Monthly Archives: March 2018

Is the minister going to panic – no way. He is in denial

If I were the minister of health, especially in England, I would be panicking. There is more and more evidence of rationing, and the euphemistic platitudes used to deny this are increasing. Prioritisation, restriction, exclusion, listing, processing etc. The safety net has more and more holes in it, and you don’t appreciate the holes until you need the particular service. Waiting on trolleys in A&E is also increasing, so that the emergency services are being seen as “second rate”, as well as the colder orthopaedic (waiting lists and infections) and cancer (exclusions and waiting times). As staffing levels fall, so do standards. (NHS ‘dangerously’ short of 100000 staff).

Women could be denied IVF treatment on the NHS in Trafford to save money – Lisa Meakin in the Greater Manchester news 18th March 2018

There’s a shortage of GPs causing CONCERN in Tyneside – Gareth Crickmer in the Shields Gazette 6th November 2017

Rationing of health care starts to bite across the district – Sarah Page in the West Sussex County Times 18th March 2018

A range of health treatments are now being rationed to people in Horsham, Crawley and Mid Sussex. Patients are being told that ‘minor’ operations – from investigative joint surgery, haemorrhoid removal, skin lesion treatment and treatment for varicose veins – are no longer being routinely funded by the NHS. There are also restrictions on a number of other conditions including cataract removals, female sterilisation and hysterectomies. The Crawley, Horsham and Mid Sussex Clinical Commissioning Groups – which are responsible for paying for local health services – have drawn up a ‘list of clinical policies’ outlining the treatments which will no longer be routinely funded…..

GPs (once again) offered cash to refer fewer people to hospital. Denis Campbell 28th February 2018 in the Guardian

GPs are being offered cash payments not to refer patients to hospital, in a move which leading family doctors have criticised as ethically questionable and a risk to health.

NHS bodies in four parts of England are using schemes under which GP practices are given up to half of the money saved by sending fewer patients to hospital for tests and treatment……

The Independent 3 days ago had as its editorial: The future of the NHS requires an informed debate from the public and politicians alike.

There are, as there always have been, trade-offs between types of care, between types of patient, geographical areas, and class. We can vary the weights given to public health, cancer care, social care, mental health or NHS dentistry, to name but a

‘Worrying’ rise in patients forced to pay for cancer drugs

‘I had no option but to spend £10000 for my hip op’

Official figures mask A&E waiting timesBig rise in A&E trolley waits at Shropshire hospitalsWoman dies after paramedic finds her on A&E trolley in cardiac arrest & Man left in agony in hospital corridor for more than 20 hours (Southmead)



So, you did not think there was post code rationing of cancer care?

Kat Lay reports 12th March 2018 in the Times: “UK behind on cancer guidelines” (she means treatments)

It may be very sensible to refuse treatments for which there is a poor return, and serious side effects. The spending of state money has to be rationed, but NHSreality maintains that this should be overt, and universal for the low volume high cost treatments. Aneurin Bevan talked about In Place of Fear ( A Free Health Service 1952 Chapter 5 In Place of Fear ) but we are doing our best to bring back fear. There are four British health café systems, each rationing differently. In each we pay up under the same tax rules. The UK is also behind on introduction of new drugs – for good reason. Mark Littlewood doesn’t believe is deserves the taxpayer funding it gets! The Times also explains why and how more people are having to pay for cancer treatments which are excluded. Sarah Kate-Templeton reports on the current private income from treating cancers privately in 2017: £360m

British cancer guidance is less likely to recommend innovative drug treatments for patients than versions used in other parts of Europe, a study has found.

Researchers at King’s College London evaluated clinical practice guidelines issued by different national bodies, finding that UK examples were more likely to focus on surgery, and slower to pick up on new research.

Their study comes after several high-profile cases where patients have had to travel abroad for treatment.

