Monthly Archives: May 2017

New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem

NHS reality  has opined before on how governments should treat populations and doctors should treat individuals. There is a natural and allowable dissonance between them but the media denies this. It is never in the interest of the 4th estate to compromise. Conflicts and opposites are what makes news sell. Nevertheless, public health experts all acknowledge this need, but they are becoming scarcer. Where will common sense rationing decisions for cancer come from.. In The Information Age one might expect a rational discussion.

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Cncer drugs are getting better and dearer – AtraZeneca’s Imfinzi costs $180,000 for a year’s treatment

THE debate in rich countries about the high price of drugs is a furious and frustrating one. The controversy is already having an impact on spending on drugs, suggest new figures from the QuintilesIMS Institute, a research firm. The rate of growth in spending on prescription medicines in America fell to 4.8% in 2016, less than half the average rate of the previous two years (after adjusting for discounts and rebates). Michael Levesque of Moody’s, a rating agency, reckons that pressure over pricing is contributing to a deceleration in earnings growth at pharma firms. Public scrutiny constrains their flexibility over what they can charge and allows payers to get tougher.

In one area, however, earnings are expected to keep rising: cancer. Oncology is the industry’s bright spot, says Mr Levesque. The grim fact is that two-fifths of people can now expect to get cancer in their lifetime because of rising longevity. This is one of the reasons why the number of new cancer drugs has expanded by more than 60% over the past decade. The late-phase pipeline of new medicines contains more than 600 cancer treatments. New cancer drugs are being approved more quickly….

Cost effective but unaffordable: an emerging challenge for health systems – New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem (BMJ 2017;356:j1402 )
New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem

With hospital wards overflowing and trusts in deficit, the introduction of cost effective but expensive new technologies places increasing strain on NHS finances. The National Institute for Health and Care Excellence (NICE) and NHS England plan to tackle this problem by delaying the introduction of interventions with a “high budget impact.”1 The change may deliver short term savings but is flawed.

What prompted the new policy? In 2015 NICE recommended the use of several new drugs for hepatitis C.2 Although they were judged clinically useful and cost effective, NHS England considered them unaffordable, with annual costs of between £700m and £1bn, and delayed adoption.34

From 1 April 2017, the current requirement to fund NICE recommended technologies within 90 days will not apply for those with annual costs that exceed £20m (€23m; $24m).1 Instead, NHS England will be granted up to three years—longer in exceptional circumstances—to conduct commercial negotiations.1 As a result, patient access to some new technologies will be substantially slowed…

Views expressed during the consultation on this policy were far from supportive. Respondents recognised the pressures on the NHS, but less than a third believed that a budget impact threshold should be introduced, and only 23% agreed with delayed implementation for technologies exceeding the threshold. When the views of NHS commissioning bodies were excluded, figures for support fell substantially.1

The policy brings affordability into NICE’s remit in an unprecedented way. To date, NICE has based its recommendations on an ethics of opportunity costs.5 New technologies are judged principally on their incremental cost effectiveness ratio, a measure of their cost effectiveness compared with existing interventions. Judgments sometimes reflect broader social and ethical values, but cost effectiveness is normally the main consideration.5

The budget impact test means that technologies costing the NHS more than an additional £20m a year will be “slow tracked,” regardless of their cost effectiveness or other social or ethical values. This risks undermining the existing opportunity costs framework. Consider infliximab, currently recommended for both acute exacerbations of ulcerative colitis and severe active Crohn’s disease.67 Its list price is the same across indications, but the total cost of treating the handful of eligible patients with ulcerative colitis is far lower than that of treating the 4000 eligible patients with Crohn’s disease. Under the new approach use for Crohn’s disease would probably fail the budget impact test, delaying introduction; use for ulcerative colitis would not.

Budget impact is essentially the price per patient multiplied by the number of patients treated. Yet the prevalence of someone’s condition should not determine their access to treatment. The principle of equity means that like cases should be treated as like; the NHS Constitution requires the NHS to respond to the clinical needs of patients as individuals.89 The new test requires NICE to treat patients in one group less favourably than those in another solely because there are more in the first group than the second. It is numerical discrimination. And if large numbers of patients experience delays, the policy threatens widespread harms.

