. It will work, but it will be unfair if it is bought in suddenly so that those only just coping have no method of planning for exclusions and co-payments. More importantly the elderly and those with complex diseases such as Diabetes still need to pay. there must be a minimum of exclusions, which encourages autonomy. Special “individual tax exempt health funds” may help, and identity cards which allow Health Service access and include medical records. NHSreality believes that to encourage fairness these ID cards will need tax codes as well.  See lord-desai-letter-on-rationing-and-replyImage result for pay Dr cartoon

Charlotte Jones in LincolnshireLive reports an MP (Sir Edward Leigh) on 15th Jan 2017:  Patients should PAY to see their GP, Lincolnshire MP proposes – and in The Independent: Tory MP calls for debate on introducing NHS charges

Health ministers did not explicitly rule out the suggestion

The NHS should consider charging people to see their GP, according to Sir Edward Leigh.

Speaking to the BBC, he said: “I think that, as in Australia, we could look at paying to go and see your GP and then it being free after that.

“I think we could look at cancelled appointments. “We could look at paying for your accommodation in hospitals.”

This is not the first time the Gainsborough MP has called for the Government to consider charging for NHS services.

Mr Leigh has referred to medical systems in other developed countries where people pay to see their doctors, and he says they work.

It comes as the British Medical Association is warning many people face dangerously long delays for treatment.

Four Lincolnshire GP surgeries closed their doors on January 7, leaving 11,000 patients without access to a GP.

The surgeries were the Arboretum Surgery and Burton Road Surgery both in Lincoln, and Metheringham Surgery and Pottergate Surgery in Gainsborough.

The future of Wainfleet GP surgery remains uncertain after it was closed in November over safety concerns.

Increasing inequalities extends to unapproved treatments. Caring properly would give a better happiness dividend.

It is no surprise that inequalities, especially in health, are increasing. Wealth is health as the wealthiest are increasing their share of the world’s capital. Is their concern with investing in “unapproved” and “unproven” treatments driven by opportunism, an expression of guilt, or altruism? Who will be included and who will be excluded, and who will decide? NHSreality knows the money would be spent differently by Public Health consultants (populations), and that these people just cannot think of anything else/better to do with their wealth. What a shame when caring properly would give a better happiness dividend. They, like our politicians, won’t even realise reality when their own time comes as they will be fully cared for. It appears that, if commissioners wont’ provide in the state controlled lottery, private capital might, if you know the right people… in the post-truth world.

Gerry Mullany in The Telegraph 16th January 2017 reports World’s 8 Richest Have as Much Wealth as Bottom Half of Global Population

Clockwise from top left: Bill Gates, Amancio Ortega Gaona, Warren E. Buffett, Carlos Slim Helú, Jeff Bezos, Mark Zuckerberg, Lawrence J. Ellison, Michael R. Bloomberg. Credit NYT; Reuters; Reuters; Reuters; Getty; European Pressphoto Agency; Getty; AP

Alexandra Frean reports in The Times 9th January 2017 : Investors back unapproved drugs database for terminally ill

A Dutch company aiming to give doctors and their terminally ill patients access to drugs that have not won official approval has raised €10 million.

MyTomorrows seeks to benefit both patients who have run out of treatments options and drugs companies, which gain access to data and fees from selling small quantities of drugs that have passed initial tests but are not yet approved for sale or use where the patient lives. The start-up has compiled a global database of unapproved medicines and acts as a broker, helping to navigate protocols and regulations in different countries.

The problem of access to unapproved drugs was raised recently by AA Gill, the writer and restaurant critic, who died last month aged 62. In a final essay he revealed that the NHS had denied him a pioneering treatment for cancer recommended by “every oncologist in the first world” because of its cost of up to £100,000 a year.

Ronald Brus founded myTomorrows three years ago after his father developed cancer and ran out of treatment options. As the former chief executive of Crucell, a vaccine company that Johnson & Johnson bought in 2010 for $2.4 billion, Mr Brus started calling big pharmaceuticals companies to see if he could get access to drugs in development.

“I thought this is not really fair. I have the opportunity to do this because of my background, but other people do not,” he said.

So far, the company has provided hundreds of patients with access to treatments, which have been paid for by insurers. The company said that in Britain most treatments it had provided had been paid for by the NHS, with the remainder funded by private insurance.

