Monthly Archives: March 2018

Man’s £54,000 NHS cancer bill raises ethical questions that can’t be ignored. Hepatitic C rationing..

When the inevitable rationing arrives it has to be seen to be just, and have a buy in from patients and politicians. The hard truths around the unaffordability of expensive new drugs, or investigations, will be much less painful if we ration the high volume cheaper items. And we need to ration for all. Meanwhile, by neglect and denial, the health divide will inevitably get larger. Those with means will pay for those treatments that the state cannot afford. And of course the Health Services of the UK face a miserable decade, not just a year, as there are not enough trained people...Desperate times demand desperate measures and paramedics will be licensed (and insured?) to treat emergencies. Lets hope they make the right diagnosis… NHS reality has consistently pointed out the threat of falling standards. When you cannot meet a target you change it. .

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Dolin Bhagawati on Thursday 29th March 2018 reports in the Guardian: The Royal Marsden said Albert Thompson’s treatment requires payment. It’s the first step in applying the same logic to us all The case of Albert Thompson has raised a worrying precedent that should worry NHS workers and patients alike.

….I am a brain surgeon and putting me in a position where I distribute care according to an immigration status puts unnecessary strain on a patient relationship where trust must be established quickly and effectively. It also flies in the face of the underlying principle of the NHS.

Thompson has prostate cancer and needs radiotherapy. He currently lives in a hostel while his cancer goes untreated after being evicted from council housing when the Home Office questioned his immigration status. His situation was looked at by Theresa May who decided not to intervene, stating it was a matter for his hospital – the Royal Marsden in London. Thompson has paid taxes for 30 years.

His situation raises the spectre of another problem as yet not considered in the current discourse – one I have not encountered during my practice as a doctor in the UK for 10 years. Such a problem is illustrated by a case I was involved with, however, in India, where I regularly go back to talk to patients with poor access to healthcare.

Four years ago, I saw a patient in my home state of Assam in the north-east of that country called Horen. He was a thin wiry man in his mid-50s who worked as a manual labourer. His salary was equivalent to £80 per month. He had been diagnosed with a very aggressive brain tumour, had undergone surgery and made a very good recovery – and he showed me his scans (on film – no computer or electronic records in remote rural Assam).

As I held up his pre-operative film to the sliver of sunlight creaking into the dark room we were sat in, my heart sank. This was a large tumour that Horen had no hope of surviving. His surgeon had fought a valiant battle and taken as much could be safely taken while ensuring Horen remained with as little disability as possible.

While I was peering at the film, with the dust dancing and forming a halo around the blue-black plastic, Horen’s husky-voiced Assamese asked me the question that jerked me back to the reality of his situation. “My doctor says I can have radiotherapy, but I don’t know whether I should pay for it or not. How much time will it give me if I pay for it? It’s a lot of money that I can give to my son or daughter.”

Seven years of working in the NHS at that point had made me forget about such dilemmas. Payment was not an issue for those I treated. Horen sat opposite to me, back at work just a few weeks after major brain surgery; he faced this decision in a context of very limited funds, even by Indian standards……..

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Billy Kenber in the Times 30th March 2018 reports on the rationing of Hepatitis C treatments: Drug firms must give £33m of profits to NHS

Drug companies, including the US manufacturer of an expensive treatment for hepatitis C, will have to pay the NHS millions of pounds a year under rules designed to reduce the cost of medicines.

The government is to claw back up to £33 million a year by requiring manufacturers of all branded medicines to return almost 8 per cent of the net income from sales to the NHS.

At present, only companies that have opted in to a voluntary scheme that seeks to control the costs of branded medicines have to make the payment but from tomorrow this will be extended to those in a concurrent statutory scheme.

This includes Gilead, which makes breakthrough hepatitis C treatments that have shown a high success rate in curing the disease without causing the damaging side- effects of other drugs.

Despite the effectiveness of the new drugs, because of their high cost NHS England has limited the number of hepatitis C patients that can be treated to 10,000 a year. A 12-week course of one Gilead drug, Sovaldi, has a list price of almost £35,000, although the NHS is likely to have negotiated a discount.

Hugh Pym for BBC News 29th March: Does the NHS face another year’s misery?

