Monthly Archives: March 2018

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..

NHSreality is against hypothecated taxation as a simple solution. Comments are listed in the postings below. The Times feels we need it, but NHSreality predicts that it will solve no problems. It will just delay solutions… We may become even more polarised, but share more…

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National (Health) Insurance – Extra health spending should be funded by a dedicated tax

When a strike by the British Medical Association threatened the incipient National Health Service, its founding minister Aneurin Bevan pushed up the wages of the nurses and gave so much to the hospital consultants he could reflect later that he had “stuffed their mouths with gold”.

The pay deal for NHS staff in England announced in Westminster yesterday was not exactly a gold stuffing but it was an overdue rise which will cost £4.2 billion in total. More than a million NHS staff have been offered increases of at least 6.5 per cent over three years south of the border and the Scottish government is now holding talks to agree a matching deal for 147,000 workers in Scotland. The English package, if it is ratified by staff, will mean that the lowest paid staff — cleaners, porters and catering staff — will receive a 15 per cent pay rise and a nurse will receive a rise of 21 per cent over three years. This is salutary news. Vacancies for nurses and midwives in Scotland have risen 353 per cent since 2011.

As welcome as it is, however, more money in the NHS can never be enough.

This is more of a commentary on the changing nature of health needs than it is a criticism of the NHS which is, by international standards, an efficient system. An ageing society in the developed world spends the bulk of its health budget on chronic conditions. As the frontiers of technology move back, patients expect better, more expensive, treatment. Social care, outside the NHS but vital to its smooth functioning, has been savagely cut and this throws costs back on to the NHS. Health inflation has been running well in advance of whole-economy inflation for many years now.

Reform programmes need to be accelerated. As long as the NHS remains organised around large hospitals it will be out of date, but attempts to centralise services in Scotland have hit such public and political backlash that progress has been stifled. Social care also needs to be integrated properly into the health service.

The creation of joint council and NHS boards to oversee community care in Scotland is yet to deliver this vision — the very reason for what has been a time-consuming re-organisation. The new joint boards still work with funding streams funnelled through health boards and councils and services talk about “set aside” budgets for hospitals. If real reform does not happen, every few years there will be a reckoning; a higher budget will be sought which will never suffice. Britain spends 8.3 per cent of its GDP on healthcare. The Kings Fund and the Office for Budget Responsibility have both estimated this will need to rise to 12 per cent by 2025 to keep pace with demand.

The funding, though, has to be made secure and the best way to do that is to separate it from general taxation. The Treasury has historically been suspicious of dedicating taxation to particular purposes but Nick McPherson, a former permanent secretary, is one of many prominent figures arguing for a hypothecated health tax. Nick Boles MP suggested rebranding National Insurance as National Health Insurance to help win public consent for the extra resources the health service needs. This would also remind users that while the service is free at the point of delivery, it is not free.

The NHS occupies a special place in British life. Its importance will not be recognised, though, by going slow on change. If we want the service to stay the same, its funding will have to change.

We must avoid the mistake of a hypothecated health tax – unless the tax takes income and capital into account.

Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

Hypothecated taxation is not the answer, and Brexit may “finish off” the UK Health services.

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

LibDems suggest hypothecated taxation – without examining the ideology

Hypothecated taxation? A separate NHS tax would rein in spending

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

Letters in the Times 22nd March 2018.

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Sir, Further to the announcement of the creation of five new medical schools (report, Mar 20, and letter, Mar 21), training more doctors in “places where doctor shortages are greatest” shows a lack of understanding by the health secretary and the Department of Health. Medical staff move around while they train; good medical/surgical experience transcends environment when the staff are valued. (Five New Medical Schools: better late than never)

More than one third of medical graduates, laden with debt, now leave the NHS either to work abroad or for other careers within three years of qualifying. This is a vast change. The medical system that provided mentor support and a sense of belonging between consultant and junior doctors has been destroyed by the European working time directive and the introduction of a shift system.