Affordability is driven by public expenditure, a fundamentally political matter. NICE and NHS England should be commended for seeking to square the circle on affordability when the current government’s response is inadequate. Perhaps the policy aims to pressurise industry to lower its prices when volumes are high. But this is to use large patient groups as a bargaining chip.

NICE’s justification for pursuing its approach—that “no alternative solutions” have been put forward—is invalid in our view.1 The recent consultation did not ask for other options. Had it done so, several could have been canvassed. NICE’s methods assume that the NHS will pay for new cost effective interventions through disinvestment, removing existing treatments that are relatively cost ineffective. This rarely happens.1011 A systematic and transparent programme of disinvestment, though difficult, could increase the resources available to fund new technologies. An increase in the NHS budget would, of course, help too. But even without that, NICE’s cost effectiveness threshold could be updated for all technologies, so treating patients equitably.12 More widespread use of risk sharing on costs might also help to reduce total budget impact. Or, most controversially, the 90 day funding requirement for NICE approved technologies could be removed entirely and the power to make decisions about affordability given back to politicians or NHS England.

Even if it is no longer feasible politically for NICE to ignore overall affordability in individual technology appraisals, budget impact could be a special consideration, modifying the cost effectiveness calculation alongside other social or ethical values. This would allow for a nuanced, case-by-case deliberative response and bring affordability into the existing opportunity cost framework.5

All these options raise important ethical and political challenges. But they should be considered before NICE commits to an inequitable approach that few support. The recent consultation should have marked the start, not the end, of a more substantial debate about the role of affordability in the NHS. It is not too late to correct this mistake.

Footnotes

  • The authors form part of the Social Values and Health Priority Setting Group (ucl.ac.uk/socialvalues) and are grateful to its members for stimulating discussions. We thank Catherine Max for contributing to the drafting of this editorial and the reviewers, Piotr Ozieranski and Iestyn William, for their comments.

The Information Age one might expect a rational discussion.

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Redefining the relationship between doctors and patients… When not to put the patient at the centre of your concern…

Doctors wish to retain a relationship with the patient in front of them. Sometimes, if it is a murdering psychotic, or an HGV driver who continues when at risk of a stroke, they have a duty to spill the beans. When the danger is time distant, as in genetic problems, the issue of right and wrong becomes blurred. Watch the result of this case – the good GP or consultant will know “When not to put the patient at the centre of your concern…” – and goes against the first GMC duty of a doctor.

Frances Gibb, Legal Editor of the Times, reports 17th May 2017: Gene-defect mother wins right to sue

A woman has won the right to sue doctors who failed to tell her that her father had a hereditary brain disease before she gave birth to her own child.

She discovered afterwards that she also had the gene for Huntington’s disease. Her daughter, now seven, has a 50 per cent chance of having inherited the incurable degenerative disease.

The woman, in her 40s, maintains that she would never have given birth had she known about her father’s condition. He did not want to tell her because he feared that she would kill herself or have an abortion.

In a landmark challenge, she will seek to sue her father’s clinicians at three NHS trusts for negligence in failing to inform her. A judge in the lower courts had previously struck out her case, saying that the clinicians owed her no “reasonably arguable duty of care”.

The case will involve judges redefining the confidential relationship between doctors and patients, after the Court of Appeal judgment.

The woman’s father displayed signs of aggression and, several years ago, shot and killed her mother. He had Huntington’s disease diagnosed two years after being convicted of manslaughter. When doctors asked permission to tell his daughter, who was pregnant, about his diagnosis, he refused.

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In The Fourth Estate (RCGP 2017; 67; 241-288), Roger Jones (editor) points out the problems of a media intent on selling bad news, and instead recommends:

“The print and digital media are potentially enormous forces for good. If I were the editor of a national daily, I would sleep more soundly if I thought that my newspaper had contributed to GP morale and recruitment by enhancing the image of the profession, rather than denigrating GPs trying their best to do a good job under very difficult circumstances. Newspapers are keen on ‘watchdogs’, and it is worth pointing out that the health watchdog, the Care Quality Commission, has recently rated 88% of all general practices as either good or outstanding. And GPs still have the highest approval ratings in the NHS.”