The Home Office is considering allowing a medical cannabis trial to treat Alfie Dingley, a six-year-old boy with epilepsy, who travelled to the Netherlands to take a cannabis-based medication last September. Jessica Rich, one of two sisters with Batten disease, a genetic disorder that kills sufferers before they reach their teens, has to fly to Germany for treatment with a drug that Nice will not fund and Ashya King, now eight, was taken to the Czech Republic by his parents for proton therapy on a brain tumour, against the recommendation of doctors in Southampton in 2014. Earlier this month his family announced that scans showed he was free of cancer.

The study, published in Esmo Open BMJ, found recommendations in continental Europe tended to focus on the use of new chemotherapy agents or targeted treatment, while UK guidelines tended to focus on surgery, screening or radiotherapy.

Mark Baker, director of the centre for guidelines at Nice, insisted the research was “poorly undertaken” and misrepresented its guidance .


No good news for those who think money is the answer….

Oliver Wright reports in the Times 12th March 2018: Hammond pledges cash for NHS but no end to austerity

Philip Hammond will open the way for a multibillion-pound investment boost in the NHS when he announces better than expected public sector finance figures tomorrow.

The chancellor is to use his spring statement to reassure Tory MPs that he is preparing to scale back austerity with significant public spending announcements in the autumn budget.

However, he will warn his critics that money must still be set aside to pay down the deficit and that there will be no immediate easing of government purse strings.

Mr Hammond hinted that spending on the NHS would take precedence and announced that the government was close to a productivity deal with health service staff that could see pay rises of up 6.5 per cent.

He also said he was looking to fulfil Conservative manifesto pledges to reduce taxation in the autumn while also announcing new money for post-Brexit infrastructure.

The chancellor made clear that there would be no new tax or spending commitments this week and the statement would be focused on the fiscal forecasts and a number of new consultations — including for a litter levy — before the budget.

“As we come to the autumn budget, if we at that point have some fiscal headroom, we will use it to keep reducing the deficit so that debt falls, but we’ve also got to support our public services,” Mr Hammond told ITV’s Peston on Sunday programme.

“There’s a negotiation going on between the unions and the management for a pay deal for nurses and [other NHS workers], and I very much hope if the management and the unions can reach a deal which through workforce restructuring, pay restructuring, efficiency gains, can deliver product improvements to the NHS, then we will put extra money into the NHS next year to fund this.”

In a message to his critics, including Theresa May’s former chief of staff Nick Timothy, who have called for an end to the age of austerity, the chancellor said that increased public spending would not come at the expense of paying down the deficit.

“I’m afraid Nick Timothy’s ignoring the debt,” he told the Andrew Marr Show on the BBC. “We have a debt of £1.8 trillion, 86.5 per cent of our GDP. All the international organisations recognise that that is higher than a safe level and this isn’t some ideological issue. It’s about making sure that we have the capacity to respond to any future shock to the economy.”

He added: “There is light at the end of the tunnel because what we’re about to see is debt starting to fall after it’s been growing for 17 continuous years. But we are still in the tunnel at the moment. We have to get debt down. There will be economic cycles in the future. We need to be able to respond to them without taking our debt over a hundred per cent of GDP.”

The litter levy that Mr Hammond is expected to announce could result in takeaway food containers being taxed for the first time. Chewing gum, which is not water soluble and takes months to decompose, is regarded as a single-use plastic in some countries.

Treasury officials are contemplating including the product in the public consultation document on a future litter tax, meaning gum manufacturers would be subjected to the sort of levy that being considered for plastic cups, cutlery, crisp packets, bottles, foam trays and other single-use plastics.

Mr Hammond has described waste from single-use plastics as “a scourge to our environment” and aides say that he wants to “put the weight of the Treasury” behind attempts to solve the problem.

John McDonnell, the shadow chancellor, accused Mr Hammond of allowing austerity to reduce UK growth. “Last year we had the lowest economic growth in the G7 countries [and] austerity is holding growth back,” he said, adding that the savings that had allowed the government to reduce the deficit had been made at the expense of those least able to cope.

“What he’s done, very cleverly, is shifted the deficit on to the shoulders of NHS managers, on the shoulders of head teachers and on to the shoulders of not just the poorest but those just about managing, who are going to be hit next month by the cuts in the support that they get through the benefit system. So this isn’t a matter for celebration.”

