Monthly Archives: May 2018

Increased funding for the Health Services

Letter in the Times 31st May 2018

INCREASED FUNDING FOR THE NHS
Sir, As we approach the 70th birthday of the National Health Service it is welcome that we are now having a national debate on its financial sustainability. Medical royal colleges have consistently called for increased funding for the NHS, public health and social care and last week’s report from the Institute for Fiscal Studies and the Health Foundation Securing the future: funding health and social care to the 2030s makes clear that increases of about 4 per cent a year will be needed if the government wishes to improve NHS services, including meeting waiting-times targets and addressing under-provision in mental health.

We urgently need a settlement for the NHS and social care that goes beyond managing short-term crises, acknowledges the financial deficits and recognises the need to invest in transformation and recruitment.

As leaders of medical professionals, we recognise that alongside increased funding there need to be substantial changes in how health and care services operate if we are to
provide first-class, integrated care
for patients.

Professor Carrie MacEwen, chairwoman, Academy of Medical Royal Colleges on behalf of Professor Derek Alderson, president, Royal College of Surgeons of England, Professor Derek Bell, president, Royal College of Physicians of Edinburgh; Professor Alan Boyd, president, Faculty of Pharmaceutical Medicine; Dr Liam Brennan, president, Royal College of Anaesthetists; Mr Mike Burdon, president, Royal College of Ophthalmologists; Professor Wendy Burn, Royal College of Psychiatrists; Professor Jane Dacre, president, Royal College of Physicians of London; Dr Anna de Bono, president, Faculty of Occupational Medicine; Professor Michael Escudier, dean, Faculty of Dental Surgery; Professor David Galloway, president, Royal College of Physicians and Surgeons of Glasgow; Dr Tajek Hassan, president, Royal College of Emergency Medicine; Dr Paul Jackson, president, Faculty of Sports and Exercise Medicine; Dr Asha Kasilwal, president, Faculty of Sexual and Reproductive Health; Mr Mike Lavelle-Jones, president, Royal cOllege of Surgeons of Edinburgh; Professor Jo Martin, president, Royal College of Pathologists; Professor John Middleton, president, Faculty of Public Health; Professor Lesley Regan, president, Royal College of Obstetricians and Gynaecologists; Professor Helen Stokes-Lampard, chairwoman, Royal College of General Practitioners; Professor Russell Viner, president, Royal College of Paediatrics and Child; Professor Carol Seymour, president, Faculty of Forensic and Legal Medicine; Dr Nicola Strickland, president, Royal College of Radiologists; Dr Carl Waldman, dean, Faculty of Intensive Care Medicine

Its going to get much worse. The difference in health, life expectancy and quality of life, in a two tier system. The finances are dire. Hospitals are bust.

It is now inevitable tat more and more people will vote wit their feet. Out of their health service, (private) or go abroad.  Its going to get much worse. The difference in health, life expectancy and quality of life, in a two tier system. The finances are dire. Hospitals are bust. And do you really think the minister will propose a sensible solution…..?

Image result for hospital finances cartoon

The Guardian today: Two in five GPs in England intend to quit within five years – survey

Warning over standards of care as NHS falls short on targets

NHS deficit last year twice as high as expected, say sources The Guardian today

Catriona Webster May 3rd in the Times reports: Shona Robison has agreed to publish the finances of NHS boards monthly after pressure from the Scottish Conservatives.

Sky News today: NHS report reveals sharp rise in waiting times for care

BBC News today: Deficit for NHS trusts in England double the amount planned

NHS trusts in England have reported a combined financial deficit that was nearly twice the amount planned.

There was a deficit of £960m in the last financial year compared with the £496m they had planned for, the regulator NHS Improvement said.

Acute hospitals were largely responsible, mainly because of increased patient demand, it said.

All other providers, including ambulance and mental health trusts, had collectively underspent, it added.

The latest reported deficit is reached after taking account of extra financial support provided by the government.

Therefore, the Nuffield Trust think tank argued that the true underlying figure was much worse, as the finances had to be patched up with one-off savings and emergency extra cash.

Senior policy analyst Sally Gainsbury said: “Given the huge pressures on NHS providers, it is not at all surprising that the reported deficit for 2017-18 is £960m……

…Ministers have promised a new long-term financial plan for the NHS, which is expected within weeks.