Kat Lay reports: Paramedics given the power to prescribe drugs

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Waste in the Health Services. It;s mainly due to staff absenses…

The Adam Smith institute weighs in on waste. The purchasing power of a large mutual (former NHS) is much greater than the 4/5 different regions:

Sir, You are right that the National Health Service requires more money in addition to tackling its “internal woes”, ie waste (leading article, Mar 26). But if the NHS is given all the money it seeks, the incentive to eliminate waste will be removed. The Department of Health and Social Care will retain 19 quangos where seven would suffice; assets such as operating theatres will remain underused; beds will remain occupied by those needing long-term care; administration will absorb time that should be devoted to patients; and adult social care will remain the poor, underfunded relation (the social care “principles” proposed by the health secretary, Jeremy Hunt, this month made no mention of money at all).

A commission will take time to deliberate, but that time will not be squandered if the NHS uses it to eliminate waste and establish a fair share of resources between medical and social care. That would resolve short-term pressures, allowing the commission to deal with longer-term issues.
Tim Ambler
Adam Smith Institute, London SW1

Cornwall and Barnsley have worst morale and absenteeism

Physiotherapy and counselling for NHS staff in drive to cut sickness rates

The NHS culture is sick – and so are its staff – But is there any “quick fix”?

“The NHS is like a tumour on the public finances, expanding so aggressively that it threatens to kill other organs of state …. Better still would be a formal policy if provision is to be limited — but the politics is too sensitive”.

NHS is unsafe, says chief

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Knowing the cost would help… In advance would be “tough love”: retrospectively is acceptable.

The argument in objecting to knowing costs in advance is that some would not take up the service. NHSreality says this is part of the “tough love” that is needed if we are to save our health services. Lord Alverthorpe’s argument is reasonable, but not tough enough. There must be too many patient representatives feeding back to the Lord.

The Times letters 29th March 2018

Sir, The government’s prospective financial birthday present to celebrate the NHS’s 70th anniversary should not detract from the search for funding reforms for health and social care (letters, Mar 24). It should encourage us to review how responsible we are for maintaining the NHS. Some of us in the House of Lords have long argued that if patients knew what the costs of NHS services were they might treat it more responsibly. The government opposes such a development for fear that it might discourage the take-up of services. So I have suggested that after treatment only those patients who request it be told the cost. They could then make a tax-free donation covering the cost or part of it to an NHS national charity established for this purpose.
Lord Brooke of Alverthorpe
House of Lords, London SW1

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

Bearing in mind that only 2 years ago, 9 applicants out of 11 were rejected for medical school  and that thousands have been disappointed when we really needed them, we now have politicians acting. They need to do more. The new places need to be graduates, rather than undergraduates, , and there needs to be additional “virtual” medical schools attached to each Deanery. If everyone is subjected to the same assessment exams, we could see whether community based training is as good as centralised raining. Careers officers should have been listened to. We have wasted a whole generation of disappointed talent.

Five medical schools are created in England in bid to increase home grown doctors BMJ 2018;360:k1328  21st March 2018

Five new medical schools have been created under government plans to increase medical student numbers in England.

In 2016 England’s health and social care secretary, Jeremy Hunt, announced a 25% expansion in medical student places in a bid to expand the number of home grown doctors rather than recruiting from overseas.1 He said that as many as 1500 more doctors would be trained in England every year from September 2018.

Health Education England (HEE) has now announced the creation of five new medical schools offering undergraduate places.2 The new schools will be at the University of Sunderland, Edge Hill University in Lancashire, Anglia Ruskin University in East Anglia, the Universities of Nottingham and Lincoln, and the Universities of Kent and Canterbury Christ Church.

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In 2017, 500 new medical school places were allocated to existing medical schools. The remaining 1000 places have now been allocated after a bidding process run by HEE and the Higher Education Funding Council for England.3

Ian Cumming, chief executive of HEE, said that the allocation of places was prioritised in areas “with a relative shortage of doctors overall, or in certain specialties, and also to widen the social profile of new medical students.”

Overall, the south and south east of England are receiving the largest increase in student numbers, with 200 student places allocated to the region, 100 of which went to a joint bid by the Universities of Kent and Canterbury Christ Church.

Excluding London, which received 137 additional places, the north east received the smallest allocation of 147 medical school places. Figures from HEE published in 2017 showed that the north east had a sufficient number of doctors per weighted population.3

References

  1. Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

    Comment on the New Medical Schools. How will continuity of care improve?