“…health could be a casualty of Brexit.” Too true.

The NHS and Brexit. A letter in the Times from Professor Martin McKee and numerous other professors. March 12th 2018.

All the points raised are valid, but omitted is the drop in the value if the pound, and consequently our ability to buy in medical supplies.


Sir, The prime minister has repeatedly said that Brexit must respect the will of the people. While there has been much debate about what that means, one thing has been clear since it was invoked in a slogan on the side of the Brexit bus. This is the high priority that the public places on health. Yet there have been concerns that health could be a casualty of Brexit, including loss of NHS staff, problems obtaining medicines, weakening of public health protections and damage to medical research. Lord Warner, Lord Hunt of Kings Heath, Lord Patel and Baroness Jolly have tabled an amendment to the EU Withdrawal Bill that would ensure that the existing health protections in the European treaty continue to underpin measures repatriated into UK law. As senior health professionals, we urge the government to resolve the present uncertainty and accept this important amendment.
Professor Martin Mckee, London School of Hygiene and Tropical Medicine; Professor David Adams, University of Birmingham; Professor Sir George Alberti, former president, Royal College of Physicians; Professor John Atherton, University of Nottingham; Professor Philip Baker, University of Leicester; Professor Raj Bhophal, University of Edinburgh; Professor Sir Nick Black, London School of Hygiene and Tropical Medicine; Professor Carol Brayne , Cambridge University; Professor David J Burn, Newcastle University; Professor Sir Harry Burns, former chief medical officer Scotland; Professor Iain Cameron, University of Southampton; Sir Iain Chalmers, James Lind Library; Professor Sir Cyril Chantler , formerly University of London; Professor Dame Anna Dominiczak, University of Glasgow; Professor Carol Dezateux, Queen Mary, University of London; Dr Clare Gerada, former chairwoman of the Council of the Royal College of General Practitioners; Sir Muir Gray, University of Oxford; Professor Trisha Greenhalgh, University of Oxford; Professor George Davey Smith, University of Bristol; Professor Sir Andy Haines, London School of Hygiene and Tropical Medicine; Dr Iona Heath, former president of the Royal College of General Practitioners; Professor Andrew Hassell, Keele University; Professor Jenny Higham, St George’s, University of London, Chairman Medical Schools Council; Professor Richard Horton, editor, The Lancet; Professor John Iredale, University of Bristol; Professor Neil Johnson, Lancaster University; Professor Ann Louise Kinmonth, Cambridge University; Professor Louise Kenny, University of Liverpool; Professor Peter Kopelman, St Georges, University of London; Professor Sudhesh Kumar, University of Warwick; Professor Deborah A Lawlor, University of Bristol; Professor Keith Lloyd, Swansea University; Professor Una Macleod, Hull York Medical School; Professor Patrick Maxwell, University of Cambridge; Professor Sir Robin Murray, King’s College London; Professor Pascal McKeown, Queen’s University Belfast; Professor Sir Michael Owen, University of Cardiff; Professor Dame Pamela Shaw, University of Sheffield; Professor Rosalind L Smyth, UCL Great Ormond St Institute of Child Health; Professor Robert Sneyd, University of Plymouth; Sir Richard Thompson, former president, Royal College of Physicians; Professor Tony Weetman, University of Sheffield; Professor Sir Simon Wessely, Kings College London; Professor Moira Whyte, University of Edinburgh; Dr Graham Winyard, former deputy chief medical officer, England

Its not just GPs: “Critical Care units are turning away patients.”

Charlie Parker reports in the Times 8th March 2018: Critical Care units are turning away patients.

When the “rules of the game” don’t allow the overt rationing of care, then prioritisation and restriction are the only methods of rationing available to them. Its cause is really little different to GPs restricting numbers to be seen, but it is covert and you won’t know until you need it for you or your family, whether it is or is not available. Like private emergency care, private critical care will start to happen in big cities first.

Image result for no nhs beds cartoon

Four in five NHS intensive care units are turning away patients because of bed shortages.

