What happens when targets (and standards) change (decline)?

The Nuffield Trust has published a paper after John Appleby did so in the BMJ. If targets decline so do standards, and inequality increases as more citizens are tempted to pay privately. Did NHSreality ever say that we would eventually get a two tier (overall) service?

What happens when targets for waiting times change?

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2584 (Published 01 June 2017) Cite this as: BMJ 2017;357:j2584

In Soviet era Russia Pyotr Petrov, manager of the state run ball bearing factory on the outskirts of Magnitogorsk studied the new production target. The target came from the chief department for ball bearing production, part of the Ministry of Automobile and Tractor Industries. From now on the Magnitogorsk factory was to produce 200 tons of ball bearings a month. “200 tons! That’s a huge increase in the number of ball bearings,” Petrov thought, “… or is it?” At the end of the month the factory had managed to meet its target: one, 3.7 m diameter, 200 ton, ball bearing.

Poorly designed or badly policed targets can create perverse incentives (a giant ball bearing), but they can also provide the right motivation to improve performance. So what has been the real life experience of the NHS and its use of targets, particularly to improve waiting times?

Two targets become somewhat iconic: one arising from the Labour Party’s 2007 manifesto pledge that “by the end of 2008, no NHS patient will have to wait longer than a maximum of 18 weeks from the time they are referred for a hospital operation by their GP until the time they have that operation” and the other, a maximum wait in accident and emergency departments for patients of four hours (before being admitted, discharged, or treated).

The referral to treatment target covered two separate standards—that a minimum of 90% of patients admitted to hospital should wait less than 18 weeks from referral by their GP, and that 95% of those seen in outpatients (“non-admitted”) should have waited no longer than 18 weeks. In April 2012, a third overarching target was added covering patients still waiting for treatment—that 92% of what were called “incomplete pathway” patients should not wait longer than 18 weeks.

But in October 2015 a review of what had now become quite a complicated set of targets recommended dropping the two earlier standards1 as the new target essentially did the job—covering patients’ total waiting experience from referral to treatment and included all patients waiting, not just those seen in outpatients or admitted as inpatients. It also avoided the perverse incentive that once a patient still waiting had tripped over the 18 week limit, as soon as they were seen in outpatients or admitted into hospital, a trust would then automatically fail on the old targets as well.

As figures 1 and 2⇓ show, by the time these targets were dropped, the percentage of patients who waited more than 18 weeks before being admitted or seen in outpatients had been on a rising trend since 2012, leading to breaches of the targets in 2014 and 2015. Since then, perhaps unsurprisingly as the targets have been dropped, the percentages of patients who waited more than 18 weeks for admission or being seen in outpatients have continued to rise—and now stand at 22.6% and 9.7% and respectively.

 

Fig 1 Percentage of admitted patients who waited more than 18 weeks from referral by their GP (English NHS).5 Estimated performance from October 2015 is author’s calculation based on historical relation between adjusted (not published since October 2015) and unadjusted statistics (which continue to be published). Adjusted figures allow for various waiting time clock stops and starts due, for example, to patients refusing offered admission dates

 

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Fig 1 Percentage of admitted patients who waited more than 18 weeks from referral by their GP (English NHS).5 Estimated performance from October 2015 is author’s calculation based on historical relation between adjusted (not published since October 2015) and unadjusted statistics (which continue to be published). Adjusted figures allow for various waiting time clock stops and starts due, for example, to patients refusing offered admission dates

 

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Fig 2 Percentage of patients seen in outpatients who waited more than 18 weeks from referral by their GP (English NHS)

Meanwhile, the one remaining target—that at least 92% of patients still on waiting lists should not be waiting more than 18 weeks—has also been rising, to the point where at a national level the target has not been met for the past 12 months (fig 3⇓). This fact is probably not unconnected to recent suggestions that this target will be “relaxed” in recognition of continued funding constraints.2

 

 

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Fig 3 Percentage of patients still waiting longer than 18 weeks for treatment (English NHS)

 

The story is similar for the four hour waiting time target for emergency departments (fig 4⇓). Although generally met across the country, in 2011 the then target that 98% should be treated, discharged, or admitted within four hours of arrival was changed to 95% because the NHS complained that there was not enough leeway to deal with patients who, for clinical reasons, may need to wait longer than four hours.

 

 

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Fig 4 Percentage of patients waiting more than four hours in emergency departments to be treated, discharged , or admitted to hospital (English NHS)

 

Within four years, the proportion waiting over four hours had risen to meet the new target, and from December 2014 it has consistently been breached nationally. As with the referral to treatment target, it seems that the widespread inability of the NHS to meet the four hour target is likely to lead to its “relaxation.” Already the government has dropped the fining system for around 40% of hospitals with particular difficulties3 and suggested restricting the target to the most urgent cases.4

Is there a lesson in all this? Perhaps it’s that targets can work but there are likely to be unintended consequences and, for systems already operating at their productive limits, universal failure.