Five new Medical Schools: better late than never. Lets hope selection criteria are different from before..

Will citizens be wise to move away from under-resourced areas of the country?

Where should you live to get the best health care? The demise of rural area DGHs, such as my own, where recruitment is a recurring problem, are compounded by the shortage of GPs. There is an irony, that as more and more beds are blocked, the hospital trusts demand more and more money, and expansion. Mr Stevens does not encourage this, and feels resources should be directed to the community and GPs. A letter in today’s Times lucidly exposed the dissonance. The result of too few doctors, and downsizing of all hospitals in West Wales, is that none of them are good enough. Once the penny drops,  more private care, including A&E  services, and more travelling are inevitable. Those that can may choose to leave… In the last week I have heard of children being sent on a round trip of 80 miles with a minor illness even thought he Out of Hours service was manned by a GP. Presumably one with stress overload.. I have accounts of patients with stroke not getting treatment because it was a Bank Holiday, and waiting lists are impossible, both for hospital and GP appointments. We may need beds, but not in hospitals..

The Western Telegraph 27th March 2018

The Times letters: Dr Stephen Mann: 

Sir, Jeremy Hunt promises a new hospital every year (News, Mar 28). In his “Next Steps” plan Simon Stevens, the head of NHS England, correctly recognises that the solution to challenges in A&E and hospitals is in the provision of joined-up health and social care based in our communities. The current provision of services is based on hospitals, with every issue prompting a “political” reaction to invest more in hospitals.
Dr Stephen Mann

Stourbridge, W Midlands

Chris SMyth in the Times 29th March 2018: NHS needs 10,000 more beds say chiefs

The NHS is more than 10,000 beds short of what it needs to look after older people properly, hospital leaders have said.

NHS Providers, which represents hospitals, said that it was impossible for waiting time targets to be met this year and warned that the government’s pretence that they would be met created a “toxic culture” similar to that which led to the Mid Staffordshire scandal.

This week Theresa May promised that a long-term plan for NHS budget rises would be agreed within months, and will be under pressure to agree increases of up to £20 billion over five years.

However, Jonathan Ashworth, the shadow health secretary, said that “a nod and
wink from the prime minister” was not enough for patients.

The NHS has not hit any of its main targets for more than two years. Chris Hopson, chief executive of NHS Providers, said: “The levels of performance expected and the savings demanded for next year are beyond reach. While we strongly welcome the prime minister’s commitment to increase long-term funding for the NHS, it makes no immediate difference to the tough task facing trusts for next year.”

Mr Hopson’s report estimates that 3.6 million patients will not be treated within four hours at A&E over the next year and 560,000 will be denied routine surgery within 18 weeks. He said that hospitals could make £3.3 billion in savings next year but that ministers had demanded 20 per cent more than this.

“This creates a toxic culture, based on pretence, where trusts are pressurised to sign up to targets they know they can’t deliver and then miss those targets as the year progresses,” his report said.

“The NHS is probably somewhere between 10,000 to 15,000 beds short on a bed base of about 100,000.”

One hospital chief executive suggested that hospital overcrowding pointed to deep social problems. He said: “As a country we don’t look after old people well. We have too many people living by themselves in houses that are unsuitable . . . In the end they get really unwell and call 999.”

“An illusory technical excape from spending choice”, “a fourfold revolution is required”, “clumsy and unreliable”…

It was Bismark who first created a safety net in social care in Europe. Not Aneurin Bevan, who was some 50 years later. Letters to the editor, in the Times 24th March 2018, tell us the truth. But our politicians, and therefore the public will not listen, and the dissonance is leading closer and closer to civil unrest. There are few people who know more about social care provision and funding than Mr Frank Field MP, and there are few people who understand the funding and problems facing the health service than Mr John Appleby, formerly of the Kings Fund, and now of the Nuffield Trust. Few people understand the economics more than Kristian Niemietz of the Institute of economic affairs. Despite this the Liberal party is committed to a hypothecated taxation increase…. At it’s best a short term “finger in the dyke” policy, but at worst something which could lead on to an impossible dilemma for a future chancellor. We have to ration honestly and overtly.

