Monthly Archives: November 2017

When he means the opposite: what it will not be possible to deliver….

British Telecom reports on the Budget November 2017: NHS bosses to discuss ‘what is possible to deliver for patients’ – The NHS was handed £350 million to cope with winter pressures.

‘We’ve had to ration some of the letters.’

NHS bosses are to meet to discuss “what it is possible to deliver for patients with the money available” after the health service in England did not get the funds it requested from the Treasury, officials have indicated.

Sir Malcolm Grant, chairman of NHS England, said the money promised by the Chancellor “will go some way towards filling the widely accepted funding gap”.

But he said the NHS “can no longer avoid the difficult debate” on what can be provided by the health service on the funds it is operating on.

In a statement, Sir Malcolm said: “The extra money the chancellor has found for the NHS is welcome and will go some way towards filling the widely accepted funding gap.

“However, we can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.

“The NHS England board will need to lead this discussion when we meet on November 30.”

Meanwhile, Professor Sir Bruce Keogh, national medical director for NHS England, said the money promised by Chancellor Philip Hammond will “force a debate about what the public can and can’t expect from the NHS”.

He warned that longer waits for care seem “likely/unavoidable”.

The comments come after the Treasury pledged more money for the NHS in England, with the specific aim of helping the health service “get back on track” with soaring waiting lists and A&E targets.

Mr Hammond acknowledged the NHS is “under pressure” as he committed resource funding of £2.8 billion to the NHS in England.

This includes £350 million to cope with pressures over the coming winter, £1.6 billion in 2018/19 and the rest the year after.

Earlier this month, NHS England boss Simon Stevens said that without more money for the NHS, the number of patients waiting to be admitted to hospital in England to have surgery will rocket to five million by 2021.

This means one in 10 adults will be on the waiting list, he said.

Mr Stevens also indicated that controversial rationing policies adopted in some parts of the NHS could be rolled out nationally without more money and he said expansion plans for mental health and improvements in cancer care could stall.

He drew on a new analysis by the Health Foundation, the King’s Fund and the Nuffield Trust which calculated the NHS needs £4 billion more next year to prevent patient care from deteriorating.

In his Budget speech, Mr Hammond said: “We acknowledge that the service remains under pressure and today we respond.

“First we will deliver an additional £10 billion package of capital investment in frontline services over the course of this parliament to support the Sustainability and Transformation plans which will make our NHS more resilient. Investing in an NHS fit for the future.

“But we also recognise that the NHS is under pressure right now.

“I am therefore exceptionally, and outside the Spending Review process, making an additional commitment of resource funding of £2.8 billion to the NHS in England – £350 million immediately to allow trusts to plan for this winter, £1.6 billion in 2018/19 with the balance in 19/20, taking the extra resource into the NHS next year to £3.75 billion in total.

“Meaning that our NHS will receive a £7.5 billion increase to its resource budget over this year and next.”

‘Due to cutbacks we’ve had to accept a sponsor for your stitches.’

A budget should make us all think. We are all lost, and in denial with health care, which depends on jobs, productivity and the economy, all of which are threatened.

Going back to the original roots of the Health Service: NHS ‘birthplace’ Tredegar’s GP services ‘unsustainable’ – why? how?

As your local Health Service safety net corrodes, you might be interested to see the headlines and links in the medical and general media following the budget. Mr Hunt would never want the health service to fall apart…. wouldn’t he? Desperate measures such as “on line” consultations are of no practical use.                 Nick Triggle for the BBC reports: NHS Budget plan not enough, say bosses

Many employees “need to leave” to keep their sanity. Threats to disallow medics and nurses from travelling seem to have been withdrawn. Doctors demanding clarity….Nick Bostock for GPonline)  and then in August in the Mail the government backed down. The Mail also reports on “physician assistants” being poached from North America! Dennis Campbell in the Guardian “Junior doctor Nadia Masood: ‘Hunt’s driven a lot of us out of the NHS’ – Medics felt justified in opposing a new contract and their defeat has left many feeling demoralised, Masood says. Health service is ‘haemorrhaging highly trained, experienced GPs at an alarming rate,’ says top GP. BBC reports on “Thousands of out-of-hours doctor shifts unfilled”, and then on the locum situation Andy Philip in the daily record 13th November reports: GP crisis forces Health Board to pay a whacking £2000 for one (8 hr?) shift.