In March, Prime Minister Theresa May said she wanted to get away from annual “cash top-ups” and would come up with a blueprint later this year to allow the NHS “to plan for the future”.

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The shortage of diagnostic and filtering skills is costing us dear. GPs retiring especially.

 It is the duty of a government first to protect the realm, then to avoid insurrection and protect the rule of law, then to protect the health of it’s people. Successive UK governments have shown they have no long term view or ability to manpower plan. We need to change the rules of the game that the politicians play, so that they have incentives to plan properly, or we need to take health away from them. The shortage of diagnostic and filtering skills is costing us dear. GPs retiring (or emigrating) especially. Add to this the parlous state of health services finance, and there is going to be trouble ahead… Image result for doctors  emigrate cartoon

Chris Smyth reports May 30th in the Times: Million patients hit by closure of GP surgeries

More than a million patients have been forced to change GP surgery in the past five years, with closures up tenfold as family doctors abandon the NHS.

Last year 458,000 patients had to find a new practice because their existing surgery shut, up from 38,000 in 2013, according to official data.

Patients are losing personal relationships with a GP and care is suffering, senior doctors warned.

The network of family doctors which props up the NHS is in danger of crumbling as GPs tire of staff shortages in a “serious failure of the system”, professional leaders warn.

Jeremy Hunt, the health secretary, has promised to recruit an extra 5,000 GPs by 2020, saying that hospitals will be overwhelmed if the NHS does not get better at looking after elderly people locally. However, more than 1,000 family doctors have been lost since he made his pledge.

Data gathered under freedom of information law by the GP magazine Pulse shows that at least 202 practices have shut down completely and 243 have closed branch surgeries since 2013. Last year 57 practices closed and a further 77 satellite surgeries were lost. Since 2013 this has displaced almost 1.4 million patients, the data suggests.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “A GP practice closing can have serious ramifications for the patient population it served [and] neighbouring surgeries . . . For those living in isolated areas, this can mean having to travel long distances to get to their nearest surgery, and is a particular worry for those who might not drive and have to rely on public transport.”

She said some centralisations into larger hubs could improve care, but warned that when a closure “is because the practice team simply can’t cope with the resource and workforce pressures they are facing, it’s a serious failure of the system.”

GPs are typically independent contractors paid by the NHS for each patient they look after. As older, sicker patients need a doctor more often, this model has become less viable and Mr Hunt has conceded GPs are on a “hamster wheel of ten-minute appointments, 30 to 40 of them every day, unable to give the care they would like to.”

With Britain short of GPs and younger doctors working fewer hours, there are fears of a spiral of decline as the overworked ones who remain become exhausted. Recent taxes on high pension pots also make it less lucrative for GPs to continue to work into their 60s.

Richard Vautrey, head of the British Medical Association’s GP committee, said that family doctors built up long-term relationships of trust with patients “but when practices close this important foundation can be put at risk and patients’ experiences may suffer as a result . . . Without proper investment in primary care, the knock-on effects on the rest of the health service and society as a whole will cost the government dearly in the long run.”

In Plymouth, one of the worst affected areas, a fifth of practices have closed in the past three years, leaving 34,000 patients without a GP. Local doctors say that they get only four hours’ sleep a night as they try to deal with remaining patients and one, Mark Sanford-Wood, said the city’s plight was “a warning of what the rest of the country faces”.

A spokeswoman for NHS England said: “More than 3,000 GP practices have received extra support thanks to a £27 million investment over the past two years and there are plans to help hundreds more this year. NHS England is beginning to reverse historic underinvestment with an extra £2.4 billion going into general practice each year by 2021, a 14 per cent rise in real terms.”

Katherine Sanz in N Ireland reports 10th May 2018: Shortage of GPs as third set to retire

Revealed: 450 GP surgeries have closed in the last five years – Pulse today

 

There is advantage in enhancing choice by enlarging trusts. And it will improve outcomes… Good news for Devon: bad news for Wales.

Apart from economies of scale, and reducing overhead, there is advantage in enhancing choice by enlarging trusts. And it will improve outcomes…

Hywel Dda and ABMU trusts in West Wales need to merge. The politics of Wales may prevent this but in England there is a utilitarian precedent in Devon. Exeter and Barnstable trusts are combining. Good news for Devon: bad news for Wales if the option is not taken.