Funding reforms for health and social care

Sir, The much-needed reform programme in health and social care must extend beyond the remedy you suggest (“National (Health) Insurance”, leader, Mar 22). Analysis I commissioned from the Commons library indicates that, in 2020, the combined deficit for health and social care in England will reach £9.1 billion.

A fourfold revolution in the national insurance system is required to meet both the immediate and the longer-term funding challenge. First, a penny increase in national insurance contributions would eliminate the short-term deficit. Second, that initial tranche of new funding must herald the creation of a national health and social care mutual that sets future contribution levels, governs the long-term financial framework for those services, and educates contributors on the costs of health and social care.

Third, extending national insurance contributions to people of pensionable age who are still in work would meet part of the funding gap in social care. Finally, the system should become more progressive. Those earning less than £11,000 a year should gain exemption from national insurance, with a starting rate of 10 per cent for middle earners and higher rates further up the scale.
Frank Field, MP

House of Commons

Sir, It is true, as your leading article says, that the NHS needs more money than the present plans offer. By 2021, NHS spending will have fallen by around 0.5 percentage points of GDP compared with ten years earlier. Hospitals are in deficit, services are being rationed, and there is still a shortage of NHS staff.

However, creating a ring-fenced NHS tax would put the spend-tax decision back to front. It might appeal to politicians faced with the tough sell of persuading voters to accept tax rises but pegging NHS funding to a dedicated tax would mean that NHS spending would fall when the tax take fell. The hard truth is that if we want to fund the NHS properly we first need to decide what we want to spend, and then how we raise the tax in a fair and efficient way. A ring-fenced tax provides an illusory technical escape from this spending choice, nothing more.
Professor John Appleby

Chief economist and director of research, Nuffield Trust

Sir, The idea of a national health insurance contribution — ie, a hypothecated NHS tax — sounds superficially attractive. We may disagree on the right level of public spending, and on how that money should be spent, but there is near-unanimous support for higher spending on the NHS. Hence, why not link a tax to a popular cause? The problem is that hypothecation has been tried many times and is mostly a book-keeping illusion. A pound of tax revenue is a pound of tax revenue — it does not matter where it comes from. There is no way to ensure that revenue from a “health tax” really is spent on healthcare.

A health tax would be a clumsy and unreliable way to achieve what continental European social health insurance systems achieve effortlessly and reliably. In those systems, your contributions go directly to the health insurer of your choice, not to the government. Those systems work. Why not go the whole hog and replace the NHS with a system of that kind?
Dr Kristian Niemietz

Head of health and welfare, Institute of Economic Affairs

Is Hyporthecated tax a solution, or a distraction? NHSreality is clearly against, but it looks as if we are all going to “share” a lot more..

Update 27th March 2018:

Sir, While news of potential extra funding for the NHS is welcome (“Hunt urges 10-year deal to fix ‘crazy’ NHS budget”, News, Mar 26), it will not solve the complex web of problems crippling the NHS. After 70 years the NHS needs an overhaul. The medicalisation of essentially social problems must be addressed to significantly reduce the demands on GP services and A&E departments. I have no easy answers but remember how the additional NHS funding of Tony Blair’s government was wasted in “reforms” producing little, if any, benefit.
Dr John Harris-Hall (retired GP)

Knapton, Norfolk

Sir, I have no objection to additional hypothecated taxation to support the NHS. However, can it be linked to those items that have a direct impact on illness: smoking, alcohol, sugar etc? In that way the user pays and we have a choice on whether to purchase items that have this additional taxation. For increasing funding to support social care, changes to National Insurance would be a fairer way of meeting the need.
John Berry

Countesthorpe, Leics

Sir, I have never understood why, when I reached retirement age, I no longer had to pay national insurance. I continued to pay car and house insurance. Now the health secretary is hinting at a hypothecated tax for the NHS. This should surely also include care. Since the people most likely to need both are the retired, I see no objection to that growing and increasingly wealthy section of society being asked to help to fund it.
Eric Johns

Swanage, Dorset

The second letter shows the regressive nature of “deserts based rationing”.

 

Child health declining: just one of the indicators – losing our first world status?

Just as overall life expectancy is set to fall, so child health is declining, and the life expectancy of ill children depends more and more on your post code, and your income group. We are losing our first world status.. Our main natural resource is our people and our children. With no significant underground resources we are in trouble if we don’t invest in education and our children more.