A survey of ICU consultants by the Faculty of Intensive Care Medicine, their professional body, found that 62 per cent of the units were unable to provide adequate care because of nurse shortages. Some 210 intensive care units across the UK were each short of 12 nurses on average, leaving patients whose lives were at already at risk more vulnerable.

The findings, which were shared with The Guardian, also revealed that patients were being transferred from one ICU to another for non-clinical reasons in 80 per cent of hospitals.

Carl Waldmann, the dean of the faculty, said: “Especially at this time of year, when winter pressures exacerbate an already beleaguered system, critical care services come close to the absolute limit of their ability to provide good patient care.”

Image result for no room at the inn cartoon


Another form of rationing: restriction of GP access should be blamed on politicians

Chris Smyth reports on March 7th 2018 in the Times: GP leaders draw up plan to turn away excess patients

This is merely another form of rationing: restriction of GP access should be blamed on politicians. They have inadequately planned for the increasing demands of an ageing population. They have mismanaged the manpower planning – for 10 successive administrations. They have ignored the work-life-years lost by the gender imbalance, and they remain in denial. The unreality of 5000 new GPs…. and killing the geese that laid the golden eggs of efficiency. (GPs)

Family doctors will be able to turn away patients once they have done 35 appointments in a day under plans drawn up by GP leaders to deal with overwhelmed surgeries.

Once doctors have exceeded a safe daily number of consultations, extra patients would be sent to an overspill centre further away in a system modelled on the “black alerts” that allow overstretched hospitals to divert ambulances elsewhere.

The British Medical Association (BMA) insists that the plan will make patients safer because they will no longer be treated by exhausted doctors who are more likely to make mistakes. It also argues that capping workloads will prevent the GP system from collapsing as doctors fed up with rising patient numbers increasingly desert the NHS.

However, patient leaders attacked the “dangerously crude” plans and NHS chiefs insisted they must not go ahead.

Ministers have accepted that GPs can no longer cope with a “hamster wheel” of rising numbers of older, sicker patients and have promised an extra 5,000 doctors by 2020. However, GP numbers fell by more than 1,000 last year, fuelled by rising numbers of early retirements. Patient satisfaction with the GP service dropped 7 percentage points last year to a 35-year low of 65 per cent.

The BMA acknowledges that there is “surprisingly little” evidence defining when a GP’s workload becomes unsafe, but suggests that anything below 25 routine appointments a day is fine, with danger levels reached at 35, or 15 more complex consultations. It says that local areas should be able to set their own limits.

A poll by the health magazine Pulse this year suggested that GPs did an average of 41 appointments or phone calls a day, with 1 per cent dealing with more than 100 patients daily.

Richard Vautrey, chairman of the BMA GP committee, said: “GP workloads have become increasingly unmanageable owing to the demands of more complex patient needs, widespread recruitment issues and years of underinvestment, all of which takes a toll on GPs’ physical, mental and social health.

“There is an urgent need for cultural shift. Having a system of overworked and undervalued GPs is unsustainable, and a change to safe working practices is vital to ensure the survival of general practice.”

In a report, the BMA acknowledges the practical difficulty of finding somewhere else to send patients, proposing a system of local “overflow hubs”. It also concedes that many doctors will be reluctant to turn patients away, saying that the black alert system “will require a cultural change to remove the current noble but potentially self-destructive urge within general practice to simply work harder and longer to meet patients’ needs.”

The Royal College of General Practitioners is supportive, with its chairwoman, Helen Stokes-Lampard, saying: “Hospitals have ‘black alerts’. They don’t use them when they don’t need to — they only use them when they can’t cope, to protect patient safety. We don’t have an equivalent in general practice, but we need one, as it is not safe for patients to be seen by fatigued doctors and their teams.”

However, a spokesman for The Patients Association said: “Blanket decisions not to see patients above a fixed number would seem dangerously crude, and guarantees cases of people not getting treatment and care at critical times, with serious consequences for their health.”

NHS England said: “While arbitrary caps on patient appointments would breach GPs’ contracts, we understand the pressures general practice is facing. That’s why the NHS is investing £2.4 billion extra in GP services, growing the number of new doctors entering general practice and rolling out evening and weekend appointments to patients across England over this coming year.”