Footnotes

• Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare

• Update 18th Jan 2021
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Millions of needless NHS 111 referrals to hospitals and GP surgeries

Ever since GPs we allowed to contract out of Out of Hours (OOH) the service for patients has been worse. The knowledge of both medicine and the families who rang him, allowed GPs working in co-operatives to manage calls appropriately. This was the highlight of my career as a GP, and the teamwork involved was superb. Even continuity of care for the palliative and terminally ill was catered for by many GPs who gave their mobile phone number to the co-op doctor. The decision to stop our co-operative was taken by our trust. At the time, Trusts were not allowed GPs on the board , and they still don’t want to listen to GP opinions today. Cluster meetings imposed by the Welsh Government are attended simply to avoid financial loss…. GPs can revive the service only if they are given real power, both in implementation and in strategic planning in a rationed health service. When something appears to be free it is not valued. An insurance policy without an excess and a no claims bones is not viable – same as the UK Health Services.

Now Chris Smyth reports 30th June 2017 in the Times what GPs could have told the government straight away once Mr Blair released us from OOH: Millions of needless NHS 111 referrals to hospitals and GP surgeries

Millions of people are needlessly sent to hospitals and GP surgeries by the NHS 111 helpline, health chiefs have admitted for the first time.
Four in five referrals to GPs and A&E could be avoided if callers were able to speak to a doctor, NHS England says.
Matthew Swindells, director for operations, said most patients’ problems could be successfully dealt with by a phone consultation, sparing them the need to go to hospital or surgeries.
The 111 helpline for urgent but non-emergency problems sent a million people to A&E and seven million to family doctors in the past year.

Mr Swindells said: “If the patients were told by the guidelines that they should go to their GP, if they talk to the GP on the phone 80 per cent of them don’t need to go to the GP.” He said that for those told to go to A&E, 85 per cent did not need to go if they could speak to a doctor over the phone.

The helpline has been dogged by claims that it sends too many people to hospital because it relies on call handlers with no medical qualifications who follow a risk-averse algorithm.

NHS 111 sends out 20,000 more ambulances a month than its predecessor NHS Direct, which was staffed by nurses. NHS England has long insisted that 111 prevented people going to A&E, but in March it admitted the service needed more doctors and nurses.

Within a year it wants a third of callers to be able to speak to a doctor or nurse, up from 22 per cent now, “so that only patients who genuinely need to attend A&E or use the ambulance service are advised to do this”.

Mr Swindells told the Health+Care conference in London that the changes were “about enhancing 111 so that when you ring you don’t just get shifted somewhere else; you actually get a clinical consultation”. Research this year found that a quarter of people going to A&E with minor problems had called NHS 111 or an ambulance first but were not given proper help.

Mr Swindells says family doctors must “deliver the first contact of care that was necessary so that people don’t turn up at GP practices, so that people don’t turn up in A&E”, Pulse magazine reported.

Chaand Nagpaul, the head of the British Medical Association, said far too many patients were coming to surgeries for “inappropriate or bureaucratic purposes” such as sick notes.

He said one in four appointments were taken by people who could have waited to get better, seen a pharmacist or needed paperwork.

“Not wasting GP appointments is also key to addressing hospital pressures,” he said at the BMA conference in Bournemouth.

Metal on metal hips – an update

The oversight of the development and introduction of new medical devices, and the evidence needed to start using them is much inferior to the evidence demanded for new drugs. This needs to change and the Metal on Metal story illustrates this well. The litigation alone is going to cost the earth…

Chris Smyth reports 30th June in the Times: Metal hip replacement patients recalled for tests

Tens of thousands more patients with defective hip replacements will be called in for regular checks after it emerged that even those with no symptoms could be at risk.

All patients with metal-on-metal hips should have scans and blood tests to spot emerging problems, regulators said yesterday.

Surgeons say that by the time symptoms emerge it is sometimes impossible to replace damaged joints properly. They want to monitor hips for longer so that they can be replaced more easily, as further evidence shows that implants can fail more than a decade after they were put in.

Metal-on-metal hips were often used in younger patients as it was thought that they would last longer than plastic or ceramic implants. However, problems surfaced a decade ago when it became clear that the hips wore faster, shedding tiny metal particles into the joint. This can cause damage to bone and surrounding tissue, causing painful symptoms and irreversible harm in some cases.

Metal-on-metal hips are no longer implanted and the Medicines and Healthcare Products Regulatory Agency last issued guidance five years ago, saying people with the implants should see a doctor if they had pain, swelling near the joint or problems walking. People with some makes of hip were advised to have more regular surveillance.

The agency is updating its guidance to say that all 56,000 people with such replacements will need regular checks even if they have no symptoms. These involve questionnaires, x-rays, MRI or ultrasound scans along with a blood test to look for metal ions. Raised levels can indicate an implant that is failing.
Neil McGuire, clinical director of medical devices at the MHRA, said: “Although the majority of patients with these metal-on-metal devices have well-functioning hips, it is known some may develop soft tissue reactions. Clinical advice indicates patients will likely have the best outcomes if these problems are detected early, monitored and treated if necessary.”
Evidence has mounted that waiting too long could make it “almost impossible” to do a full repair, Dr McGuire said. “The information we’ve been working through does suggest that if people have emerging problems, if they are being followed up closely with appropriate imaging, you’re in a better position to decide if something needs to be done or not. We’re trying to avoid any patient getting to the point where they have to have a revision and the surgeon finds the job is more difficult.”
Checks could range from every year to once in seven years, depending on the type of device and symptoms. Replacing the hip should be considered if there are signs of problems on the scan, blood metal levels are rising, or if function is deteriorating, the guidance says.
Dr McGuire said it was also now clear that problems could emerge after many years, changing the calculation as the devices neared the end of their lives.