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Jacqui Wise reports in the BMJ: Child health crisis: calls for urgent action must be heeded (BMJ 2018;360:k1270 )

The data pointing to a reversal in the health of British children are mounting, reports Jacqui Wise

After years of progress the UK is stalling in areas such as infant mortality and immunisation levels and is lagging behind similar countries on mortality, breastfeeding, and the prevalence of obesity.

Several new reports detail the worrying state of the nation’s child health. Health professionals say that the latest figures are cause for alarm and are calling on the government to act urgently to develop a comprehensive child health strategy.

Rising infant mortality

Latest figures from the Office for National Statistics show that the number of babies dying in the first year of life is rising,1 a reversal of several decades of the NHS’s success in reducing infant mortality. In England and Wales the rate has increased to 3.8 deaths per 1000 live births, up from 3.7 in 2015. Neonatal death rates have also risen, from 2.6 per 1000 births in 2015 to 2.7 per 1000 in 2016.

Furthermore, the ONS figures show that the infant mortality rate in the most deprived areas of England was 5.9 per 1000 live births, more than double the 2.6 per 1000 in the least deprived areas.

The news comes after findings in a report from the Nuffield Trust and the Royal College of Paediatrics and Child Health that the UK is falling behind most other high income countries in many key areas of child health.2

The report’s author, the paediatrician Ronny Cheung, warned, “The recent changes to the UK’s trajectory on life expectancy, premature deaths, and immunisation should set alarm bells ringing for policy makers about the effects of cuts to public health and early years services.”

The analysis, which compared the UK with 14 other countries—10 in Europe and also the US, Canada, Australia, and New Zealand—found that in 2014 the UK had the fourth highest infant mortality rate. The UK also has the second highest prevalence of babies born with neural tube defects.

The UK’s rates of breastfeeding are among the lowest in the world: only 34% of UK babies receive any breast milk at six months, half the 62.5% in Sweden. The UK’s proportion of children and teenagers who are overweight or obese is considerably above the average among high income countries.

Diphtheria, tetanus and whooping cough, and pneumococcal vaccines have all seen their uptake fall in the past year, and the UK lags behind Sweden, Spain, Germany, and the Netherlands in the uptake of measles vaccine.

Poverty set to increase

The report said that inequality, which has been proved to have a negative effect on child health, is rising. Last year a report published by the Royal College of Paediatrics and Child Health showed that UK children from deprived backgrounds had much worse health on 24 of the 25 indicators measured, including higher rates of mortality, obesity, non-intentional injury, maternal and adolescent smoking, and emergency hospital admissions for asthma or poor diabetes control.34

The situation is likely to get worse, because child poverty rates look set to rise even further. Another new report, from the Equality and Human Rights Commission, looked at the effects of changes to taxes and social security between 2010 and 2018. It concluded that children will be among the hardest hit by the changes.5 One and a half million more people will be in poverty by 2022, it predicted, and the proportion of children in lone parent households who will be in poverty will rise from 37% to over 62%.

Russell Viner, president of the Royal College of Paediatrics and Child Health, argued in The BMJ last week that the problem was that NHS England didn’t prioritise children and teenagers.6 In contrast, Scotland and Wales have both recently announced new national strategies to improve the health of young people.

In a press release accompanying the college’s report Viner said, “We want to see the UK government develop a comprehensive, cross departmental child health strategy, which includes a ‘health in all policies’ approach to policy making. It’s also crucial that some of the biggest threats to child health are tackled boldly—for example, tighter restrictions on junk food advertising to tackle obesity, the reinstatement of child poverty reduction targets, and, crucially, the reversal of damaging public health cuts.”

Michael Marmot, director of University College London’s Institute of Health Equity and a leading expert on health inequalities, told The BMJ, “The worrying part is when a downward trend that has gone on for years stops. While the increase in infant mortality has been small, we should be doubly concerned. First, because one extra death that might have been avoidable is a tragedy for the family concerned. Second, because a rise in infant mortality is an indicator that things are perhaps not going well in society, as well as in the healthcare system.”

He added, “Child poverty rates are set to rise in the UK, and growth in funding for the NHS is way below historical trends. The Nuffield report shows that breastfeeding rates are low in Britain. The government needs to pay attention to all three of these with a good deal of urgency.”

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