The Motherwell Times spares no one: GP recruitment has failed and since 1/5th or 20% are from overseas, and many are returning or retiring….. These tend to be working in the less popular areas, and some cities are now appreciating the crisis: David Ottwell for the Manchester Chronicle 18th November – NHS at ‘breaking point’ as GP numbers fall and patients soar in North East

The British Medical Association warns a chronic shortage of doctors is putting patient care at risk

The Belfast Telegraph tells us overseas doctors are crucial….

Whilst management attempt to apply artificial waiting times as “routine”. Henry Bodkin for The Telegraph 13th November offers : “Phantom waiting time branded unethical”. The Sun calls it “Op woe”.

In April atie Foster for the Independent warned us: Almost half of GPs plan to quit NHS due to ‘perilously’ low morale, survey suggests and then in November: Jeremy Hunt’s GP recruitment pledge in tatters as 1000 full-time …

If you cannot register or see a GP then you may not have a local A&E to go and see a medical student or a junior inexperienced Dr for your primary care needs either:  Dennis Campbell in the Guardian: A&E units, GP surgeries and walk-in centres to close as cash crisis bites

NHS bodies have decided in the last four months alone to shut or downgrade 70 services, says campaign group 38 Degrees

The Mirror: Budget pledges extra £1.6 billion for NHS next year but it’s less than half what health service chief asked for – The announcement also included a commitment to fund a pay rise for NHS nurses, midwives and paramedics – but only if negotiations on wider pay reform are successfully concluded.

Promises have been broken and the profession have no faith in discredited politicians. We always knew 5000 instant Drs and GPs was impossible. There are many doctors being trained, of whom 80% undergraduates are women, but the graduate courses are usually 50:50. men to women. Many will take career breaks, or work part time, or go abroad for relevant experience. They may decide to stay!  Chris Smyth in the Times 22nd November: Fewer GPs despite pledge to hire 5,000

GP numbers have fallen again, throwing a key NHS pledge of thousands more doctors into question.

The NHS has 541 fewer family doctors than a year ago. Doctors said they were “gravely concerned” by the figures at a time when patients were waiting ever longer to see a GP.

NHS Digital figures show that there were 41,324 GPs working for the health service in England at the end of September, 240 fewer than in June and 541 fewer than September 2016.

Full-time numbers are down even more as doctors cut back their hours, citing intolerable workloads. The NHS has the equivalent of 33,302 full-time GPs, 1,193 down on a year before.

Jeremy Hunt, the health secretary, has promised to recruit 5,000 more GPs by 2020. However, Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “We need to start seeing some progress, and fast. We understand that change takes time, but we desperately need more family doctors.”

A Department of Health spokeswoman said: “There are more than 3,000 GPs in training and 500 new medical school places will be available in 2018, with a further 1,000 in 2019. We’ve also outlined more flexible working options so we can retain the expertise of more experienced GPs.”

We have rationed medical school places for too long. The country does not deserve to be treated like this. We need honesty and admit that we cannot have “Everything for everyone for ever“.

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

The breaking up of the old “National” health service into the 5/6 different health services (If we include London) is a form of self harm in many ways. The benefits of a large mutual in health, where we cannot predict our future diseases, or our own “lottery of life” ticket, were fully understood by Aneurin Bevan.

The NHS Executive (England) announced 26th October: NHS ahead of schedule for procurement savings but this is still small savings in relation to the potential. The Logistics Manager, Supply Chain reports 30th October: NHS Supply Chain delivers £250mn of savings, nearing £300mn …But the “Public Finance” site 9th November reveals the truth in its concern to compare: DoH to rank NHS hospitals in ‘procurement league tables’. You have to believe in the power of the mutual to understand the reduction in risk, as well as the potential savings. Devolving powers is all very well, and “liberal”, but if it reduces life expectancy by increasing risk, reducing choice and purchasing power, and makes a Regions (such as Wales) bust then it is not a public good.  Imagine if we were so “liberal” as to give each citizen a health budget of their own? The benefits of mutuality are lost as those lucky enough to avoid disease choose to lead hedonistic lifestyles at the expense of the unlucky. The post-code lottery is reality, but nobody knows it until they are a victim. Dead patients don’t vote.