Sarah Howells for the North Devon Gazette reports that “North Devon MP welcomes move to share health care bosses with Exeter”.

North Devon’s MP has said a new collaboration between Exeter and North Devon’s healthcare trusts could increase the services available in Barnstaple.

Peter Heaton-Jones released a statement reacting to the news Northern Devon Healthcare Trust (NDHT) and Royal Devon and Exeter (RD&E) will be working in collaboration.

If agreed by both trust boards, Exeter’s chief executive and chairman will take over the running of NDHT as well.

Mr Heaton-Jones said: “Last week I met the acting chief executive of the Northern Devon Healthcare Trust, Andy Ibbs, and the board chairman, Roger French, to discuss these new arrangements.

“I sought and received assurances that the collaboration has a single purpose: to ensure that all acute services can continue to be delivered in Barnstaple.

“Last year, the NHS England review concluded rightly that all services should be retained at the NDDH, but set the challenge of doing so in a sustainable way.

“This new arrangement does just that, and means we can share resources and expertise to our long-term advantage.

“In fact, I have been told that some procedures currently not available in Barnstaple may be able to be delivered here in future as a result of this collaboration..

“The local community is passionate about our hospital, and I will soon be meeting the new chief executive to hear more about the collaboration and how it will safeguard the future delivery of services in Barnstaple.”

Hospital campaigners have welcomed the move, and a spokesman for Save Our Hospital Services said the group hoped the new management would ensure the retention of acute services in North Devon.

As part of the draft agreement, a senior management team will be based at both North Devon and Exeter hospitals, and an appraisal will look into a long-term solution.

However, Devon County Councillor Brian Greenslade, said he felt the move could cause concern for those already worries about a loss of services in North Devon.

He said: “For the people of North Devon the critical thing is to protect the delivery of acute services provided in the NDDH.

“This is my key objective and where I will focus my scrutiny attention.

“I will also be probing to see whether this proposed collaboration gives the opportunity to repatriate some acute services from the RDE to Barnstaple.

“I also believe with the increasing population in North Devon there is a case now to look at growing the facilities at the NDDH.

“We have been very lucky to have such a good hospital in North Devon with such dedicated staff.

“Let us remember that had it not been for former MP Jeremy Thorpe and the 50,000 signature he presented to Parliament, we probably would have not had this facility in our community.”

Jennifer Howells, regional director South West for NHS Improvement and NHS England, said the two trusts were ‘determined to do the right thing’ for the community.

She added: “Working with the RD&E through this agreement, and with ongoing support from NHS Improvement, I am confident that NDHT will have the best possible support to make the necessary, sustainable improvements that will enable them to provide the quality of services patients expect from the NHS.”

Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

Radical and simple. Why not expand this suggestion? Fundin the ealt Services..

The Times letters 28th May:

Why do we know that this suggestion will not be acceptable? Because it means that access is not free at the point of delivery. Who on earth made this a sacred cow? We have charges for eyes, dentistry, and prescriptions (in some post codes), so why not an income related co-payment? My only query is why not allow for all means, including capital, as there are many people who would be excluded without. we always want to kick the party tat suggests tax increases…

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NHS FUNDING (The Times letters 28th May 2018)

Sir, There is one way to increase NHS funding without raising the nominal tax or national insurance rates (Comment, May 25, and letters, May 26). Every time a UK citizen uses the NHS the appropriate charge should be logged with HMRC which will then alter the beneficiary’s tax code. This would mean that the beneficiary would pay not the whole amount, but a proportion equivalent to their marginal rate of taxation. Those who do not pay tax would still receive free treatment, while other users would pay a proportion of their benefits.
Christopher Buckmaster

London SW11

 

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Update wit further letters 29th May:

Sir, Paul Johnson (Comment, May 28) excellently highlights the fragmentation and funding crisis of elderly care services. May I offer some considerations for long-term solutions?

Beveridge designed the National Health Service as a “make-you-better” service, offering acute interventions that cure patients who can resume normal life. It was never intended as a “look-after-you-for-ever” service for increasing numbers. The major policy failure arises because no government has allocated pre-funding for care needs. Rising demand and costs have resulted in ever-stricter rationing of care provision, which inevitably increases NHS costs.

Reforms of health and care services in recent decades have focused on highlighting problems rather than implementing solutions as costly reorganisations addressed parts of the system, rather than the whole.