The latest funding round is being led by the London-based Octopus Ventures, which previously has invested in Zoopla, LoveFilm, SwiftKey and Magic Pony, and EQT Ventures, a Stockholm-based fund.

MyTomorrows raised €4.5 million in 2014 in its first institutional financing.

World’s eight richest as wealthy as half humanity, Oxfam tells Davos

World’s 8 richest men are worth as much as 3.6 billion people – The Telegraph

myTomorrows – Expanding access to drugs in development

Oxfam attacking the world’s richest shows just how little they understand the global economy and poverty ·  The Sun

The rich get richer … and the poor get shorter lives, less choice, but more local care.

Cleaning up the UK Health Services, changing the culture and importing honesty..

Having a “rant” at General Practice – it’s hard for some to see the opportunity ahead. A letter in The Times reveals the same for A&E..

NHSreality wants scapegoats – and suggests the successive ministers of health (for England). Allyson Pollock might agree..

Tell Wales it isn’t working. Inequality is increasing…. better to “aspire to excellence”.

Inequality revisited.

Pre-emptive treatment is going to be possible, and if the state does not fund then it will increase inequalities… regressive taxation is pragmatic but may be divisive..

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….

Happy 2017: …politicians’ ‘persistent, blinkered denial’ – Say no to a post-truth health service

NHS History

 

Conspiracy Theorists: Are this week’s dire NHS headlines a Government plot? Let’s hope so… Listen to the Radio 4 debate on 8th February

Janet Daley opines in the Telegraph 14th Jan 2017: Are this week’s dire NHS headlines a Government plot? Let’s hope so…  We need a reform of the supply side, and an end to centralised bureaucracy. No mention of rationing, so Janet is also in denial… Questionnaires to Doctors and GPs rarely ask the right questions and could start with “is the current system and ideology sustainable?”…. And lead on from there. Questionnaires (Such as the Lib Dems to GPs 2016) rarely address problems without their own agenda.. It would be helpful if the questions were published along with the analysis. What matters is the omitted questions… and without addressing these the conspiracy theories thrive.

Since conspiracy theories seem to be the order of the day, let me run another one past you: the Government, the NHS hospital trusts and the medical Royal Colleges are deliberately encouraging coverage of the impossible pressures being put on A&E and primary care in order to soften up public opinion for a radical re-think of health funding.

While all those dreadful headlines may look like a national scandal and a horrendous political embarrassment, in reality they are the most effective way to bring about acceptance of the need for change.

Everyone in touch with the reality of this situation – reasonable politicians of all parties, clinical staff and NHS managers – knows that the present arrangements are unsustainable. But nobody can figure out how to retreat from the testament of unquestioning faith in “Our NHS” which is indispensable for survival in public life. Hence, the apocalyptic tone…

Join us in the BBC Radio Theatre in London on 8th February 2017!

BBC Radio 4’s Inside Health is hosting a special debate on the current state of the NHS. Dr Mark Porter and guests discuss what needs to give.

The last few months have seen the service creaking under unprecedented demand, and there is likely to be worse to come.  Something needs to give. Is it simply a matter of more resources, or do we also need to change our expectations of what the NHS provides? Is rationalisation and rationing the way forward? 

Mark is to discuss the issues with a panel including regular contributor Margaret McCartney GPClaire Marx, president of the Royal College of Surgeons, and Chris Hopson, chief executive of NHS Providers.

Tickets will be available from the BBC website soon

Submit a question for the panel by EMai to insidehealth@bbc.co.uk

NHS complaint body is ‘biased and ineffective’

Chris Smyth reports on the comments from Katherine Murphy, Chief Executive of the Patients Association in The Times 16th Jan 2017: NHS complaint body is ‘biased and ineffective’. The Ombudsman’s Health Report: “Learning from mistakes” seem rather ironic..

The NHS fails to learn from its mistakes because the body that investigates complaints is incompetent and biased, patient advocates say today.

The Patients Association accuses the NHS ombudsman of failing to stand up for people who have suffered at the hands of the health service. People who complain face a battle against an organisation that is ineffective and unfair, a report published today has concluded.

“The experience of too many complainants remains of a system which is too complicated, unresponsive and lacking in compassion,” Katherine Murphy, chief executive of the association, said. The report accuses the ombudsman of ignoring evidence, dragging out investigations for years and being biased in favour of the NHS.