In the same journal another editorial is about ” Secrecy and coercion in the QOF (the method of paying GPs by performance) : a scandal averted? ” by Charlotte Williamson.

…”Information about the QOF is in the public domain, posted on the internet.9 But patients and the public are not alerted to this resource and so cannot search for this crucial information. GPs’ surgeries seldom (if ever) provide leaflets about it. Over the last few years, I’ve asked many friends, strangers, and fellow patients in hospital clinics if they have heard of the QOF. Few have. All were surprised or dismayed when I then outlined the financial angle. In our conversations, some patients told me about their experiences of the QOF, once they realised that some of their care had probably been affected by it.

Within the GP–patient consultation, reticence had ruled for these patients. ‘It was never mentioned’ said one patient who knew about from other sources. Most other patients are probably unaware of the QOF and its financial implications. If then they consented to a rewarded clinical action, that consent was obtained coercively, without respect for their autonomy. In addition, when patients were called to the surgery, they could fear that their GP knew something ominous about their health that they did not. (I talked with one patient just after she had received such a letter; she was upset by it.) When they were offered tests or screening, they could suppose that was due to their GPs’ professional concern. So secrecy can deceive patients about something as fundamental to medical practice as the doctor–patient relationship.”…

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Who on earth should health workers vote for? “Infantilised as a democracy….”

For those of us in the Health Services this is the most important issue facing us all, and yet all our options in voting are dishonest.. I would like to know it was built on a rock before I die, but increasingly this looks less likely. Issues such as GP indemnity and recruitment are brushed under the carpet. Professional leaving the health services are forgotten or ignored. Exit interviews are virtually unknown. Honesty is dying, and the infantile approach of the media lets politicians off the hook on ideological issues. (Such as whether we can afford care, and new methods of funding).

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Matthew Paris in the Times 27th May opines: May won’t say it but Brexit is all that matters – It’s time the PM talked about the most pressing issue the country faces — and helped restore her damaged reputation

….What the hell are we doing having a general election just as the British government embarks on decisions about our nation’s future that will define the country we leave to our successors — without talking about Brexit?

We’ve been talking about grammar schools. They aren’t going to happen. Never were. No return to the 1944 Education Act. The whole debate has been much ado about little. We’ve been talking about social care, and dementia; and ended up with a consultation that will totter into oblivion, and a few modest tweaks.

We’ve been talking about “capping” energy prices. This won’t happen either. Some token caps will be imposed and the market will find ways to dodge them, just like last time in the 1970s. And now we’re talking about security and terrorism. The micro-debate — how to safeguard — is fairly pointless as we hardly know what our security services are up to and we probably shouldn’t. The macro-debate — how we got here in the first place — has already been won by Jeremy Corbyn. That invading Iraq, Afghanistan and Libya was anything but a blunder is now believed by very few people in Britain, most of them newspaper columnists.

Education spending? The NHS? Whatever is said now, ministers after June 8 will set their faces against hefty increases in spending, only to be worn down gradually by the pressure of evident need.

Meanwhile we sail almost silently onward towards the biggest, hardest negotiation our country has faced in my lifetime. And nobody speaks. Theresa May is all but struck dumb. The Labour Party is muted, trying to avoid an argument about whether it even wants this to happen. The Lib Dems, led by a glorified bingo caller, duck behind the cover of a hoped-for second referendum.

Will nobody talk about Brexit? Are we to enter the polling booths in 12 days with the biggest question all but undiscussed, still hanging above our country? It would be like conducting a British general election in 1938 without mentioning the Third Reich…..

What’s to happen to farming? Will there still be subsidy, and how targeted? Food imports: is protecting our farmers a red line in trade deals we hope to negotiate with food-exporting nations? The City? Is getting a special deal on equivalence in financial rules a priority?

How about immigration once we’ve taken back control? We make country-by-country rules, and will for the EU as a bloc. Any thoughts, Amber Rudd? Don’t business, the City and farming need to know before they vote? What analysis has been done (or planned) of the costs to our economy of migration limits?