Care funding should be a core element of 21st-century retirement planning. Kick-starting care funding through baby-boomers’ pensions or long-term savings could be facilitated by allowing tax-free pension withdrawals for care funding, or an inheritance-tax-free care Isa allowance.

In addition, national insurance (or tax) must encompass elderly care, not just pensions, for future generations.
Baroness Altmann

House of Lords, SW1

Sir, There is no doubt that the NHS would be helped by a tax hike or an increase in national insurance but would that solve the problem (Comment, May 25, and letters, May 26 & 28)? A modest charge on a GP appointment has been suggested and that would deter unnecessary users. What the NHS does now is far more than what was envisaged at its inception 70 years ago. Putting aside contentious matters such as gender changes and homeopathy, heroic attempts to extend life can sometimes be as costly as they are cruel. Assisted dying is to be avoided at all costs but resuscitation of the terminally ill or operating on them to extend life by a few weeks is cruel, costly and puts a load on often-elderly relatives.

Throwing taxpayers’ money at the problem is not the solution; caring about care may be.
Dr Robert J Leeming

Coventry

Sir, Christopher Buckmaster makes a good point on NHS funding (letter, May 28). When I lived in France 30 years ago a similar system existed. When visiting the doctor you handed over FF100 (about £10) and were given a receipt: the local tax office would refund the amount against the docket. If the state offered you a life-saving procedure, you were given the option of paying for it or attending a month’s residential course on improving your lifestyle.
Denis Harvey-Kelly
Sherborne, Dorset

Update 31st May Times letters

INCREASED FUNDING FOR THE NHS
Sir, As we approach the 70th birthday of the National Health Service it is welcome that we are now having a national debate on its financial sustainability. Medical royal colleges have consistently called for increased funding for the NHS, public health and social care and last week’s report from the Institute for Fiscal Studies and the Health Foundation Securing the future: funding health and social care to the 2030s makes clear that increases of about 4 per cent a year will be needed if the government wishes to improve NHS services, including meeting waiting-times targets and addressing under-provision in mental health.

We urgently need a settlement for the NHS and social care that goes beyond managing short-term crises, acknowledges the financial deficits and recognises the need to invest in transformation and recruitment.

As leaders of medical professionals, we recognise that alongside increased funding there need to be substantial changes in how health and care services operate if we are to
provide first-class, integrated care
for patients.

Professor Carrie MacEwen, chairwoman, Academy of Medical Royal Colleges on behalf of Professor Derek Alderson, president, Royal College of Surgeons of England, Professor Derek Bell, president, Royal College of Physicians of Edinburgh; Professor Alan Boyd, president, Faculty of Pharmaceutical Medicine; Dr Liam Brennan, president, Royal College of Anaesthetists; Mr Mike Burdon, president, Royal College of Ophthalmologists; Professor Wendy Burn, Royal College of Psychiatrists; Professor Jane Dacre, president, Royal College of Physicians of London; Dr Anna de Bono, president, Faculty of Occupational Medicine; Professor Michael Escudier, dean, Faculty of Dental Surgery; Professor David Galloway, president, Royal College of Physicians and Surgeons of Glasgow; Dr Tajek Hassan, president, Royal College of Emergency Medicine; Dr Paul Jackson, president, Faculty of Sports and Exercise Medicine; Dr Asha Kasilwal, president, Faculty of Sexual and Reproductive Health; Mr Mike Lavelle-Jones, president, Royal cOllege of Surgeons of Edinburgh; Professor Jo Martin, president, Royal College of Pathologists; Professor John Middleton, president, Faculty of Public Health; Professor Lesley Regan, president, Royal College of Obstetricians and Gynaecologists; Professor Helen Stokes-Lampard, chairwoman, Royal College of General Practitioners; Professor Russell Viner, president, Royal College of Paediatrics and Child; Professor Carol Seymour, president, Faculty of Forensic and Legal Medicine; Dr Nicola Strickland, president, Royal College of Radiologists; Dr Carl Waldman, dean, Faculty of Intensive Care Medicine

Some of the options, all unpleasant, for raising money for the UK Health Services. Tax reform – “fishing for funds” in the Economist