With the inefficiencies in mind, one wonders why London has been approved as the 6th health system in the UK? The only explanation I can believe is that it muddies the water even further: it allows more comparisons, and less choice. Politicians of course, with access to London will always have access to the best! For the rest of us it will be second rate care or a private plan/ purchase option.Image result for the mutual health cartoonI wonder if the youngsters understand the principles behind a mutual organisation? It is not hard to find examples which we revere such as the John Lewis partnership. The question of “what is the John Lewis Model” was addressed in the Guardian. If you want to read and then answer questions on a “business case study” the opportunity is here.  In Insurance, such as the old NHS, the advantages are clearer still…

Oliver Wright reports in the Times 20th November 2017: No cash bailout until you make savings, Hammond tells NHS ( a reality warning before the budget ).

Health service leaders have failed to keep their promise to save billions of pounds to spend on frontline services, Philip Hammond claimed yesterday, as he ruled out a budget bailout for the NHS.

The chancellor rejected calls by Simon Stevens, the chief executive of NHS England, for a £4 billion funding boost, saying that people running public services often claimed “Armageddon” if they did not get the money they wanted from a budget.

He warned that although the government might find some money for “particular pressure points” in the NHS it would not be at the scale demanded by Mr Stevens. The chancellor is understood to be prepared to find the money to fund limited pay rises for nurses and some capital investment programmes but there will be no significant increase in total NHS revenues.

Mr Hammond’s comments came after Mr Stevens said that the government should honour the pledge of the Vote Leave campaign and hand some of the money “saved” by Brexit to the NHS…….

Drawing on analysis by the Health Foundation, King’s Fund and Nuffield Trust charities, Mr Stevens suggested that the NHS needed about £4 billion more next year to prevent patient care from deteriorating.

Mr Hammond said that the government had already agreed to provide the NHS with an extra £10 billion by 2020 — a figure requested by Mr Stevens in his five-year plan.

“That plan is not being delivered,” Mr Hammond said. “We need to get it back on track.” He added: “In the run-up to budget, people running all kinds of services come to see us and they always have very large numbers that are absolutely essential, otherwise Armageddon will arrive.

“I don’t contest for one moment that the NHS is under pressure. We have been doing some very careful work with the Department of Health, with the NHS, to look at where those pressures are, to look at the capital needs of the NHS, to look at where the particular pressure points around targets are. And we will seek to address those in a sensible and measured and balanced way.”

His remarks about the five-year plan irritated NHS England, which sent out a series of tweets shortly after Mr Hammond was interviewed on The Andrew Marr Show on BBC One, citing “evidence” that Mr Stevens’s reforms were working. The shadow health secretary, Jonathan Ashworth, described Mr Hammond as out of touch. Mr Ashworth said that an extra £6 billion was needed to avert “Armageddon”.

He told Sunday With Niall Paterson on Sky: “It’s incredibly serious and if I may say so I’ve seen Philip Hammond doing interviews today, being dismissive of the calls for more money for the NHS, saying well you know it’s not going to be Armageddon.

“This is happening now, today, in the NHS, and if he doesn’t realise that, he’s completely out of touch. We are calling on the chancellor to put aside an extra £6 billion in this budget.”

NHS England declined to comment but is understood to reject suggestions that the plan it set out for NHS efficiency savings is not working.


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

Devolution of health to Wales was a mistake?

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

The democratic deficit. Applies to health as well as devolution, and to leaving the EU. The first honest party should get public support.

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

Stroke survivors ‘are dumped by the NHS’. Dead patients don’t vote, and those near death don’t appear to count…

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

American rationing – an opinion from the Sun Journal

It is not only the UK with it’s 5 medical systems, (soon to be six) but the whole world that has to address rationing. The politicians are ducking the issue in the UK, but NICE has opined on the Life-Year-Value below which the state should intervene. In the USA the vitriolic debate on socialised care and mutual funding is still active, but the US needs to be reminded of the duty of government to treat populations. It is the duty of doctors to treat individuals within the “rules of the game” as defined by government and private insurers, and within the law. An example such as this one rightly makes us think …. The reality is that all health systems are rationed. (What would the world’s best health system look like? NHSreality’s book review of “In search of the Perfect Health System by Mark Britnell) Free prescriptions, as in Wales, means more covert rationing, and less patient autonomy. Te health service itself will die if we cannot address this truth.