Should there be lighter regulation in order to reduce inequalities? How high earning professions lock their competitors out of the market. Old style GPs are becoming extinct.

Doctors in full time work are high earners. More and more doctors are part time, which brings earnings to average. The pressures and drivers to this part time medical profession are well documented on NHSreality but it is the patient who suffers. The lack of continuity of care, of palliative and terminal care from your family doctor, and subsequent distrust and disillusion with General Practice are evident. The goose that laid the golden eggs is becoming extinct.  This article is food for thought. Should there be lighter regulation in order to reduce inequalities?

In the Economist Feb 17th 2018: ” How high earning professions lock their competitors out of the market ” derives how to rig the market!

EVERY month Debbie Varnam of Shallotte, North Carolina, must pay a doctor’s bill. It is not for treatment. Ms Varnam is a “nurse practitioner”, a nurse with an additional postgraduate degree who is trained to deliver primary care. North Carolina, like many states, does not allow nurse practitioners to offer all the services they are trained to provide. Ms Varnam cannot, for example, prescribe the shoes diabetics often need to prevent the skin on their feet from breaking down. To do so, she needs the approval of a doctor. So Ms Varnam employs one. For about $1,000 a month, the doctor reviews and signs forms that Ms Varnam sends him. The doctor, she says, has a similar arrangement with five other offices.

Occupational licensing—the practice of regulating who can do what jobs—has been on the rise for decades. In 1950 one in 20 employed Americans required a licence to work. By 2017 that had risen to more than one in five. The trend partly reflects an economic shift towards service industries, in which licences are more common. But it has also been driven by a growing number of professions successfully lobbying state governments to make it harder to enter their industries. Most studies find that licensing requirements raise wages in a profession by around 10%, probably by making it harder for competitors to set up shop.

Lobbyists justify licences by claiming consumers need protection from unqualified providers. In many cases this is obviously a charade. Forty-one states license makeup artists, as if wielding concealer requires government oversight. Thirteen license bartending; in nine, those who wish to pull pints must first pass an exam. Such examples are popular among critics of licensing, because the threat from unlicensed staff in low-skilled jobs seems paltry. Yet they are not representative of the broader harm done by licensing, which affects crowds of more highly educated workers like Ms Varnam. Among those with only a high-school education, 13% are licensed. The figure for those with postgraduate degrees is 45%.

More educated workers reap bigger wage gains from licensing. Writing in the Journal of Regulatory Economics in 2017, Morris Kleiner of the University of Minnesota and Evgeny Vorotnikov of Fannie Mae, a government housing agency, found that licensing was associated with wages only 4-5% higher among the lowest earning 30% of workers. Among the highest 30% of earners, the licensing wage boost was 10-24% (see chart 1). Forthcoming research by Mr Kleiner and Evan Soltas, a graduate student at Oxford University, uses different methods and finds no wage boost at the bottom end of the income spectrum, but a substantial boost for higher earners.

One way of telling that many licences are superfluous is the sheer variance in the law across states. About 1,100 occupations are regulated in at least one state, but fewer than 60 are regulated in all 50, according to a report from 2015 by Barack Obama’s White House. Yet a handful of high-earning professions are regulated everywhere. In particular, licences are more common in legal and health-care occupations than in any other (see chart 2).

These professions share two characteristics. First, it takes years of study—and often lots of student debt—to join them. Becoming a doctor takes a four-year undergraduate degree, a four-year postgraduate degree, and then a multi-year medical residency. Those barriers to entry mean that once the law requires the involvement of a doctor, costs soar. Yet it surely does not take all that training, argue nurse practitioners, to know when to prescribe diabetic shoes. The evidence is on their side. A review of the literature in 2012, paid for by the federal government, found that no study raised concerns about the quality of care offered by nurse practitioners. There are plenty of comparison points, because 22 states have overcome doctors’ objections and given nurse practitioners so-called “full practice authority”.