Doctors and Nurses are equally sanguine about the future of their health services. They are usually honest, and can see the long term problem. The public citizen, led by their politicians and the media, does not see anything other than the short term results – waiting lists and treatment deficiencies, exclusions of cancer patients, and mental health problems that they do not understand. CEOs, Chairmen and other board members have insight, but never get to peak out openly. There are no exit interviews for board members, and no way for feedback if there were. The “chiefs” are waiting for their gongs, which will arrive if they keep their mouths shut for long enough. …. One option the Economist has not considered is for co-payments, overt rationing along the lines of New Zealand. Higher taxes will likely be regressive, but they have to hit the “average” wage earner, as those poorer will not contribute, and those richer will avoid and evade taxation. Whatever and whenever we choose, it will be a better solutions than America’s. At least means related co-payments could address deserts based rationing slightly…

See the source image

 

Fishing for funds. Wanted: radical proposals to fill Britain’s giant fiscal hole – what are the options? – Politicians are slowly facing up to the fact that higher taxes are needed The Economist 17th February 2018

ALMOST every morning Britons wake up to another alarming story about their threadbare public services. Since 2010 the state has endured its biggest financial squeeze on record, and it is beginning to show. The National Health Service is battling a “winter crisis”. Social care is not keeping up with the ageing population. The number of rough sleepers has almost trebled. Prisons are short of guards.

The government’s fiscal watchdog has issued sobering forecasts. Its calculations suggest that to put the public finances on an even keel over the long term, tax rises or spending cuts worth around £80bn ($111bn), or 4% of GDP, will be required. Further cuts are a non-starter, since there is little fat left to trim. Some right-wing MPs see the foreign-aid budget as ripe for a shakedown, an idea that has gained traction following a scandal at one big charity (see article). Yet even abolishing aid entirely would get Britain barely one-sixth of the way towards its target (see chart 1).

So politicians are slowly coming round to the idea of higher taxes. “There’s quite a strong argument that fiscal policy ought to change,” Nick Timothy, who once did most of the prime minister’s thinking, said recently. “While the NHS needs reform, it also needs more money.”

Broadly speaking, a government can tax three things: income, consumption and wealth. Economists like taxes to be simple and to avoid unintentionally distorting behaviour. Where should the government cast its net?

Start with taxes on income. At first sight they are an obvious target for revenue-hungry politicians. They are progressive (ie, those on higher incomes pay more). And Britain looks overdue for a rise. Since the 1970s income taxes have fallen as a share of the total (see chart 2). The basic and higher rates of income tax, as well as the corporation-tax rate, have been slashed. Britain now raises far less in income taxes, broadly defined, than the average OECD country.

The Labour Party wants that to change. It would raise corporation tax from 19% to 26% and jack up taxes on those earning above £80,000 a year. It says such policies would yield around £25bn, a large chunk of what Britain requires. Yet it is not clear that the tax system needs a big extra dose of progressivity. It is already about as redistributive as the OECD average, reducing pre-tax income inequality by about one-third. And beyond a certain point, progressivity conflicts with efficiency. Rich folk work less, make bigger contributions to their pensions (which enjoy favourable tax treatment) or leave the country. The Institute for Fiscal Studies (IFS), a think-tank, says that Labour’s higher taxes on personal incomes may raise less than hoped—and perhaps nothing at all.

A better approach to taxing income might involve broadening the base. Since 2010 the tax-free personal allowance has risen from £6,475 to £11,500. Reducing it to £10,000 would raise some £9bn a year. The Liberal Democrats have proposed adding one percentage point to all rates of income tax. That would yield around £6bn.

But any move to raise taxes on income has a cost. Research by the OECD suggests that income taxes, more than those on consumption and wealth, strongly discourage people from working, cramping economic growth. This implies that Britain’s relatively low income taxes are a strength, rather than a problem to be fixed.

Higher taxes on consumption might, therefore, be considered. Some want extra levies on socially damaging activities such as unhealthy eating and pollution. In April Britain will introduce a “sugar tax”, which should raise some £500m a year. A “climate-change levy”, a tax on energy use by businesses, already exists. Doubling all environmental taxes would raise perhaps £14bn. It would also make Britain greener.

To raise serious money, though, politicians could turn to VAT, which is levied at 20%. It looks ripe for reform. With a plethora of carve-outs—for food, children’s clothes and much else—Britain’s VAT covers only about half of what the average person buys. That makes it the seventh-leakiest VAT in the OECD.