March 4th 2017 and the Sun Journal in the USA opined: Do we ration health care? without doubt.

For those who fear the government is about to start rationing health care in America, there many examples of how we already do.

Here’s one.

Each year, about 115 high school athletes across the U.S. die from undetected abnormal heart rhythms.

And, for years, some have argued that an electrocardiogram, or ECG, could, if administered to all student athletes, prevent many of these deaths.

However, after studying the issue in 2007, the American Heart Association concluded it would cost about $2 billion to screen and evaluate ECG results for the 10 million students competing in high school and middle school sports.

That means it would cost about $17 million per life saved, if indeed every death could be prevented.

What’s more, trying to screen every student in the U.S. would put a tremendous burden on the health care system. Some questioned whether there are even enough physicians, technicians and machines in the U.S. to handle the load.

Then there is the issue of false positives. About 16 percent of the tests show a problem where there is none, so those students would have to undergo expensive retesting and evaluation.

So, a national testing program has not been adopted.

While it seems callous to say so, the medical community applied a cost/benefit ratio to the problem and decided that 115 deaths is acceptable compared to the massive cost and difficulty of testing every young athlete.

That implies there is a point — a dollar value — at which a life, even a young life, is not worth saving.

But that point isn’t fixed forever. As the result of its own research, Harvard University, has decided to give ECGs to student athletes, according to a story in Monday’s Boston Globe. Italy also tests all competitive athletes between 12 and 35.

And a new Stanford University study says the cost is actually less than previously estimated, perhaps as little as $43,000 per life saved, according to the Globe.

Now, is $43,000 worth saving a single young life? That’s now in the same range as mammograms and pap smears.

But, as you can see, this is sort of rationing at work. At one price, the procedure seems outrageously expensive and it is not performed. At another price it seems like a bargain.

We are simply choosing among various alternatives in order to spend our health-care dollars as effectively as possible?

The real question is who sets these standards and makes the decisions, particularly when it comes to publicly funded programs.

Right now, insurance companies decide which drugs and procedures are available to those with insurance.

The federal government decides for older citizens.

And the uninsured have their health care severly rationed. If they can’t pay for it, they don’t get it.

In some countries, like Canada and England, public panels of scientists, researchers, doctors, patients make the decisions based on established criteria. Of course, those would be labeled “death panels” here.

Still, as health care costs mount, and pressure to contain them grows, we will need some rational way to making these difficult choices.

Mark Britnell – In Search of the perfect Health System. 

Why having so many women doctors is hurting the NHS: A provocative but powerful argument ……. Women should “lean in”..

For several years NHSreality has been advocating “graduate entry” to medical schools rather than undergraduate entry. It is simply better value for money, and it means that the gender recruitment gap is reduced or negated. If we add to that virtual medical schools run from centralised Deaneries, then teaching and learning can be in the communities that doctors live in and come from. Instead we have high performing female suburban school students ruling the roost for places as undergraduates, and, in general, they do not wish to work in the shires. Paediatrics is a case in point…

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Prof J Meirion Thomas writing in the Mail 2nd Jan 2014 opined on: “Why having so many women doctors is hurting the NHS: A provocative but powerful argument from a leading surgeon

By 2017, for the first time, there will be more female than male doctors in the United Kingdom.

Although I am a feminist — in the NHS hospital in which I work as a surgeon, some of the best doctors are women — this shift of the gender balance in medicine is a worrying trend.

I believe it is creating serious workforce problems, and has profound implications for the way the NHS works.

For many years — until the Sixties — fewer than 10 per cent of British doctors were female. Then things changed. For the past four decades about 60 per cent of students selected for training in UK medical schools have been female.

This is understandable in academic terms because girls achieve slightly better A-level grades than boys. They also mature earlier and may present themselves more impressively to medical school selection committees at the age of 17.

The effect is beginning to be seen. In 2012, a total of 252,553 doctors were registered with the General Medical Council. The male-to-female ratio was 57 to 43 per cent.