It’s not enough for Theresa May to say we’ll keep the “soft” border with the Republic of Ireland. How? This is desperately important.

If we want to stay with Europol, the European arrest warrant, the Schengen information system, how do we reconcile this with the European Court of Justice’s jurisdiction? Does the Manchester atrocity affect priorities? Have we assessed the costs of setting up new bureaucracies if we leave EU regulatory agencies on medicines, competition, aviation safety and the like?

With Donald Trump looking flaky and Nato shaky, might we seek associate membership of the EU’s foreign and defence policy-making? Or are we prepared to depend entirely on America?…

May says “no Brexit deal” is a possibility. Would we then raise tariffs against countries (including the EU) that impose tariffs against us? Or do we believe in open trading even where others don’t reciprocate?

These questions are capable of discussion now. Of course the British government can’t fully “reveal its negotiating hand” but major insistences (leaving the single market and customs union) and major concessions (paying our fair share of the bill for divorce) have already been announced. These have consequences. Both major parties owe the electorate a look-in on their thinking about how to approach them.

We’re being infantilised as a democracy. May, meanwhile, is in some trouble this weekend. She needs to break out of an impression of haplessness that can only feed itself if she goes silent. How better, 12 days before this country’s last chance to vote on Brexit, than by a fireside chat in which she trusts us with her thoughts? Or is the cupboard bare? People will begin to wonder.

Chris Ham (kings Fund) is afraid to mention rationing. So is everyone else. A plague on all their houses?

What does the engaged profession think: “Lead ‘national debate’ on what services NHS should cut, GPC told”

With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness.

The dissonant ideology between social care and the NHS: “One is heavily rationed and means-tested, the other free at the point of use and tax-funded”.

There are thousands of “ranting doctors”, but they keep their rants to themselves. Times for honest and open “exit interviews”.

An exodus because of poor planning and the shape of the job. Deprofessionalisation….

BMJ 18th May: Next government must tackle GP indemnity costs, royal college says

infantilizationmeme

What does the engaged profession think: “Lead ‘national debate’ on what services NHS should cut, GPC told”

The sensible voice of the small number of the profession still engaged with the political decision making has come up with overt rationing of some low cost high volume services. This of course has no chance with the politicians or the media.. but it says it all in two motions. In Wales NHSreality would add “Reintroduce prescription charges. Give GPs the right to prescribe privately when this will save the patient money”.

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Caroline Price reports in Pulse 24th May 2017 “Lead ‘national debate’ on what services NHS should cut, GPC told”

Grassroots GPs have instructed the GPC to launch a ‘national debate’ with Government and health bosses on what care the NHS should stop funding.

The policy was devised at the annual LMCs Conference, where delegates argued GPs are getting the blame for ‘postcode lottery’ rationing decisions that are preventing patients from accessing treatments.

Delegates voted in favour of a motion proposing the GPC ‘engages the country in debate on what should be rationed’ – despite counter-arguments that the new policy would ‘play into the Government’s hands’, and warnings from GPC that it would detract from work on other more GP-specific concerns.

Proposing the motion, Dr Brian McGregor from North Yorkshire LMC said: ‘GPs are left holding the baby and having to have that discussion with the patient – yes, we can do something for this but I can’t because the CCG won’t let me, you don’t tick the boxes…

‘What we need is for GPC to take a lead on this, get politicians and management involved and actually bring in some guidelines that don’t give us a postcode lottery, that actually give quality of care to everybody and make it clear for everyone that this is the system, this what you need to do and this is where you get your care from.’

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But, arguing against the motion, Dr Annie Farrell from Liverpool LMC said passing it meant ‘playing right into the current Government’s hands’.

She said: ‘This Government is doing much more than just not discussing this, it is actively promoting untruths or “alternative facts” about funding for and availability of care for patients within the NHS.

‘Rather than playing into their hands and doing the Tories’ dirty work for them and colluding with the Government in rationing care, the GPC should be aggressively challenging this misinformation… and promoting the model of a properly funded NHS through taxation which is a viable option if there is a will in the country to do it.’