The contracted training scheme introduced by Kenneth Calman, the chief medical officer, in 1996 with no guarantee of future employment encouraged many of those who were well qualified not to wait until unemployment loomed but to jump before they were pushed. The enforced new contract by Jeremy Hunt has been the last straw for my younger colleagues and also some towards the end of their careers.

The appraisal and revalidation system for doctors introduced after the Harold Shipman affair is regarded by my colleagues as a complete waste of time and a further burden on a strained workforce. The GMC has meekly accepted all this and indeed has helped to inflict early retirement on those who wish to avoid this bureaucracy, leading to a huge loss of medical experience and expertise.
Professor Colin G Fink
Clinical microbiologist, University of Warwick

Sir, Your report that five new medical schools are to open in the next two years to train 1,500 more doctors a year indicates that the government has misunderstood the issues facing the health service. The solution is to make the doctors who are already being trained want to stay and work in the NHS for their whole career. The money earmarked for the new medical schools should be spent on improving existing resources and to support NHS staff.
Gill Lewis
Retired consultant anaesthetist, Solihull, W Midlands

Patients abused and dying in NHS mental health care

Chris Smyth reports in the Times 21st March 2018 on the forgotten and politically inert area of mental health, which accounts for a large part of the Health services budgets. Once Dementia becomes more commonplace, and can be treated, it will be even more….

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Patients abused and dying in NHS mental health care

Mental health patients are being failed by “appalling” care daily, the NHS ombudsman has said.

Patients died because their symptoms were dismissed, a baby was taken from its mother with no explanation and a woman who had been sectioned was forced to menstruate into a plastic cup, Rob Behrens said in examples of mistreatment.

Britain should be shocked at how vulnerable patients were routinely stripped of their dignity by a system that did not have enough skilled staff, an overview of 200 cases concluded.

Bosses must start learning from repeated mistakes rather than succumbing to a “nothing I can do, guv” attitude and ministers must realise that fine words are not enough, Mr Behrens said. “This report shows the harrowing impact that failings in mental healthcare can have. The most important aspects are about the lack of respect for patient dignity and human rights. Some of these cases are appalling.”

While Mr Behrens said most staff were doing their best he insisted that “these things are happening on a daily basis”. “There aren’t enough skilled and qualified staff, there is a problem in recruiting them and there is overuse of agency staff”, he said.

Despite problems of money and staffing he insisted that bosses were not powerless. “[Some trusts] don’t learn the lessons of having made mistakes . . . You can change that, it’s about cultural attitude.”

Theresa May has called the treatment of mental illness a “hidden injustice”. Mr Behrens said that government policy said the right things, but he added: “Having a plan is not enough”. Saffron Cordery, of NHS Providers, said: “Every patient deserves to be treated with dignity . . . Funding commitments must be met with action.”

NHS Ombudsman (Rob Bohrens) calls out ‘harrowing’ failings in mental health care

Chris Smyth 21st March 2018: Start saving for dementia drug, NHS told


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

Beginning to realise the mess they are in, New Medical Schools have been announced, which will produce new doctors in 6-10 year’s time. The full details have yet to be announced, but there will be less wastage, more efficiency, more long term work hours, if the places are predominantly for graduates. It’s still not enough, and why didn’t we do it 20 years ago? The rejection of 9 out of 11 candidates for years is unforgiveable. Lets hope the new Deans listen to Dr Cairns advice (see letter below)

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BBC News 20th February: Under-doctored areas to get new medical schools

…Places at existing schools are also being increased as part of the government’s commitment to increase student places by 25%.

It will mean by 2020 there will be 1,500 more students each year.

Health Secretary Jeremy Hunt said the new schools were being targeted at parts of the country where it “can be hard to recruit and attract new doctors”.

Overall 90% of the new places will be outside London.

“It will help us deal with the challenges of having around one million more over 75s in ten years’ time,” added Mr Hunt….