Immoral Science (and research) – e.g. NHS to ban ‘toxic’ metal-on-metal hip implants

Orthopaedic wounds heal better WITHOUT staples. But District General Hospitals are still using staples.

Litigation has the potential to kill the Health Services: More than 800 women sue NHS and manufacturers over vaginal mesh implants

After failing to tax sugar – Doctors want warnings on sweets and chocolate to scare children off sugar…

Lets face it, it’s the same ignored and disenfranchised families in the Grenfell tower as the people who don’t get to the dentist. They are an important sub-group. The dental contract needs renewal, and dentists are altruistic enough to want a service that prevents both long term and short term complications. If the BDAs approaches have failed to make caries important (short term) then perhaps the emphasis on preventable heart valve disease (long term) will make government see sense. NHSreality still feels there are too many perverse incentives in a system where the surgeon is the same person as the assessor…

Chris Smyth of The Times reports 30th June 2017 on the BMA ARM conference: Doctors want warnings on sweets and chocolate to scare children off sugar

Warnings on sweets and chocolates are needed to scare children off sugar and help to fight tooth decay and obesity, the British Medical Association has said. The labels could include pictures of rotten teeth and overweight children, although milder “traffic light” warnings may also be considered.
The BMA also wants free toothbrushes for children under five, and for schools to teach children about brushing their teeth to help cut the “shocking” number who need surgery.
A third of children are overweight or obese when they leave primary school and tooth decay is the most common reason for children to be admitted to hospital. The BMA said tougher action was needed after Theresa May dropped plans to curb promotion of junk food in a government obesity strategy last year.

Iain Kennedy of the BMA said 18,000 children under five had been admitted to hospitals in the past two years to have teeth removed, often under general anaesthetic. He said: “Doctors are calling on the government to help prevent further children from needing these operations by regulating food manufacturers to place warnings on sugary foods.”
Mick Armstrong, chairman of the British Dental Association, backed the plans, saying: “These simple steps could ease a huge burden being felt across the NHS. Political indifference has allowed a preventable disease to become the number one reason for hospital admissions among children.”

Graham MacGregor of Action on Sugar said: “We should have warning labels and they should show rotten teeth, people who are obese and amputated legs, because that’s the reality.”

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Five million children failed to see a dentist in past year..

How do politicians of all parties maintain that the NHS is free at the point of delivery? Dental care is certainly not..

Open Wide – The system for dental care is letting patients down. Regulatory gaps need filling and dentists seem to agree..

Patients at risk as GPs face forced shutdown – will Primary Medical Care follow Dental Care into being covertly rationed?

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…

 

Whistleblowing law is expanded.. but hardly applies to GPs

The Times Law Report on 26th June: More than one employer can be liable to ‘whistleblower’

The trouble is that GPs are self employed and have no whistleblowing liable employer. However, GPs are more and more “portfolio” a career doctors with some time as partner or salaried partner, some time as educator, some time as referral centre letter reader, sometimes as Out Of Hours doctor or A&E assistant.

Court of Appeal

Published: June 26, 2017

Day v Lewisham and Greenwich NHS Trust and Another

Before Lady Justice Gloster, Lord Justice Elias and Mr Justice Moylan

[2017] EWCA Civ 329

Judgment: May 7, 2017
For the purposes of the protection for “whistleblowers” in the workplace, a person in training might be employed by both the employer with whom he had been placed and the training body that had made the placement, if the training body had substantially determined the terms under which he worked.
The Court of Appeal so stated when allowing the appeal of the claimant, Dr C Day, against the dismissal by the Employment Appeal Tribunal (Mr Justice Langstaff) ([2016] ICR 878) of his appeal against a decision by an employment tribunal to strike out his claim against the second defendant, Health Education England, that it had subjected him to a detriment for making a protected disclosure or “whistleblowing”. The first defendant was Lewisham and Greenwich NHS Trust. Public Concern at Work intervened in the proceedings.

Part IVA of the Employment Rights Act 1996 (as inserted by section 1 of the Public Interest Disclosure Act 1998) provides, so far as relevant:
“43K(1) For the purposes of this Part ‘worker’ includes an individual who is not a worker as defined by section 230(3) but who (a) works or worked for a person in circumstances in which (i) he is or was introduced or supplied to do that work by a third person, and (ii) the terms on which he is or was engaged to do the work are or were in practice substantially determined not by him but by the person for whom he works or worked, by the third person or by both of them . . . and any reference to a worker’s contract, to employment or to a worker being employed shall be construed accordingly.
“(2)(a) For the purposes of this Part ‘employer’ includes (a) in relation to a worker falling within paragraph (a) of subsection (1), the person who substantially determines or determined the terms on which he is or was engaged . . .”