Speaking on behalf of the GPC, Scottish GPC chair Dr Alan McDevitt also urged conference delegates not to pass the motion.

He said: ‘You keep telling us at GPC our job is to represent GPs and we should spend our time, money and effort represent you.

‘The effort to do this to engage the whole nation in a discussion of [wider NHS rationing] could consume all our energies for years to come.

‘We would also be seen as having a vested interest in that.’

But despite the plea, LMC delegates voted to pass the motion.

Later on in the debate, grassroot GPs also set out GPC policy to push for negotiators to ensure GPs are no longer required to write prescriptions for over-the-counter medicines and foods.

Although Dr Shaba Nabi from Avon LMC said this also counted as ‘a form of rationing’ she added: ‘We need it, GPs in deprived areas are drowning in demand.

‘Patients are not coming to see us because they want clinical expertise but because they want a free prescription, because they believe they are entitled to.’

Dr David Wrigley, BMC council deputy chair and GPC member, warned this would be ‘catnip’ to the Government, as ‘GPs making the decision to restrict medicines or services, or introduce co-payments, is just what they want to hear’.

Dr Wrigley said: ‘This will be the thin end of a very large wedge.

‘More medicines will be deemed unsuitable for the NHS to pay for.’

But indicating support for the motion, GPC prescribing lead Dr Andrew Green said that as it did not suggest GPs could not prescribe items where necessary it did not amount to rationing.

He said: ‘It is about protecting GPs from doing work they don’t have to do.’

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The motions in full

Rationing

‘That conference believes NHS rationing is happening, and politicians will not discuss this due to the implications; conference demands that GPC shows some genuine leadership and engages the country in debate on what should be rationed.’

OTC medicine

‘That conference demands that NHS prescriptions are no longer required for the NHS provision of:

i) OTC medications

ii) Food products’

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With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness.

 

Don’t kid yourself. You could get mentally ill. This is why so many GPs and consultants are looking to go part time. The result is less continuity of care, and especially in GP land, lack of the doctor patient relationship which stopped complaints and led to understanding. I used to look after mild anorexics myself, and there is evidence that they do worse in the hands of the “experts”, but then of course only the worst get to the experts. Now a new NICE guideline means they will all go into the mental health system.. Without continuity of care perhaps this is just as well.

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With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness. It is so sad that with no votes in it, no large party is really interested in mental health.

40 % of primary care is mental health, and yet GPs do not all get mental health training.

In the Times 23rd May 2017 Kat Lay reports: Police investigate up to 20 deaths at mental health unit

Police are investigating the deaths of “up to 20 patients” at a mental health facility in Essex.

Last week an inquest ruled that the authorities had failed to protect Richard Wade, 30, who died in May 2015 after staff at the Linden Centre in Chelmsford failed to confiscate the item he used to hang himself when he was admitted.

Matthew Leahy, 20, died at the centre on November 15, 2012. The inquest into his death concluded there had been “multiple failures”.

The court heard that observation slots were missed, the ward was short staffed and no care plan was put in place for Mr Leahy after he was sectioned on November 7.

The two men were among seven inpatients known to have died at the centre since 2001, all of whom had attached a ligature to fixtures or furniture. Mr Leahy’s mother, Melanie, said that Essex police had told her they were “still investigating my son’s death but are also looking at . . . up to 20 patients, who all died by the same means”.

A Care Quality Commission report in 2016 on the Essex Partnership Trust, which runs the Linden Centre, found improvement was required at the trust and said that there were too many places where patients could hang themselves.

It warned: “Over the past five years, CQC inspectors, along with Mental Health Act reviewers, have inspected this trust several times. Each time we have identified problems that the trust needed to address; for example regarding safety at both the Linden Centre and the Lakes locations. Each time the trust had given assurances and then has not done so.”

Ms Leahy welcomed the fresh investigation and said: “I have worked tirelessly to collect evidence going back to 2001, which proves the trust knew about the ligature points on the ward.

“As proved by the Care Quality Commission inspection in 2015, the wards were not up to the standard required to ensure patient safety.