However, in its annual report last year, the GMC documented the changes in the UK medical register between 2007 and 2012.

The most significant change was that the number of female doctors under the age of 30 had increased by 18 per cent, while the number of males decreased by 1 per cent.

Indeed, in this age group, 61 per cent of doctors are now women and 39 per cent men.
In the age group 30 to 50 years, over the same period, the number of female doctors increased by 24 per cent compared with 2 per cent for males. In this age group, men still outnumber women by 54 per cent to 46 per cent — but that ratio will soon reverse.

I fear this gender imbalance is already having a negative effect on the NHS.

The reason is that most female doctors end up working part-time — usually in general practice — and then retire early.

As a result, it is necessary to train two female doctors so they can cover the same amount of work as one full-time colleague.

Given that the cost of training a doctor is at least £500,000, are taxpayers getting the best return on their investment?

There is another important issue. Women in hospital medicine tend to avoid the more demanding specialities which require greater commitment, have more antisocial working hours and include responsibility for management.

nstead of taking on a specialist career, many women prefer to look for a better work-life balance when they have young children of their own.

A section in the GMC’s 2013 report is illuminating. It lists the number of female doctors by speciality for 2012, and shows how many are attracted to general practice rather than other areas of medicine: general practice 29,272; anaesthesia 3,118; paediatrics 2,477; psychiatry 1,778; general medicine 1,054; general surgery 467; trauma and orthopaedics 191.

Compare this with the number of male doctors by speciality, and you can see the huge difference in general surgery as well as trauma and orthopaedics — both of which involve the complex, antisocial hours that deter so many women: general practice 31,711; anaesthesia 6,940; paediatrics 2,578; psychiatry 3,302; general medicine 3,737; general surgery 3,779; trauma and orthopaedics 3,629.

Dame Carol Black, former president of the Royal College of Physicians, pointed out this growing discrepancy in 2004, when she controversially suggested that the feminisation of the medical profession would lead to its degradation.

She said the issue was not whether women doctors could do their job properly, but whether they were willing to devote time and effort, beyond their clinical responsibilities, to activities such as committee work and research.

Politicians are concerned, too. In a Commons debate in June, Anne McIntosh, a Tory MP, said that women doctors who had received expensive medical training but went part-time after starting a family were a huge burden on the NHS.

In reply, Anna Soubry, then a health minister, agreed that they were a drain on resources.
Within hours, after angry responses, some from the British Medical Association and the Royal College of GPs (two professional bodies opposed to any meaningful reform of general practice), Ms Soubry was forced to retract her comment and apologise.

Of course, it is perfectly reasonable that women should have career breaks to have children. But is part-time working on such a large scale in the public interest, even if it is considered perfectly acceptable by our ultra-politically correct NHS management?

GPs are very well paid. Their average salary is around £103,000 — quite sufficient for a woman doctor who is also a mother to be able to afford quality childcare at home.

But the salary also means that part-time working still allows for a comfortable lifestyle.

In addition, doctors tend to marry within their own socio-economic group and, in many cases, the wife is the secondary earner. This also encourages less demanding part-time work.

A female junior surgical trainee told me recently that when she went to medical school, some female students announced from the start that they intended to be part-time GPs when they qualified.

But in general practice, part-time working and job-sharing have an effect on patients.

They can deprive them of continuity of care, which is the service they most value. That once key value of the NHS — the cradle-to-grave relationship with patients — has become a thing of the past.

Indeed, I believe that current general practice fails to meet the needs of the modern health service and its patients.

That such a great and growing number of GPs are part-time is a major problem, but it is not the only one.

Because GPs tend to work in small group practices, there is a danger that these can become backwaters, isolated from the nourishing influences of mainstream hospital medicine.

Failure to keep up with the latest developments is a real risk. The perfect solution, suggested by health minister Lord Darzi in 2007, was ‘polyclinics’ — super-surgeries in which GPs and hospital consultants would work together. Sadly the idea was not implemented.

In truth, general practice is organised for the convenience of doctors — particularly, I suspect, for female GPs — and not their patients.