Alex Matthews-King in the Independent:Emphasis on training doctors in areas with staff shortages will expand university places in Sunderland, Lancashire, Canterbury, Lincoln and Chelmsford

The Lincolnite: New Medical School to address staff shortage.

Chris Havergil in the Times Educational Supplement: 5 new Medical Schools

Chris Smyth in the Times: More medical schools to fill NHS gaps

Five new medical schools will open in the next two years to train doctors as fears grow about NHS staffing gaps.

Anglia Ruskin University will train medical students at its Chelmsford campus from September, followed by the University of Sunderland and a partnership between Nottingham and Lincoln universities next year. Schools will open in Canterbury and at Edge Hill University in Lancashire in 2020.

The NHS is short of thousands of doctors and ministers have promised to increase training places by a quarter. Health chiefs say that staff shortages are rapidly overtaking money worries as the biggest threat to care.

Jeremy Hunt, the health secretary, said yesterday: “Setting up five new medical schools is part of the biggest ever expansion of our medical and nursing workforce, which will help us deal with the challenges of having around one million more over 75s in ten years.”

The 33 existing schools take 6,000 doctors and the 1,500 places Mr Hunt promised have been allocated, giving priority to areas where shortages are worst. The Chelmsford school will take 100 this autumn and there will be 530 more at existing schools. Places will increase by 690 next year and 180 in 2020.

Comment from a Dr Andrew Cairns in the Times 21st March 2018: MEDICAL ATTRIBUTES
Sir, I hope that the introduction of new medical schools to train 1,500 more doctors each year (report, Mar 20) will bring with it a review of selection criteria. Too many medical students have been high-achievers throughout their short lives and have not experienced failure. When this occurs, as it inevitably will in a medical career, they may not have the resilience to cope. The academic bar should be lowered and attributes such as common sense, stamina, resilience, a sense of humour, dexterity and interpersonal skills encouraged.
Dr Andrew Cairns (retired GP)

Petersfield, Hants

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Dying NHS chief wants GP’s help to end agony

NHSreality supports Dr Cosford, and would ask for exactly the same treatment and expectations… What a pity that our elected representatives are afraid to take action in the same way that Canada has. And if we don’t address the issue many doctors fear using the palliate care painkillers in appropriate doses, as they can then be accused of accelerating death.

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Dying NHS chief wants GP’s help to end agony – Sarah Kate-Templeton in the Sunday Times March 18th 2018.

The man responsible for improving the nation’s health has been diagnosed with incurable cancer and has revealed that he would like “a quiet chat” with his GP when his time is nearly up.

Professor Paul Cosford, director for health protection and medical director of Public Health England (PHE), would like to be able to ask his family doctor for enough medication to ease his pain — even if this hastens his death.

In a frank account of his illness in a blog on a medical website, he wrote: “I wish I could have a quiet chat with my GP and ask him to make it easier when the time comes.

“That is not a conversation you can really have these days. In the past, easing the process of dying with sufficient medication to ease symptoms but which might also hasten your passing was generally accepted but it seems difficult to have this conversation now because there have been so many legal concerns raised.”

He told The Sunday Times: “It feels to me as if we trusted the relationship between a doctor and a patient much more and now there is a temptation to put a legal framework around everything.

“Sometimes people are so concerned about the legal consequences that we forget about good, humane, personalised medical care.”

Cosford, 54, has lung cancer. He has never smoked and realised he was ill only when he could not complete a 600km (372-mile) cycle ride.

Following his diagnosis, his interest has turned to the quality of life for the terminally ill. Addressing a meeting of the Royal Society of Medicine in February, he said: “Thinking that I might have some control at the end of my life allows me to focus on living life well now.

“I will probably be able to make that happen as things currently stand because of my knowledge of the system, but it is apparent to me that this is not the same for everyone.”

Cosford, a father of four who is married to a doctor, needs to know that he could “bring things to a conclusion” if he loses all hope.