Basic errors such as wrong names and treatments litter the ombudsman’s reports and investigators lack rigour, the association said. It also says the ombudsman does not do enough to make sure the NHS avoids repeating mistakes. “Some people describe that they feel they are battling the [ombudsman],” Ms Murphy said. “They feel exhausted by the whole process.”

Complainants said they felt investigations were a whitewash, or failed to challenge “manifestly duplicitous and flawed NHS processes”. Staff were rude, dismissive and insensitive, they said. One case highlighted a family who had to keep retelling the story of their daughter’s death to new investigators.

A spokeswoman for the ombudsman said: “Our processes are fair and robust and we constantly seek feedback from complainants. We recognise there can be times when people find it hard to agree with our findings.”

Image result for health bias cartoon

 

The government shows its misunderstanding of GPs – scapegoating the resentful and disengaged may lead to unintended consequences.

Perverse incentives abound in all health care systems. The job of public health consultants and strategic advisers to government is to anticipate the possible actions of all the stakeholders. They need to see that new perverse incentives do not result in unintended consequences and outcomes.

unintended-consequencess

GPs are self employed. They work in partnerships, some very large and able to cope with extra hours, and change, and some very small, unable to cope with their current workload. The latter are equivalent to Mrs May’s “Just about coping” cohort of the population at large, but this time with workload rather than money.

The government shows its misunderstanding of GPs – scapegoating the already resentful and disengaged will lead to unintended consequences.

Many GPs are at or near retirement. They can afford to  leave and become locums or salaried doctors working within less stressful contracts. This is the choice for many with young children. It is only the ongoing partners who will have a duty to provide 12 hours cover, as they will hold the contract with the .commissioning group.

Since there in an undercapacity provision of a sufficiently skilled and experienced workforce, and successive administrations have failed in their manpower planning, locums will be able to demand and receive high payments. Whilst stronger partnerships who use internal cover for leave might tolerate this situation, smaller partnership may disintegrate.  The first step would be to hand back the contract giving 3 months notice.

Partnerships that own property would be wise to move it into a company if they have not already done so.

The civil service administration would recruit from overseas.

So to summarise the possible unintended consequences:

  1. Fewer GPs and GP hours consulting (especially those with families) .
  2. Higher locum pay.
  3. Disintegrating – smaller practices in particular.
  4. Emigration from the English Health Service
  5. Reduced access for patients.
  6. More demand for Private Practice
  7. Increasing inequality
  8. Public unrest starting in peripheral and less affluent areas
  9. More employment of immigrant doctors with poorer language and cultural appreciation. (these doctors, mainly from outside of the EU, will then block places for future doctors when we get the manpower planning right, thus repeating the cycle started in the 1950s whereby we take doctors from countries that can least afford to lose them)

No wonder many GPs think there is a conspiracy to undermine and destroy the former NHS. What is left is not National, is in poor health, and is becoming such a poor service that private care seems a reasonable option to those who can afford it. Anger and resentment mean the insult seems even worse..

BBC News 13th Jan 2017 reports: GPs urged to commit to seven day service or lose funding

Chris Smyth reports in The Times 13th Jan 2017:  May demands 7-day GPs

PM blames early-closing doctors for fuelling A&E crisis

Theresa May has ordered GPs to stay open seven days a week as she blamed doctors who close early for fuelling the A&E crisis. The prime minister said that surgeries should provide appointments at times convenient for patients rather than themselves. Cash allocated for longer opening hours…

Image result for unintended outcome cartoon

Update 14th Jan 2017:

Damien Gayle reports in the Guardian: May’s scapegoat attempt could spark mass resignations, says top GP – Dr Kailash Chand says GPs are rightly angry at government effort to shift blame for NHS crisis on to them with seven-day threat

BBC letters: The NHS is making people sick, GP tells BBC

Update 16th Jan 2017 – Times letters

Sir, The final blow to general practice has been dealt by Theresa May’s seven-day-a-week plan (News, Jan 14). It sounds eminently sensible, but where are the GPs to run this service? In the past two decades there has been a ten-fold increase in the number of hospital specialists — doctors who would otherwise have entered general practice — as well as a significant change in the workforce. Sixty per cent of medical graduates are now women, which offers many advantages but only a small number are full-time. General practice is dying on its feet as there are so few who wish to become partners and keep the profession going. This latest gambit will see all those close to retirement resigning from partnerships and taking the softer option of working as assistants and locums, leaving precious few to even attempt to provide extended hours.