No wonder many people, faced with a medical problem, ignore their local surgery and go straight to A&E — one reason why emergency medical services are at breaking point.
The problems with A&E are very much in the public eye. Not so the issue of part-time working — but it certainly should be, as it is linked.

In the UK we have a serious shortage of medical school places, with the result that more than half of male applicants with the required grades are rejected. As we have seen, many women who take up medical school places subsequently work part-time and, on the whole, tend to avoid A&E.

We make up the shortfall in medical manpower by importing about 40 per cent of the doctors we need. Most now come from austerity-stricken EU countries.

Does this make economic sense?
We need accurate data on the extent of part-time working in order to allow public debate which could then inform medical school selection.

For my part, I believe medical school places should be given to those most likely to repay their debt to society.

Last year (2013) the U.S. businesswoman Sheryl Sandberg published a book called Lean In. It should be compulsory reading for female medical students.

Her thesis is that too few women make it to the top of any profession. She acknowledges the conflict between professional success and domestic fulfilment, but says women should commit more professionally and not ‘lean out’.

How do we persuade female doctors to ‘lean in’? It is a question we urgently need to address.

Gender bias. The one sex change on the NHS that nobody has been talking about

Poor Paediatric workforce planning and career structures

2,000 foreign GPs needed to tackle growing shortage. How about an apology to 20 years of rejected applicants to medical school?

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Another call for a cross party fudge? We continue to break up the large mutual safety net which used to ensure choice, equity, and benefitted all.

BBC News reports on another slicing up of the English Health service. Already Manchester may be reported differently, and now London, when the WHO (World Health Organisation) compares different countries and systems and methods of delivery. The ultimate break up in health is to reduce it to each individuals own resources and their own budget. The absurdity of the current trend may be driven by politicians wishing to avoid blame for failure. So, lets break up the “mutual” a little more….. and lose the advantages of choice and size. Wales had shown what a disadvantage it is to be really small. Yet no lessons are being learnt. Even palliative care is private and charity funded, and in Wales this means “cut”. We used to have a National Health Service, but no longer. No party has shown the courage to rebuild and reinstate it, hence the call for a cross-party group? Small is not beautiful in high tech health care… In addition, no amount of money or manipulation can negate the need for rationing (cutting) overtly, as for vasectomy.

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BBC News 16th November 2017 reports: Sadiq Khan: ‘New deal will help London be world’s healthiest city’

Sadiq Khan says a new deal to improve healthcare in the capital will help London become “the world’s healthiest city”.

London’s health and care services will be devolved to the Mayor of London and London’s councils.

The NHS is being encouraged to sell buildings and surplus land in London which could be used to develop more housing.

Money would be reinvested to build new hospitals and GP surgeries.

The Mayor of London said it would encourage the healthcare organisations to work better together – around issues including payments and workforce.

Mr Khan said: “[The deal is] a really important step in the right direction in our journey to becoming the world’s healthiest city.

“It is vital London has the powers to plan and coordinate health services.”

‘Poor condition’

According to City Hall, the NHS is one of the largest owners of land in London – with an estimated value of more than £11bn……

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

Devolution of health to Wales was a mistake?

Dennis Campbell in the Guardian 16th November: A&E units, GP surgeries and walk-in centres to close as cash crisis bites NHS bodies have decided in the last four months alone to shut or downgrade 70 services, says campaign group 38 Degrees

BBC Bristol news reported 9th November: Nine NHS groups consider vasectomy funding cuts

BBC Wales reports 10th November: Jobs threat at Marie Curie cancer charity centre, Pontypool NHSreality believes that care in the community, hospice at home, etc is the only sensible way to proceed in poorer areas of the country whilst death and dying are not covered.

Cradle to grave? Why the cost of dying is rising.

Hugh Pym for BBC News 18th November 2018: Social care: MPs seek cross-party group to ‘sustain’ NHS



The Health Services in “Reality”: even the chief says it’s broken

How on earth did we get here, to this point in denial and lack of long term thinking. Now, if we employ GPs directly from overseas, we will be negating years of training and Improving standards. Teaching Hospitals and Deaneries will be irate. In the longer term the places filled from overseas will be blocked to UK trained doctors. History repeating itself from the pressure in the 1950s? The Health Services are in “Reality”: even the chief says it’s broken. More money will not make more qualified doctors and nurses. The options outlined do not include rationing health care overtly. A knee jerk response tells me it may happen suddenly and unfairly, and without a national debate on the best way to achieve fairness within rationing.