“The trust had been advised to change things after other patient deaths.”

One nurse, who left the trust in mid-2016 after a decade, speaking anonymously to the BBC, said that ligature points had been identified “many years before” Mr Leahy’s death but had not been resolved.

“If you asked too many questions you were deemed as a troublemaker and things made difficult for you,” he said.

A spokesman for Essex police said that the force was “conducting initial inquiries into a number of deaths which have occurred at the Linden Centre since 2000”.

He added: “This work follows further allegations surrounding the death of Matthew Leahy at the facility in Chelmsford on November 15, 2012.

“We would not put specific links to specific deaths, the research phase will look at the circumstances of a number and then identify those that may have a link due to the circumstances of how the individuals died.”

A spokesman for the Essex trust said the serious incidents were of “great concern” and the trust was “improving systems to ensure that investigations are carried out rigorously. The trust will co-operate with any police inquiries.”

Greg Hurst in The Times 24th May: Refer anorexia cases immediately, GPs told

Mental health now area of most public concern within NHS

No place but cells for those having mental breakdowns

The cost of poor mental health

The production line mentality of government. They are behaving like the worst employers..

Plan your hospital advocate…. NHSreality warned you that it was happening near you. The problems of Mid Staffs and Sussex Mental Health services are endemic, and Christmas is not a time to be ill..

1 in 5 mentally ill children turned away by the NHS. The “random walk” of health care decision making…

There is no money – and now there are no beds! Mental Health is a jungle…

Despite the crisis in child and adult mental health – The (depressing!) message that most politicians give us is that there are no votes in it.

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The dissonant ideology between social care and the NHS: “One is heavily rationed and means-tested, the other free at the point of use and tax-funded”.

You cannot take your house with you to the hereafter. We are all going to die and pay taxes … Sure, whilst you are alive there should be an incentive to save, but there is also a duty of self-care. The balance between the states encouragement of autonomy and paternalism is the struggle between left and right wing philosophies. It is true that social care is heavily rationed and means tested – overtly.  Health is no different: it is just rationed covertly. The dissonance needs debate, and pragmatic leadership, and this is something our media will not allow.. NHSreality believes we will have to ration overtly in both Health and Social Care. There is, by the way, an incentive for individuals with the determination, means and ability to say exactly when their lives should end, saving costs and unhappiness in their family…. (About time too – Doctors ponder ending ban on assisted dying ) Using this “right” may increase the social divide..

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Richard Humphries opines in the Guardian 22nd May 2017: We have to address the faultline between social care and the NHS – One is heavily rationed and means-tested, the other free at the point of use and tax-funded. And when assets are involved, the issue becomes politically toxic

In his first speech to the Labour party conference as prime minister in 1997, Tony Blair declared that he did not want his children to be brought up in a country “where the only way pensioners can get long-term care is by selling their home”. Twenty years later this remains a politically toxic issue – even though many people with care needs might wish they had a home to sell. The events of the past few days illustrate why the bold promises of successive governments to reform the way social care is funded have come to so little.

The Dilnot commission’s proposed cap on the lifetime costs of care was accepted by the coalition government in 2011 – albeit with the cap set at £72,000 rather than the £35,000 to £50,000 range proposed by Dilnot. It even made it on to the statute book as part of the Care Act 2014, and was generally welcomed as providing protection from the “catastrophic” costs faced by the one in 10 who need care costing at least £100,000. Implementing the cap was a Conservative manifesto pledge in the 2015 election but, barely 10 weeks later, the government announced this would be postponed until 2020 as the circumstances were “too difficult”.

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While the cap was a notable absentee from last week’s Conservative manifesto, proposals that did make it included the replacement of the current means-testing thresholds with a new single limit that would allow people to retain £100,000 of their savings and assets – but, more controversially, it proposed to include the value of property in working out how much people should pay towards care at home, as is currently the case for residential care.