Dr Duncan Hall Sid Valley Practice, Sidmouth, Devon

Sir, To read that the current crisis in the NHS is the fault of GPs is yet another kick in the teeth to a primary care service that is on its knees. I and my GP colleagues around the country routinely work 12-plus hours a day and are struggling with low morale, a lack of resources and chronic recruitment problems. To lay the blame at the door of general practice when the real cause is a serious lack of NHS funding, and in particular significantly under-resourced social care, just emphasises further that the government has no clue what is going on in the NHS and no plan to resolve this crisis.

Dr Catherine Sherwin (GP) Tiverton, Devon

Sir, Theresa May’s demand for seven-day opening by GP surgeries will not increase access to a GP. Moving a surgery or two into the weekend will reduce weekday access; similarly, moving the morning surgery to the evening will not alleviate the GP crisis. Moving surgery times will not by itself create extra appointments over the whole week. We need more working GPs, not just surgery buildings being open all hours.

Dr Steve Norman Milton Keynes

Sir, Perhaps the prime minister could set an example to GPs by making parliament sit seven days a week in order to debate all matters that need resolving for the impending Brexit.

Alistair Lenczner London SW4

Sir, There seems no doubt that if GP surgeries were funded to “open all hours” and treat people not registered with them, far fewer people would need to visit A&E. In the past few years I have felt I had no choice but to take relatives to A&E with: a badly cut hand, a painful knee infection, a ripped-off toenail (the football injury of a pupil at my school), plus a few others that could have been treated locally but but for “we cannot treat a person not registered here”, “the surgery is closed” or “no appointments available”. I now do not hesitate to drive the 15 miles to A&E.

Linda Miller Dereham, Norfolk

Sir, Angus Hanton (letter, Jan 14) agrees with Simon Stevens that older people who use the health service more should pay more towards health costs. They are both missing one important point: that older people have been paying all their working lives, therefore longer than young people towards health costs. It is unfair to pick on the elderly to raise an £2 billion a year when they have already paid into the system when they were young and fit.

John Mitchell Lincoln

Sir, I read with interest Professor Joy’s letter bemoaning the number of reorganisations there have been that have undermined the health service.

He then proposes another.

Charles Dewhurst London W4

 

 

 

 

 

Desperate NHS needs a desperate remedy – care is already rationed

if I was an overworked GP I would be tempted to go “part time” and close the doors. There are just not enough of us, and a reasonable defence mechanism is to reduce the pressure.  Philip Collins does not seem to appreciate that his local Health Service is already rationed, but covertly, and in a differential post coded manner. He has not recognised that several other countries who initially tried to imitate the 1948 model, have abandoned it. (NZ and Scandinavia). The ironic laughter with which the profession saw the Olympic Ideal portrayed in London needed to be seen by politicians. It is too late for a “turnaround” because the goodwill has gone, along with many of the staff. It has to get worse now, and a new model of care will evolve. It looks like being a two tier system with insurance or private care for those who can afford it, including emergencies. The care tsunami will overwhelm us..

Image result for care tsunami cartoon

Philip Collins opines in The Times 15th Jan 2017: Desperate NHS needs a desperate remedy – If the medical profession continues to cry out for more money, the health service will have to start rationing care

When Theresa May said, at prime minister’s questions, that the Red Cross had been “irresponsible and overblown” to describe the state of the NHS as “a humanitarian crisis” she was right. The Chelsea and Westminster hospital is not Aleppo. But the Red Cross has devalued the debate more than that. It has encouraged the pretence that the crisis is sudden and government-inspired. In fact the crisis is truly chronic.

Simon Stevens, chief executive of NHS England, told a committee of MPs that the health service is under severe pressure while the prime minister, who is in danger of falling out with a civil servant she really needs, is said to believe that the crisis is no more than the typical winter discontent. An iron law of politics applies: in any political argument it is more than likely that both sides are right.

The situation is both severe and typical. The NHS will now be permanently “in crisis”. Every so often there will be a flashpoint such as the junior doctors’ strike or a winter surge. December 27, 2016 was the busiest day in the seven-decade history of the NHS; the number of elderly patients waiting on trolleys has trebled. If the prime minister is tempted to take the attitude of “Crisis, what crisis? she would be foolish. Real people are suffering, some of them fatally.