Different VAT rates are designed to help the poor afford essentials. But it is a costly way to do so, as the rich benefit from the exemptions, too. A bold reform would be to extend VAT to nearly all spending, which might be enough to fill Britain’s fiscal hole. By itself it would be regressive, not to mention politically poisonous (newspapers’ outrage over VAT on baby food would be matched only by their fury at VAT on newspapers). So the government would need to help the losers. The IFS reckons that it could get rid of most VAT carve-outs, compensate the poor (say, by boosting benefits) and still have a lot of money left over.

Going after the grandparents

Increasing wealth taxes, levied on everything from property to financial assets, may be a more palatable option. A housing boom, intergenerational inequality and the need for more health and social care have given rise to a feeling that old, rich people ought to pay more.

Some say that the wealthy already pay enough. Britain raises more of its overall tax take from wealth taxes than any other OECD country. But look at it another way. Wealth taxes tend to be the most growth-friendly. By historical standards, Britain’s wealth looks undertaxed. Since the 1970s, as house prices and equities have soared, total household wealth has risen from three times income to eight times. Taxes on that wealth relative to GDP have remained steady, however. Council tax, one of the biggest wealth taxes, is based on property valuations from 1991. Rich people often pay less than poor. Buckingham Palace attracts a council-tax bill of £1,400 a year, around the same as some flats in Bradford.

Basing council tax on up-to-date values would be a start. Other forms of wealth could also be tapped. Cancelling a proposed loosening of the inheritance-tax regime is one idea, though it would not raise much revenue.

A land-value tax is another option. An annual levy of 0.5% might fill almost a third of the fiscal hole. Such a tax would be hard to avoid, since land cannot be hidden or easily substituted. The evidence also suggests that it is landowners, rather than renters, who bear the burden of such a tax.

Today, no prime minister would dare to implement these radical ideas, least of all the timid, distracted incumbent. But the fiscal logic is brutal. If Britons want good public services, they will need to pay more. Real tax reform is coming sooner or later.

Addressing the “black hole” in the health budgets – wait for political denial.

Health is closely correlated to Wealth – If you are poor you get no choice (Wales), and live a shorter life, but if you are rich, or born abroad, you live longer and you do get choice! So much for equity…

A new generational contract:

See the source image

 

Mark Britnell is very perceptive, but avoids the reality of rationing. This means his contribution is not appreciated by the profession. He does ecognise that inaction is paving the way for private health care.

NHSreality was asked to review Mark Britnell’s book: What would the world’s best health system look like? Mark Britnell is very perceptive, but avoids the reality of rationing. This means his contribution is not appreciated by the profession. By default, and denial, the way to private health care becomes clearer daily.

In “Paving the way for private healthcare” 12th Jan 2017 in the Independent:

…..”One is reminded of Mark Britnell’s comments a few years ago at a private equity conference that the NHS would be shown “no mercy” and that it would become a “state insurance provider, not a state deliverer” of care.”

( Mark Britnell “In search of the perfect health system”, (published by Macmillan Education and Palgrave ISBN 978-1-137-49661-4)  2015 by Mark Britnell)

Can “patient centred care” become a reality in the NHS? Mark Britnell 14th May 2013 in the Guardian

Mark Britnell | The Guardian

Books and reading pertinent to the NHS | NHS reality. An NHS …

Five principles behind the world’s most efficient health systems | The Nuffield Trust

[PDF]Something to teach, something to learn by Mark Britnell – NHS England

[PDF]Mark Britnell has been scouring the globe for the perfect health system – Health Service Journal

 

 

A ringfenced NHS tax is just sly nonsense: as our foreign aid commitment proves, tying the government’s hands over spending is never a good idea

Who would accept the post of health minister in any of the 4 jurisdictions, if the health budget was hypothecated (and restricted) but rationing were not overt? The scapegoating of health board CEOs and Chairs has to stop: the real people t blame are the politicians of all parties who are in denial, as indicated in the Times on the same day as the article below (Matthew Paris)  by Philip Aldrick. Emergencies, crises and “events” always arise, and its true “you cant fool all the people all the time”, especially doctors and nurses.