Mr James Laddie, QC and Mr Christopher Milsom for the claimant; Mr David Reade, QC and Mr Nicholas Siddall for the second defendant; Mr Thomas Linden, QC, for the intervener.

Lord Justice Elias said that Part IVA of the 1996 act, read together with sections 47B and 103A (as inserted by sections 2 and 5 of the 1998 act), protected workers who disclosed information about certain alleged wrongdoing to their employers (colloquially known as “whistleblowers”) from being subjected to victimisation or dismissal as a consequence.

The appeal concerned the proper construction of section 43K and the application of that section to a certain category of doctors operating in the health service.

The claimant was a doctor who wanted to specialise and was accepted by the body then responsible for training doctors in London to take up a post from August 2011. He entered into a training contract that the parties agreed was not a contract of employment. He was allocated to the first defendant NHS Trust. Subsequently, the training body was taken over by a training board that was part of the second defendant, Health Education England.

Trainee doctors were allocated for relatively short fixed periods to NHS trusts. They entered into contracts of employment with each trust. The claimant worked, inter alia, at the Queen Elizabeth Hospital. While there, he raised a number of concerns with both the trust and with the South London Health Education Board about what he considered to be serious staffing problems affecting the safety of patients.

He alleged that those were protected disclosures within the meaning of the legislation on whistleblowers and he asserted that he was subject to various significant detriments by the second defendant as a consequence. He took proceedings before the employment tribunal against both the trust and the second defendant, as the body responsible for the actions of the South London Board.

The second defendant denied any wrongdoing, but took a preliminary point. To bring a whistleblowing claim the claimant had to fall within the statutory definition of worker and the defendant had to be his employer. The second defendant contended that that was not the position and, accordingly, that even if the facts alleged by the claimant were true, the second defendant could not be liable in law for any acts causing him detriment.

The only question was whether the claimant was a worker within the extended definition in section 43K and the second defendant was his employer as defined in that section.

His Lordship would refer to the person for whom the individual worked as the end-user and the party introducing or supplying that worker as the introducer. It was envisaged in section 43K(1)(a)(ii) that the terms on which an individual worked might be substantially determined by both the end-user (the heath trust) and the introducer (the training body). That might be either because the introducer and the end-user determined the terms jointly, or because each determined different terms but each to a substantial extent.

The extended definition of “employer” in section 43K(2)(a) was not limited to the person who played the greater role in determining the terms of engagement. Since both introducer and end-user could in principle substantially determine the terms of engagement for the purposes of the definition of worker, there was no basis for concluding that they could not do so when it came to applying the extended definition of employer.

That would in some cases have the effect that both introducer and end- user were employers and each would then be subject to the whistleblowing provisions. Indeed, that would seem to be an inevitable conclusion if the terms were determined by the end-user and introducer acting jointly. If only one party could be the employer, it was difficult to see by what principle it would be possible to determine who that should be.

The Employment Appeal Tribunal had been wrong to find that the fact that the health trust was a section 230(3) employer precluded the training body from also having that status.

There had to be some limitation on the words of section 43K, which began by providing: “For the purposes of this Part ‘worker’ includes an individual who is not a worker as defined by section 230(3) . . .” The insertion of some such phrase as “as against a given defendant” after “includes an individual who” would allow the section to operate against one of those parties even if there was a section 230(3) relationship with the other.

Accordingly the training body could in principle fall within the scope of section 43K(2)(a), notwithstanding that the claimant had a contract with the hospital trust.

The employment tribunal had not engaged directly with the question whether the training body itself “substantially determined” the terms on which the claimant was engaged. A tribunal should not limit itself to focusing solely on the contractual terms, although no doubt the terms would be overwhelmingly contractual. The section required the tribunal to focus on what happened in practice.

When determining who substantially determined the terms of engagement, a tribunal should make the assessment on a relatively broad brush basis having regard to all the factors bearing upon the terms on which the worker was engaged to do the work.

The case would be remitted to a fresh tribunal for determination of the preliminary issue whether the training body substantially determined the terms of engagement of the claimant.

Lady Justice Gloster and Mr Justice Moylan agreed.

Solicitors: Tim Johnson Law; Hill Dickinson, Manchester; Solicitor, Public Concern at Work.

Whistleblowing in the NHS – how safe are you? (Sharmila Chowdhury 4 August 2014)

[PDF] Wales’ GP Heroine Whistleblower…. The Spectator reveals “How the …

NHS reality. An NHS soapbox. Speakers’ corner for the NHS …400 × 305Search by image

The Spectator reveals “How the NHS silenced a whistleblowing doctor” – No cultural change yet… | NHS reality. An NHS soapbox. Speakers’ corner for the NHS.

Reflections on the BMA conference in Bournemouth. A complete lack of trust..

ARM 2017 in Bournemouth

The annual representative meeting (ARM) is the BMA’s main policy-making body. Around 500 doctors from across the profession and the UK gather to consider and debate key matters of interest to the medical profession.