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Chaand Nagpaul, in the BMA Blog in the BMJ opines: A crisis acknowledged and a political choice

Last week, in a speech at the NHS Providers conference, Simon Stevens – chief executive of NHS England – broke ranks from his political masters and laid bare the full extent of the crisis in the health service.

Far from the ‘we’re spending more than ever in the NHS’ rhetoric, or the illusory mantra of politicians promising world-class convenience on second-class funding, Mr Stevens was unequivocal that the NHS was broken, declaring that the current budget ‘…is well short of what is currently needed to look after our patients and their families at their time of greatest need.’

He was openly critical of the impact of austerity on the NHS, describing it as ‘the exceptional choking back of funding growth of the past seven years.’

He mirrored the BMA’s own analysis of the NHS being woefully underfunded compared to European counterparts, arguing: ‘If instead you think modern Britain should look more like Germany, France or Sweden then we are underfunding our health services by £20bn to £30bn a year.’

Indeed I felt a sense of ‘at last’ in hearing language that could have been lifted from the BMA’s own NHS at breaking point campaign.

And as Mr Stevens made patently clear, we are not arguing simply about a number here but about the impact on the health of millions of lives, including explicit government priorities, saying that ’on the current funding outlook it is going to be increasingly hard to expand mental health services or improve cancer care’.

He went further to state it was a ‘duty of candour’ – relating to speaking up when patients were at risk – to ‘explain the consequences’ of this starvation of funds to the NHS.

He also spoke of the impact of inadequate resources on workforce: ‘On the current budget, far from growing the number of nurses and other frontline staff, in many parts of the country next year hospitals, community health services and GPs are more likely to be retrenching and retreating.’

And instead of the usual DH pronouncement of a wishful 5,000 more GPs he was candid: ‘GP numbers over the last seven years have actually fallen but their workload has risen’ – exactly what the BMA GPs committee have been warning of repeatedly.

Mr Stevens also argued for the ‘clinical and the financial logic for integrated care rather than fragmented competition’ – in doing so he reflected 25 years of BMA lobbying opposing the market-driven purchaser provider split.

I hope that he will now go one step further and unequivocally call for an end to competition law enshrined in the Health and Social Care Act – only that will put an end to fragmented care and the billions wasted in the transaction costs of competition.

It is these procurement rules that allow private companies to provide cherry-picked services in the NHS, and also mean that the future proposed accountable care organisations could be sold off to multinationals.

Mr Stevens speech crucially reinforced what the BMA has always argued – that with the UK being a leading health economy globally, the level of funding of the NHS is a political choice by Government. He said: ‘No-one disputes that these are choices that a chancellor could make.’

More specifically he claimed that next year’s funding gap is likely to be £4 billion, citing the analysis of three leading think tanks (the King’s Fund, NHS Providers and Health Foundation).

He asserted this should not be a challenge for the politicians, since it would only bring the NHS back to historic norms. ‘[The independent analysts] show there’s nothing out of the ordinary about needing such a sum. In their words, it would just be a return to the average increases of the first 63 years of the NHS’ history.’

Mr Stevens also rightly reminded government of the promise to the nation of an extra £350m per week paid into the NHS to leave the EU – at a time when indications show the antithesis that Brexit is likely to act as a further drain on NHS resources.

He called on the Government to meet this funding pledge on the fundamental matter of not undermining public trust: ‘You voted Brexit, partly for a better funded health service. But precisely because of Brexit, you now can’t have one.’

It is probably no accident that Mr Stevens’ comments came ahead of next week’s budget; so it’s over to the chancellor, health secretary Jeremy Hunt and the prime minister. The case for investment is overwhelming, as is the daily experience of an NHS that is failing patients, doctors and other NHS staff.

The Government has a choice, of whether to acknowledge the evidence it faces and whether to heed the clear message from the boss it appointed to run the NHS. And a choice between punishing patients or belatedly properly funding the health service this country needs, deserves and which the government itself has promised.

Chaand Nagpaul is BMA council chair

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