He told the meeting that he wanted to “develop a tacit understanding that, at the point that all my reasonable options run out and, if it is all too much for me, I will have the wherewithal to bring things to a conclusion myself . . . And I sort of assume I might have a syringe driver and will just need a bit extra available if I need it.”

Keeping life as normal as possible, he continues to work in his high-powered role. He believes passionately in the health benefits of exercise and still completes one 100-mile cycle ride a month. He hopes that if he continues to receive the latest treatments he will live another three or four years.

He can also laugh at the absurdities of terminal illness. When inquiring about travel insurance, he was asked if he had a date for his death.

“I said, ‘I have an incurable cancer, are you meaning that that is terminal and would that exclude me from your policy?’ The person on the other end of the line said, ‘Well, have you been given a date for your death?’”

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A sign of falling morale (and standards), and lack of “buy in” to the health service philosophy…?

Doctors don’t go on strike easily. Junior doctors are 80% women, and they strike less easily than men. The strikes of 2017 have been replaced by “legal action”. Is this not a signal to politicians, of falling morale, and lack of “buy in” to the health service philosophy…? In other countries, Germany, USA, Canada etc. the doctors work harder and longer hours. So this case may be a proxy for general discontent. Who amongst them has had an exit interview, and who would trust an HR department to report feedback dispassionately. Only this week I heard of a consultant offered (rare event) an exit interview, and he is thinking hard about it. Could he be punished when he is a patient (downside risk)? Will he be taken seriously? Is anything likely to change as a result? He would certainly tell them standards were falling..

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Junior doctors take trust to court for denying them breaks every four hours (BMJ 2018;360:k852 ) Clare Dyer

A junior doctor has accused her former employer of breaching her contract by not allowing breaks every four hours, in a High Court test case with reverberations throughout the NHS.

Sarah Hallett is acting on behalf of herself and another 20 junior doctors who trained with Royal Derby Hospitals NHS Foundation Trust in 2013-14, when she was in her foundation year. In a case supported by the BMA they argue that they did not receive the breaks they were entitled to.

At the Royal Courts of Justice in London, where the four day case opened on 20 February, John Cavanagh QC, representing Hallett, said, “This case is of general public importance . . . It is a test case which is of significance across the NHS.”

He told Mrs Justice Simler that NHS trusts were obliged to allow junior doctors a 30 minute rest period after every four hour working period. “If they do not have the opportunity to take these breaks, this affects their safety and welfare, with consequent effects on patient safety,” said Cavanagh.

NHS trusts that did not comply with the rules had to pay juniors double their normal rate for missed breaks, he told the court. But Hallett’s primary objective was not money, he said, but to make sure that NHS trusts met their contractual obligations.

“It is the responsibility of trusts to make sure that they do not run overly fatiguing or unsafe rotas,” he added. “Junior doctors who have to work for many hours in very stressful and high pressure conditions without even a short break will be exhausted, and this will potentially lead to risks to patient safety.”

If Hallett, who is a deputy chair of the BMA’s junior doctors committee, wins her case and the 21 doctors claim compensation for the lost rest periods it could cost the trust £250 000 (€283 000; $349 000). Richard Leiper QC, representing the trust, said, “The potential cost to the trust, let alone to the NHS as a whole, would be dramatic.”

A trust spokesperson said, “This trial is simply about how Derby Teaching Hospitals monitored junior doctors’ working hours back in 2013. The approach we took mirrors that taken by a significant proportion of NHS trusts up and down the country.”

Junior Doctors strikes had significant impact on patient care – Paul Gallagher 19th February 2018 I news who also reports 18th March 2018 on the increasing death rate “Stunning figures reveal more than 10,000 excess deaths”…


Consultancy firms make hospitals worse

This article represents the opposite of rationing: wastage. When you are wriggling on the hook set by an unsympathetic and “in denial” political administration, you reach desperately for anything: a straw is no help in this slow motion disaster.