Following the criticism that greeted these proposals, Theresa May today promised that, if re-elected, her government will publish a green paper with proposals for an “upper limit” on now much people should pay. This about-turn reflects the difficulties faced by all governments in addressing the hard choices and trade-offs involved in resolving this thorny issue. But while the reinstatement of the pledge to introduce a cap is welcome and could help to achieve a fairer balance in how costs are shared between the individual and the state, its impact will depend on the level at which it is set: the higher the cap, the fewer people will benefit; the lower the cap, the more it will cost the taxpayer. The detail in the proposals will require carefully scrutiny.

But reforming means-testing alone does not address the deeper challenges facing the social care system. Many thousands of older and disabled people have not been able to acquire property, savings or pension pots, and instead are wholly dependent on local authority-funded care budgets that have been cut by £5.5bn over the last six years. The Conservative manifesto is silent on how much they would invest in the local authority system over and above the additional £2bn announced in the spring budget. The proposal to means-test winter fuel payments for pensioners will bring more money into the system, although it is unlikely to be enough to bridge a looming £2.1bn funding gap in 2019/20.

Nor do the proposals address the deeper inequities in entitlements between the NHS and social care. Although all three main parties are committed to further integration of health and social care, none of their proposals will remove the historical faultline between the NHS – free at point of use and funded through taxation – and social care – which is heavily rationed and means-tested. As the Barker commission concluded, this is neither sustainable or equitable: develop cancer or heart disease but not dementia, and your house and savings will be intact.

The Conservatives are right to say that reforming social care is not just about money. Big changes are also needed in the way services are delivered to offer better outcomes for people and to tackle the mounting workforce problems facing the sector. However, none of the manifestos offer any new or imaginative thinking that address the scale of these challenges. A green paper early in the term of a new government would be an opportunity to put that right.

One letter in the Times 23rd May explains the dissonance in ideology: (all are here: Letters on Social Care funding )

Sir, It seems to me that there are three types of fairness involved in paying for health and social care. First, it should not matter whether the illness requires health care or social care. Second, it should not matter where the care takes place. Third, payment should be by pooled risk paid for on a progressive basis. I would be happy to pay on this basis, and it would probably cost me tens of thousands of pounds. It is confiscatory and vindictive to require payment of almost unlimited amounts, or nothing, purely based on whether one gets ill or not. If Libby Purves is happy for her house to fund her social care, why doesn’t she propose the same system for the NHS? Life is unfair but there’s no need to introduce unfairness deliberately.

Simon Hunter

Brookmans Park, Herts

Chris Woodhead: “Britain lacks courage to help me die”

About time too – Doctors ponder ending ban on assisted dying

Affirming a right to die with dignity

Will you still be alive in five years? Take the quiz and the “Ubble” index.

The dam’s about to burst on the right to die – but politicians and administrators are either fearful or have their hands tied, or both.

Right-to-die granny, 86, starves herself to death

GPs back the right to die for terminally ill

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Mean arguments over subtle changes of direction demean the politicians… They should be discussing social care philosophy…. and the real reason for the parlous finances.

Mrs May and the conservatives won some brownie points from NHSreality today. Her acknowledging that there is not enough money, and that we don’t have a plan to provide enough for social care is refreshing. The responses of the Liberals and Labour are pathetic tickertape: word bunting for short term points with a shallow media. What she proposes is fair, and a similar form of overt rationing should arise from a subsequent debate on health.

Mean arguments over subtle changes of direction demean the politicians… They should be discussing social care philosophy and ideology…. At last one political leader is leading by discussing the unpalatable need to ration, and provide. Mrs May has not yet suggested a “mutual” but that may eventually come from a responsible opposition. I hope it’s the Liberals who agree to tell the “hard truths”… but Mr Fallon’s response was unworthy..

Henry Zeffman, & Francis Elliott report in the Times 22nd May 2017: Theresa May announces cap on social care policy as Tories’ lead dwindles

….the insertion of a pledge for “an absolute limit” left the bulk of the policy unchanged.

Under the Conservatives’ plans, property would be counted towards the means-test for domiciliary as well as residential care, but the figure for costs to be capped rises from £23,500 to £100,000.

Initially there was no further limit to liability, meaning that wealthier families risked having to spend a greater proportion of their assets to care costs. After intense pressure Mrs May has now pledged to introduce a cap — with the precise figure to be set after the election.