Second, it is often practitioners themselves who define—and expand—the boundaries of the regulated profession. For example, in North Carolina a board of dentistry, mainly elected by dentists themselves, regulates the profession. In 2006 it tried to stop hygienists and beauticians from whitening customers’ teeth, after dentists complained that they were being undercut on price. (The Federal Trade Commission (FTC) objected, and in 2015 the Supreme Court put a stop to the practice by ruling that the board was not exempt from competition law.)

Occupy K Street

Both problems are acute in the legal industry. Almost every American state forbids those who do not have a three-year law degree from providing most legal services. Bar associations—composed of lawyers themselves—often define what counts as legal practice. In 2000 the American Bar Association, after rejecting a proposal to allow lawyers to split fees with non-lawyers, asserted that “the maintenance of a single profession of law” was a core priority. “In no other country does the legal profession exert so much influence over its own regulatory process,” writes Deborah Rhode of Stanford University in her book “The Trouble with Lawyers”. Outsiders typically cannot even invest in law firms, limiting funding for innovative new business models, such as providing fixed-fee legal advice over the internet, or through retailers. Even those who are qualified can struggle to compete across state boundaries, because of the need to pass a separate bar exam.

Advocates for reform compare America’s model unfavourably with that of Britain. There, non-lawyers have a built in majority on legal regulatory bodies, which are tasked with promoting competition as well as protecting consumers. Outside court, anyone can offer legal advice, or provide basic legal services like drafting documents. The result seems to be cheaper access to justice, and more innovation. The World Justice Project ranks America 96th of 113 countries for access to and affordability of justice, sandwiched between Uganda and Cameroon. (It does not help that there is hardly any legal aid.)

American policymakers are increasingly aware of licensing’s potential to chill competition. In 2017 the FTC launched a task force on “economic liberty” to campaign against unnecessary licensing. Some states have implemented reforms in recent years. Arizona rolled back some licensing requirements in 2016 and has since made it easier to challenge regulations in court. Last year Mississippi brought its licensing boards under closer supervision. Delaware, Nebraska and Wisconsin are considering proposals for reform.

State courts can also intervene. In 2015 the Texas Supreme Court struck down a law requiring eyebrow-threaders to obtain expensive and unnecessary training in cosmetology. The judges found that the Texas constitution guarantees a minimum level of economic freedom from regulation. Some scholars think such a right can be found in the federal constitution, implicit in the right to “due process”. The federal courts have mostly resisted this idea since a Supreme Court ruling in 1955 gave states plenty of room to regulate their economies as they themselves saw fit. But President Donald Trump’s appointments to the federal courts might help “shift the centre of gravity” on the issue, says Dick Carpenter of the Institute of Justice, a libertarian legal charity, optimistically.

When it comes to medicine and law, however, it can be hard to convince the public that some licensing requirements are frivolous. California not only requires that nurse practitioners are supervised by doctors, but also bans doctors from overseeing more than four. Three liberalising bills, which would have given nurse practitioners full-practice authority, have failed since 2007. The California Medical Association, a trade group for doctors, has campaigned hard against reform.

The medical and legal professions account for around a quarter of the top 1% of earners, whose incomes have grown faster in America than in other rich countries in recent decades. A study published in Health Affairs, a journal, in June 2015 found that the average doctor earns about 50% more than comparably educated and experienced people in other fields. Another study, from 2012, put the wage premium from working in law at 23%.

Doctors are also unusually well-paid compared with those in other countries. The average general practitioner earns $252,000 and the average specialist $426,000, according to the Bureau of Labour Statistics. According to OECD data on a handful of other rich countries, the averages there were $130,000 for generalists and $273,000 for specialists in 2014. (These figures adjust for differences in living costs, and include only self-employed doctors, who tend to earn more.)

More competition would surely bring both wages and prices down. And less licensing across the board would make entrepreneurship easier. It might even palliate populism, which is partly driven by voters’ sense that the economy is rigged to benefit the rich and powerful—a hypothesis which the evidence on licensing plainly supports. Politicians in distant Washington are usually the target of populist anger. But most licensing laws are local. Those looking to level the economic playing field could start closer to home.