Chris Smyth in the Times reported 21st Feb 2018: Consultancy firms make hospitals worse

The hundreds of millions of pounds the NHS spends on management consultants actually make it less efficient, the first study of its kind has concluded.

Not only are hospitals wasting their money but the consultants appear to make finances marginally worse.

Researchers said that “inefficiency is the norm” in NHS consulting projects.

Health unions reacted furiously to the “scandalous” findings, urging ministers to divert money from management consultants to doctors and nurses. Hospitals and consultants insisted that external advice was needed, but conceded that the results underlined the need for clear measures of value for taxpayers’ money.

Andrew Sturdy, professor in management at Bristol University, who carried out the study, said: “Our research has clearly shown that management consultants are not only failing to improve efficiency in the NHS but, in most cases, making the situation worse . . . this is money which, many argue, could be better spent on medical services or internal management expertise.”

Despite consistent political criticism of management spending from both main parties, the cost to the NHS has increased under both, reaching £640 million in 2014 before falling to £263 million in 2016-17.

Professor Sturdy gathered data on 120 NHS hospitals over four years, comparing spending on consultancy with an efficiency measure recording how much it cost them to carry out standard procedures. Each £100,000 spent on management consultants led to extra costs of £880, he concluded in the journal Policy & Politics.

The average trust spent £1.2 million a year on management consultants and afterwards became less efficient by about £10,600 a year. Professor Sturdy said: “The big question is what that money could have been spent on instead.”

He also tracked efficiency changes after the consultants were brought in, to rule out the possibility that the worst hospitals needed more outside advice. He found no clear effect of consultancy spending on quality of care.

“What stands out is how widespread that increase in inefficiency is across the board. Inefficiency is the norm,” Professor Sturdy said. He argued that British hospital bosses, unlike those in places such as Germany, seemed to “default to external management consultants” and needed to be more rigorous about their use. About a third of a subset of hospitals seemed to improve efficiency using consultants he said, adding that he wanted to find out what could be learnt from them.

“There will always be a role for external management consultants. A lot of people will say don’t use them at all but this isn’t the conclusion of this study. The message here is the need to assess and be more cautious and sceptical,” he said.

“Clearly an organisation like a hospital does need management advice, the big question is what terms is it on.”

Chaand Nagpaul, head of the British Medical Association, said: “At a time when patients are enduring long waits due to overstretched hospitals and GP surgeries, it is scandalous that huge sums of money are being spent on management consultants in the NHS. This is not just a waste of taxpayers’ money — these findings show that they lead to a rise in inefficiency and are actually making things worse.”

Janet Davies of the Royal College of Nursing said that her members would be “exasperated” by the findings.

However, hospitals defended the use of management consultants, saying they had been told to lay off so many managers that some projects could only be done with outside help.

A spokesman for NHS Improvement, the financial regulator, said: “We are working with all trusts on reducing their costs which includes spending less on management consultants; and have had some success . . . in future, we will continue to work with trusts on keeping their consultancy spending to a minimum, and on commissioning it better.”

Behind the story
There is nothing management consultants love more than a data-rich analysis — except, it seems, when it comes to their own performance (Chris Smyth writes).

Even though such consultancy has been embedded in the NHS for decades, there has been little published research on whether it works. If this study does nothing else, it throws down the gauntlet to management consultancies to demonstrate which of their efforts really do justify their fees.

Much of the scepticism comes from a suspicion that when managers reach for outside consultants, it is simply because they do not have any better ideas, or to legitimise a decision they have already reached. It is striking that the researchers behind this study say that the answer to wasteful consultants might be not to spend the money on doctors and nurses, but to use it hire more permanent managers who know what they are doing.

Consultants say they are already trying to prove their worth with contracts that link their fees to the money they save, or the clinical results they improve. The NHS must explore this. But at a time when the NHS is struggling to implement its long-term strategy for joined up care, there is a more fundamental question: how does the NHS make the change it needs to survive? Anyone who can crack that question will be worth the money.