I have never been to a BMA conference before. his conference from 25-19th June was an eye opener. The volume of business, and the number of people was daunting. Agenda items ranged from the political to the clinical. and some of us thought some issues would be best addressed by politicians. Throughout the meeting there was a complete lack of trust by doctors of government, dishonesty, and denial by politicians and administrators, and resulting anger and resentment in the body politic. This is spreading beyond the profession and the unrest following the Grenfell tower will be as nothing to the unrest as the health safety net is seen to fail.

BMA council chair Mark Porter – opening speech  – Health Service running on fumes

STPs(Stick Toffee Puddings , or Slash Trash and Privatise

Agenda Items on Monday of which I as speaking at 1:34 into the meeting

Dr Roger Burns speaks up abut West Wales. (https://pharmaphorum.com/news/millions-affected-nhs-cuts-doctors/#) in response to Motion 16 (I):

Recognises that greater medical involvement in the design and planning of health care is crucial in ensuring that improved patient services are properly designed and effectively implemented.

There were plenty of retired members present, of whom I am one. It looks as if the retired members are trusted to represent their younger and busier colleagues. What is need is a way to vote from a distance. Members need to log into the website and watch a webcam and be prepared to vote at an instant. This would allow members to check in and relate to any particular motion but ignore others.

There was a couple of motions with the implication of rationing, but without mentioning the word itself:

Motion 12 (v) “Calls for government and NHS lead bodies to have an open dialogue with the public and patients about what services the NHS should provide for the funding available, and what services should no longer be funded by the NHS.

New attendees need to be aware that they need a speedy induction if they are to take advantage of the opportunity to speak. New conference members, and those who vote against a motion are given preference. I spoke out about the reconfiguration of Wales Health Trusts. NHSreality is in favour of one NHS trust for 3 million people, and this would at least endure choice within Wales. I spoke against the motion on the grounds that it failed to mention rationing, and the need for the politicians to get on board with this concept before we can make sense of the health service, and bring the hearts and minds of the doctors on board. Sometimes “hard truths” need to be said. Napoleon did this with the French after their revolution. By offering to bring order he took away a little liberty. Lack of choice is a loss of liberty, but it may be worth it if standards of treatment for important and expensive problems rise.

All local BMA groups need to plan ahead of the ARM to present notices of motion. Clinical and social meetings are also needed, and could be combined with politics.. My suggestions to be considered for the future include:

Wales residents should be given choices within Wales. If this can only be facilitated by one Health Trust then we support this proposal.

All Wales staff should be offered exit interviews by the BMA, and if they wish, in conjunction with other organisations such as the Nurses and Midwives, and other professions. Since no credence would be given to a summarised internal HR report, external consultants should be charged with this task.

In West Wales infrastructure needs to be improved, especially for travel, but also to replace old buildings and plant.

Medical Publications should always inform the reader if the paper was rejected by another publisher. The on line information should then reveal why rejection occurred.

All Wales BMA members should be offered the option of group/mutual medical insurance

and for local debate: A decision not to build a new hospital at Whitland / Narberth in 1996 is to be regretted.

Henry Bodkin in the Telegraph 27th June: Doctors call for abortion on demand as BMA votes to decriminalise terminations for first time ever 

Ann Furedi comments for BPAS: Why UK abortion laws should be scrapped – they are 50 years out of date 

Pharmforum comments on STPs on June 28th: Millions will be affected by STP health service cuts, say doctors

Hunt stayed silent over 700,000 lost letters to patients (The Telegraph)

Crowdfunding of Wheelchairs

UK falls behind in International league of doctor numbers (BMJ)

Government using GPs as scapegoats instead of taking responsibility for crisis in NHS

Margaret McCartney: Health inequality has to be political BMJ 2017;357:j2978

 

BMA annual meeting: GPs working at unsafe levels should issue “black alert”-style warnings, says BMA (Wales sees steep rise in “at risk” surgeries.

Frances Gibb in the Times 27th June: Medical negligence payouts ‘unaffordable’

Doctors call for national rules on OTC prescribing (BMJ 25th March)

BBC2: Hospital – How do you cost life? 

Kat Lay in the Times 12th June: NHS blocks drug to help babies with spinal muscular atrophy

London commissioning group plans to restrict cataract surgery

Oliver \moody on 26th June: NHS urged to find money for cystic fibrosis drug

Kat Lay: ‘Overworked’ GPs demand to close their surgery doors

 

 

 

 

 

Doctors let dying patients waste their last days in Accident and Emergency

Since the GP was excused from covering Out of Hours, the quality of continuity of care and palliative care has fallen. Care in the community (Hospice at home etc) is much more affordable, and sustainable than in patient care, especially in rural areas. It has to become normal to die at home..