A cap was the central recommendation of the 2011 Dilnot Report into care funding and was due for introduction at a level of £72,000 in 2020…..

Polly Toynbee has it right when she says: Labour’s failure on the NHS is prolonging this health crisis (Feb 2017) and LIbby Purves continues to make sense today in the Times: Why I’m happy for my house to fund my care – The affluent middle classes live in disgustingly overvalued moneyboxes. It’s high time this wealth was put to better use 

…The idea is to admit that, whether you stay put or move to a care home, it will now be considered that your means-tested wealth includes your house. Only the last £100,000 of the total gets protected for your heirs. Nobody, and no surviving partner, would have to sell that house in their lifetime. But after death the state would do so, to repay the cost of publicly provided care. The protected £100,000 inheritance is four times as much as under present rules, but the clinching difference is that now the house’s value will be counted as if it were cash.

It’s a bold move, and though tweaks and explanations are needed, a necessary one. Those shouting “dementia tax” — often panicking Conservative candidates — are closing their eyes to two things. One is the reality of an ageing population. The other is that the present low, underpaid standard of home care simply will not do. Nor can I sympathise with dementia charities which, unforgivably, in their propaganda try to set sufferers against one another by complaining that if you were in hospital with cancer your care is free on the NHS, but if you are at home with dementia needing social care you have to contribute……

In Case you did not get the message Dennis Campbell reports the truth which government stooges would suppress:  NHS trusts overspend by £770m despite bailout funding – Trusts fail to limit overspending to £580m but make inroads into previous year’s £2.45bn figure…

…“There was a significant improvement in NHS trusts’ finances last year. That was [from] a combination of taking out £750m from the cost of agency staffing and delivering almost another £1bn in efficiency gains,” said Hopson.

New research by his own organisation has found that trusts ended 2016-17 with a combined deficit of £700m-£750m. “That figure would be bigger than that without the £1.8bn sustainability and transformation fund money. That money has clearly been very helpful, too,” Hopson said.

But Sally Gainsbury, a senior policy analyst at the Nuffield Trust health thinktank, said: “The £770m is a very poor measure of how much the NHS is actually overspending by. In reality, the NHS overspent by significantly more than the £770m that HSJ reports because the £770m only comes after a whole series of one-off accountancy adjustments, such as deferring payment of bills from last year into this year and changing the valuation of property [owned by the trust]….

“And there is also the £1.8bn emergency bailout funding from the Treasury. Without it, NHS overspending would probably be in the region of £2.5bn.”

However, Gainsbury added, the NHS’s real deficit at the end of 2015-16 was about £3.7bn, once bailouts were included, so trusts did genuinely improve their finances by £1.2bn during last year.

“The underlying NHS overspend, whatever it turns out to be once NHS Improvement publish their figures, is more a measure of underfunding than of NHS profligacy,” she said.

HSJ’s figures are based on figures contained in board reports for 217 of the 236 trusts and trusts’ responses to its direct requests for information.

Siva Anandaciva, the chief analyst at the King’s Fund health thinktank, said trusts ending the year £770m in the red was an “impressive” performance, given how demanding last winter had been.

But, he added: “Set against the original ambition for lst year’s deficit and given the heavy reliance on sustainabaility and transformation fudning and other financial support, the NHS provider sector clearly remains some way from a balanced financial footing.

“Most worrying is the amount of one-off actions that have been used to improve the 2016-17 position. Delaying payments to suppliers, deferring capital spending and selling land do not address the underlying financial problems facing the NHS each year.”

NHS trusts would only regain control of their finances when “the fundamental imbalance between funding and rising demand is rectified”, he added.

NHS finance experts say that none of the three major political parties’ manifesto pledges of extra money for the NHS during the next parliament will be enough to let it maintain quality of care, meet treatment waiting time targets, improve cancer and mental health services and transform the way it looks after patients.

Key bodies, such as the National Audit Office and the Commons health select committee, have claimed in recent months that the NHS’s finances are unsustainable and need to be put on a stable footing.