It helps nobody, though, to pretend that this is all the fault of Jeremy Hunt, the health secretary. His intentions for the NHS, despite the wild accusations of some critics, are nothing but good. The problem is much bigger than the identity of the minister or the political complexion of the government. The Office for Budget Responsibility (OBR) has calculated that unless the current productivity rate in health improves, the cost of the NHS will push the national debt to more than 200 per cent of GDP by 2060. We cannot pretend that we can keep finding enough money. As Giuseppe di Lampedusa wrote in The Leopard, “If we want things to stay as they are, things will have to change”.

The first change is to recognise that the National Health Service is not really any of those three things. Variations in quality mean the NHS is a regional service with a national logo. Second, the nature of modern illness, which depends so much on diet, means that health is looked after at home; the NHS is an illness checker and fixer. Finally, the NHS is not a single service. The current problem with A&E occurs because GPs, happy recipients of a crazy contract, are closed or there is no local minor injuries centre, which would be a much better place for many of the people in A&E. Hospitals cannot discharge the elderly because local government cuts — the falsest economy in the sorry history of austerity — have turned a poor social care service into a shameful one. The NHS is the repository of problems, not the cause….

Yet we are sickly sentimental about it. To provide health care by need rather than by ability to pay is a noble principle which should remain the centrepiece of the system. But too often it functions as a sign that warns off trespassers: “No reform here.” It’s too late for that; winter is upon us.

The NHS budget has been protected, at least relative to other services. The much bigger problem is that demand is racing ahead. The country is older than it was and getting older. In 2015 there were three times as many people aged over 85 as there were in 1990. Medical science can do more than ever before, and in a system in which people are not rationed by cost they understandably want all the care they can get. Inflation in the NHS is in the region of 7 per cent per annum, just to achieve the same results.

If we really want to defend the principle of the NHS then we have to countenance unpopular measures. The first is a campaign to close hospitals. Routine problems such as hip replacements no longer need to be done in the district hospital. Victims of heart attacks, coronaries and strokes are better treated in small specialist units. Ultrasound can now be done by GPs. Some acute care can be offered at home. The day of the all-purpose district hospital has gone.

The NHS was designed in an era when care was done to patients by doctors. That is no longer true. Two thirds of the NHS budget goes on the 15 million people in the country who have a long-term condition. Patients with dementia, diabetes, arthritis and hypertension take up half of all GP appointments, two thirds of outpatient appointments and 70 per cent of inpatient beds. Moving their treatment out of hospitals could save £4 billion a year. Most chronic care is administered by the patient him or herself. It is worrying that a 2010 Commonwealth Fund report compared seven health systems. The NHS came top for effective care and efficiency. On putting the patient in control it came bottom.

Next, politicians, especially on the left, will have to stop screaming “privatisation” at every reform. At the moment less than 8 per cent of the NHS budget is spent on private providers. Competition has lowered costs for cataract procedures, MRI and knee replacements and shortened waiting time for hip operations. If it increases capacity and quality without demanding a payment from patients, people need to get over themselves on private provision.

One person under no illusions about any of this is Simon Stevens. NHS England’s Five Year Forward Review set out a bold reform programme to replace the “factory model” of the NHS. It is obvious what will happen if reform does not follow. There will be charges. Instead of rationing by queue the NHS will begin to ration by price. The only alternative will be to define a core NHS offer that applies to all taxpayers and charge for additional treatment. None of these is a good option but this is where we will end up if critics and the profession simply cry for more money.

I shall not hold my breath. The British Medical Association is every bit as hostile to change as the RMT but much more adept at preventing it. It is posing as a friend of the NHS when it is its unwitting enemy. Whatever happens now, this will not be the winter of discontent in the NHS. That line is always misunderstood. Shakespeare meant that the discontent was coming to an end. In the NHS it has hardly started.

 

 

Three quarters of surgeries shut out patients in GP blackspots

Up to three quarters of GPs’ surgeries in some areas shut their doors to patients on weekday afternoons, according to figures highlighting the growing difficulty of seeing a doctor. Some surgeries offer appointments for only three hours a day, making it hard for patients to get a consultation. Inspectors have warned that surgeries face…