Chris Smyth reports in the Times 14th June 2017: Doctors let dying patients waste their last days in A&E

Tens of thousands of dying cancer patients spend their final year in and out of A&E because doctors are reluctant to tell them the end may be near.
Some are taken to hospital every other week in pain or struggling to breathe because of a lack of proper palliative care, analysis of NHS data shows.
Patients and their families wasted precious time in a “revolving door” of emergency treatment that was unlikely to extend their lives, said campaigners. They urged the health service to stop poor co-ordination between hospitals and local services.
One in ten hospital inpatients will die during their stay, but a review of services by the Royal College of Physicians last year found big variations, with only one in ten hospitals offering round-the-clock palliative care.
Researchers at Macmillan Cancer Support have looked at data on 316,000 patients with eight of the most common cancers, finding that 90 per cent had at least one emergency visit in the last year of their life.

More than 33 per cent had to be taken to hospital five times or more, equivalent to 22,000 patients a year, the charity found.
Five per cent, or 3,000 a year, had more than ten emergency visits, researchers will tell the Public Health England Cancer Data and Outcomes Conference in Manchester today.
This included nearly 200 patients a year visiting A&E more than 20 times.
Jane Maher, Macmillan’s chief medical officer, said that hospital staff were reluctant to tell patients that they may be dying.
“We haven’t really accepted as a society that people can both have cancer treatment hoping for the best and prepare for the end of life. Oncologists find it very difficult to have those ambiguous conversations,” she said.

GPs and district nurses can help with pain relief and contingency planning, while 24-hour support lines can help people cope with emergencies out of hours, but Professor Maher said that they would only be used if people had frank discussions and there was better co-ordination to stop them “falling through the cracks”.
Some studies have found that people who have aggressive treatment to prolong their lives die sooner than those given palliative care.
Jonathan Ellis of the charity Hospice UK, said: “Sadly, many people approaching the end of life are caught in a revolving door of repeat emergency visits to hospital . . . The lack of integration between health and social care services means that alternative options to hospital, such as community-based hospice and palliative care, are often overlooked.”

Simon Chapman, of the National Council for Palliative Care, said: “One of the core ways we should be looking at the NHS is the way it looks after people at the end of their lives.”

Case study
When Audrey Girling complained of a cough, doctors said she was just getting old. It was not until she was taken to hospital struggling to walk that she was found to have lung cancer, which had spread to the brain.

Mrs Girling, from Norwich, died within six months at the age of 80. Her daughter, Chris, said she and her sister were her carers until they could not cope any more. “In terms of actual care there was pretty much nothing,” she said. “We felt we were on our own.”

Mrs Girling was adamant that she wanted to die at home, but one Friday night she started fitting and her daughter phoned the ambulance. “She was so breathless that the GP had to beg the hospital to take her at A&E. There was no alternative and we were exhausted,” Ms Girling said.

She never left. Too ill to go home, Mrs Girling “just slowly deteriorated,” her daughter said. “It was quite drawn out. It was horrible. With the right end of life care, this would never have happened and her wish to die at home would have been possible.”

 

Why not implement no-fault compensation? Because it needs a longer term perspective and a PR system to get it through.

Frances Gibb reports in The Times 23rd June 2017: Medical negligence payouts ‘unaffordable’

Reforms to curb the soaring costs of medical negligence, which could see taxpayers paying out £2.6 billion a year by 2022, must go ahead, a report has urged.
The NHS spent £1.5 billion on clinical negligence claims last year, enough to train more than 6,500 doctors, the Medical Protection Society said. The not-for-profit organisation , which supports 300,000 healthcare professionals worldwide, is calling for a package of legal reforms that would strike a balance between compensation that is reasonable but also affordable.
Its proposals include a cap on future care costs which would be paid on a tariff to be agreed by an expert working party. It also wants to use national average weekly earnings to calculate damages awarded, to avoid unfairness between high and low-income earners.

and the comments are good as well. In Wales the amount set aside for future litigation/compensation is more than one year’s budget. Why not implement no-fault compensation scheme? Because it needs a longer term perspective and a PR system to get it through. Apologies would then be like confetti..

and that’s not to mention apologies from our masters re both contract and staffing levels:

Scotland (and I hope Wales will follow) has announced legislation to protect doctors if and when they apologise. Doctors in Scotland get legal protection when apologising, explains MDU

Doctors in Scotland are being given legal protection when apologising to patients, the Medical Defence Union (MDU), explained today.

The Apologies (Scotland) Act 2016, the relevant part of which comes into force on 19 June 2017, makes it clear that an apology (outside of legal proceedings) is not an admission of liability. In the new Act, an apology is defined as:

‘…any statement made by or on behalf of a person which indicates that the person is sorry about, or regrets, an act, omission or outcome and includes any part of the statement which contains an undertaking to look at the circumstances giving rise to the act, omission or outcome with a view to preventing a recurrence.’

Mr Jerard Ross, MDU medico-legal adviser, said:

‘Saying sorry to a patient when something has gone wrong is the right thing to do and is an ethical duty for doctors. The Apologies (Scotland) Act provides further reassurance to doctors that apologising is not an admission of legal liability. In the MDU’s experience, a sincere and frank apology and explanation can help restore a patient’s confidence in their doctor following an error and help to rebuild trust. This is important for a patient’s future healthcare and can help to avoid a complaint or litigation.’

Doctors have a professional duty of candour, set out in the General Medical Council’s Good medical practice which states: ‘You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress you should put matters right (if that is possible), offer an apology, explaining fully and promptly what has happened and the likely short-term and long-term effects.’

A legal duty of candour was also introduced for health and social care providers in Scotland under The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 although it has yet to be brought into force by enabling legislation. It will mean that doctors and other health and social care staff in Scotland will have to inform patients and their families when a patient has, in the reasonable opinion of an uninvolved registered health professional, died or been unintentionally or unexpectedly mentally or physically harmed as a result of their care or treatment.

Although the Apologies Act does not apply to the legal duty of candour, the Health Act itself makes it clear that ‘an apology or other step taken in accordance with the Duty of Candour…does not of itself amount to admission of negligence or breach of a statutory duty’.

The GMC has published ethical guidance on the professional duty of candour which explains in more detail what constitutes an effective apology for healthcare professionals. This includes advice that apologies should not be formulaic and that the most appropriate team member, usually the lead clinician, should consider offering a personalised apology, rather than a general expression of regret.

In Wales the amount set aside for future litigation/compensation is more than one year’s budget.

David Williamson for Walesonline 30th Dec 2016 : More than £600m allocated to pay for clinical negligence and personal injury claims against the Welsh NHS in the future

In the last financial year £74.6m was paid out and £682m has been set aside for future payments

NHS faces ‘compensation time bomb’ as clinical negligence …  GP online–25 Jul 2016

520 results (0.30 seconds)

 No win, no fee adverts ‘common on NHS advice cards’

BBC News–28 Nov 2016

 

Leimyoscarcoma treatment options unfair…. in west Wales where choice is anathema.

I do not mind if something/some service is denied to everyone in the UK paying into the same mutual. What I do not like to hear is when someone in my town and post code is denied a treatment which is available in London. The National Sarcoma centre is at the Marsden, and there is a National Sarcoma Service. Unfortunately, unbeknown to the citizens and taxpayers of Pembrokeshire, until they suffer from sarcoma, is that this service is not available to them. This is what NHSreality calls COVERT rationing because one is not aware of it in advance. Net result is that money is raised, and this one patient gets “private” care. What about all the others in Wales? Local exclusion would be all very well for high volume low cost treatments, (this is not allowed) but is patently unjust for low volume high cost treatments. (allowed under the current “rules of the game”) Will the trust respond by saying they feel this is reasonable rationing? No way. They will use the words exclusion, restriction or prioritisation to justify their position. As a trust in special measures ( bankrupt and getting worse) it is not surprising they wish to save money… and the treatment may be poor value for money but this shows how unfair the situation is for those in West Wales, and it is repeated across many specialities and treatments.

BBC News reports today 23rd June 2017: Haverfordwest mum’s ‘roadblocks’ to SIRT cancer treatment

NHS Wales has been accused of “not being set up to deal with” certain types of cancer.

Anca Falconer, 36, from Pembrokeshire, was diagnosed with Leiomyosarcoma (LMS), a type of soft tissue sarcoma, just days after giving birth in 2010.

Her request for specialist treatment in England was refused.

The Welsh Health Specialised Services Committee said the success of Selective Internal Radiation Therapy (SIRT) “has not currently been established.”

Mrs Falconer, who lives in Haverfordwest, initially underwent extensive surgery and chemotherapy for her rare liver cancer, but it returned.

Her first request to the committee was rejected in 2013 on funding grounds, and her cancer consultant refused to submit another application, describing the efforts as being “futile”, and she was told she would have to find the money herself.

Fundraising efforts allowed her to receive the first round of SIRT, which involves injecting radioactive microbeads into the liver, at a cost of £10,000.

Mrs Falconer, who had been bedbound for about three months, said she felt transformed after the treatment.

“Within days I was able to stand up again. I can play with Mary and take her to school,” she said. “I had lost hope before.”

The second round of treatment costs £20,000 and is due by late August.

Mrs Falconer’s husband, Richard, 51, said NHS Wales was “not set up to deal with soft tissue sarcomas” with many of the specialist centres in England.

He added that he thought experts in Wales had “given up on his wife” four years ago and that she had received “nothing more than palliative care” and “roadblocks to all curative options that should have been on the table”.

Dr Sian Lewis, medical director for the Welsh Health Specialised Services Committee, said the “clinical effectiveness” of SIRT for the treatment of liver cancer “has not currently been established”.

She said it is only available to a limited number of patients in NHS England as part of a programme to assess its effectiveness.

The Welsh Government said NHS Wales will make a decision regarding the routine commissioning of SIRT when the results of the evaluation become available next year.

False hopes

Abertawe Bro Morgannwg University Health Board, which provided chemotherapy to Mrs Falconer, said if previous funding requests have been declined by the committee any subsequent submission has to contain “new clinical evidence”.

A statement from the health board said, while it could not comment on Mrs Falconer’s case, its “clinicians fully appreciate the distressing situation its patients are in”.

“It’s because of this they would never consider falsely getting a patient’s hopes up by resubmitting an already declined request when there is no new clinical evidence available.”

Hywel Dda University Health Board has also been asked to comment.

September 2016 – Mark Smith for Walesonline: Three Welsh health boards have been placed under additional Welsh Government scrutiny

Cardiff and Vale, ABMU and Hywel Dda are just one level short of ‘special measures’

Adrian O’Dowd in the BMJ 15th June 2017: Trusts boost ratings by engaging staff and including clinicians in management

Adrian Dowd in the BMJ 23rd June 2017 : The only way is up: the “special measures” trust that got back on its feet

 

Mums, you have a 1:200 risk of stillbirth – what can you do about it?

Sorting out the figures from the office of National Statistics is not easy. Comparisons between the 4 different jurisdictions are not obvious. Different countries produce figures in different years and the speciality is changing rapidly. Concentration of specialist services has been shown to work, provided transport links are good. Even remote areas of Canada and Australia can have good figures given the right infrastructure. The latest (2013) BBC report from Wales indicates there is a lot to be done in our poorest region. (Stillbirth rate ‘unacceptably high’ in Wales say AMs) The rates for the different Welsh regions are summarised and available in real time, and show that Cardiff and Vale trust is worse than Hywel Dda. 15 babies a year die daily (The SANDS charity) in the UK. It is time to address this, and locally led midwifery units at a distance from specialist centres may not help. Deprivation and smoking go together…

So what can you do about it? Mums can stop smoking, stop alcohol, stop drugs, reduce weight if obese, eat a better diet, keep active and fit, go to antenatal classes, and meet other mums for support. Moving to a richer area would not affect an individual’s risk, but if moving meant the specialist services for a high risk pregnancy were closer this might be well worth considering… The governments job is to treat populations and the illiberal success of the anti-smoking lobby is a major gain. Going privately may increase your chances of intervention (perverse incentives) and figures for private outcomes are not available from the UK. Australian results suggest worse outcomes.. Its an option not only to make the baby on holiday, but to have it away from home..

There is good news in the latest statistics, but the BBC announced yesterday that there was only one country worse in the EU and that was Malta. There is much to be done.. The Times leader on Stillbirths – by Janet Scott of SANDS.

Chris Smyth reports in the Times 21st June 2017: Better care during birth could have prevented hundreds of baby deaths

Three quarters of babies who die or are brain damaged during birth could have been saved with better care, a study has concluded.
Hundreds die each year because mistakes are repeated and hospitals must improve heart-rate monitoring and staff communication, the report by the Royal College of Obstetricians and Gynaecologists said…. almost one in 200 babies is born dead…

and on June 22nd: Stillbirth rates decline for the first time in a decade

Stillbirth rates have started to fall for the first time in a decade, according to figures that underline the importance of pressing hospitals to take action.

In 2015 about 250 babies survived who would have died two years earlier, figures that recorded an 8 per cent drop in stillbirth rates suggest. Experts said that the fall would have to speed up to meet a target to halve stillbirths by 2030.

There are also still big variations, with death rates a third higher in the worst-performing areas than in the best-performing.

The Royal College of Obstetricians and Gynaecologists (RCOG) said yesterday that three quarters of babies who died or were brain damaged at birth could have been saved had they received better care.

It was the latest in a series of reports and safety initiatives underscoring repeated errors in maternity units that have appeared since The Times highlighted complacency in the NHS over stillbirths in 2012. The latest figures suggest that such messages are starting to filter through, with stillbirth rates falling from 4.2 per 1,000 births in 2013 to 3.87 in 2015, according to the most authoritative academic study…

…Overall in the UK the number of stillbirths fell to 3,032 in 2015 from 3,252 the year before, but deaths before and soon after birth still vary around the country, from 5 to 6.5 per 1,000…. Disappointingly, the findings show only a small reduction in neonatal death rates.”

…Deaths within the first week of life were 1.74 per 1,000 in 2015, compared with 1.84 two years before….

Infant Mortality and Stillbirth in the UK – Parliament UK (2014) .pdf

Infant death rate ‘lowest ever’ recorded – BBC News (best in the affluent areas, and some areas saw worse results).

It does  not help when a charity (Kicks Count) is reported in the South Wales Argus 20th June:  Baby heartbeat detectors should be banned, says pregnancy charity when they really mean for unqualified patients.

In Scotland the Herald on 15th June reported the main reason for improvement: Smoking rate in UK second lowest in Europe after 25 per cent fall …

The long term results of rationing midwives and doctors in training…

“Reducing the ratio (of maternity staff in Surrey) to balance the books is the worst of all decisions.”

Stillbirths in all different UK systems are still too high

50,000 short – not £millions but staff…. 

and now we need more despite Brexit: (Chris Smyth June 22nd – NHS in talks to recruit Indian nurses to deal with staff crisis).

Michael Safi in the Guardian 2014: Babies born in private hospitals ‘more likely’ to have health problems – The Study, which looked at 700,000 ‘low-risk’ births in NSW, suggests higher rates of medical intervention could be the cause

The Times leader on Stillbirths – by Janet Scott of SANDS.