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The Times May 28th 2018: A ringfenced NHS tax is just sly nonsense:  as our  foreign aid commitment proves, tying the government’s hands over spending is never a good idea

A warning. Ministers are considering a new way of pulling the wool over your eyes. They think our National Health Service needs extra money. True enough. They know taxes will have to rise to pay for this. True too. And they fear people would like a boost for the NHS but resent a hike in income tax. Too true.

So they’re mulling over an attempt to square the circle by increasing health spending, leaving income tax rates untouched, and inventing a new surcharge on our tax bills, dedicated to health spending alone.

“NHS” is a hooray-term and “tax” a boo-term. So they’ll avoid the word “tax” and call it (let’s guess) “NHS supplement”. They might have chosen instead to debauch the word “contribution” but David Lloyd George got there first in 1911 in a misdescription designed to sweeten a new tax to pay for pension and sickness benefits. The focus slipped, of course, and national insurance contributions (NIC) have long been seen as an add-on to general taxation.

But it helped Lloyd George over a difficult patch. The worlds both of politics and retail have learnt that if you can sneak extra costs away from the main price tag, voters (and shoppers) will, at least for a while, tend not to choke on these marginal additions. As the travel writer Simon Calder points out, airlines might just as well have imposed a “staff uniforms surcharge” as a surcharge on “fuel”.

It really is possible to fool some of the people some of the time. Polling last year showed an overwhelming majority of voters think the NHS needs extra funding but a clear majority of these think this should be paid for from a “new NHS tax”, not general taxation. In January Sir Nicholas Macpherson, a former head of the Treasury, suggested such a move. Today the health and social care secretary, Jeremy Hunt, is pricking up his ears. A cross-party group of MPs including the Tories’ well-regarded Nick Boles, Labour’s doughty Liz Kendall and the admired Lib Dem former health minister Norman Lamb want to harvest extra NHS and social spending from national insurance in “a dedicated health-care tax”.

I applaud these MPs’ desire to market a needed tax hike, but such gimmicks are nonsense: a sly nonsense that complicates tomorrow in order to simplify today. Let’s expose some of the tricksy terms involved — “dedicated,” “earmarked,” “ringfenced,” “supplement” — to more critical gaze.

For this family of ideas there’s a long and boring word; long, boring, but important. The word is hypothecation. Most taxation is not hypothecated; it goes into a general fund upon which government draws to pay for the many things it does, according to changing priorities. Hypothecated revenue, by contrast, is said to be tied to a particular area of expenditure.

The word is used, however, to cover a range of ties, from the very loose to the very tight. To place any claimed hypothecation on that range we need answers to the following questions: is this impost to pay for all and is it to pay for only the spending to which it is linked?

Income tax, for instance, in essentially its modern form, was introduced in Britain in 1799 for a limited time to pay for war with France. As we all know, the tightness of both timescale and focus slipped.

Likewise, vehicle excise duty and fuel duties (which some poor motorists imagine were supposed to be spent by government on roads) are not, and never really have been, properly linked to spending on transport in general, let alone roads, and yield far more than the roads budget. TV licensing, however, arguably a branch of hypothecated taxation, is genuinely linked to the financing of the BBC, which must cut its cloth accordingly.

It is unlikely and undesirable that any government would try to create a dedicated levy to pay for all health spending. You could cut income tax and NIC by about 20 per cent but only by piling on a massive new health tax, and making the allocation of public spending even more rigid. But even if (as is more likely) a new health tax is claimed to be dedicated “only” to “extra” health spending, the truth is that this will temporarily take pressure off the Treasury’s general fund, allowing other spending to rise a bit. As NHS spending rises further, however, and the supplement is found to be insufficient, it will only confuse the public as to where the extra spending would come from. The right size for a health budget will rise or fall depending on circumstances we cannot predict. Wars, epidemics, new treatments, possible new charges for treatment, ageing populations, staff shortages . . . all these require porous borders between health spending and spending on many other huge and fluctuating priorities.

Every time an area of spending is sealed off from general expenditure, ministers’ room for manoeuvre and readjustment within the rest of public spending is cramped. Eventually government has to break faith with the electorate and snap these distorting bonds. Sooner or later they’ll be doing this with overseas aid, whose mechanical gearing to a notional 0.7 per cent of overall spending is grotesque. If aid, why not education?

Every time politicians ringfence this or that, or hypothecate a named source of revenue to a named expenditure (the sugar tax, for instance, is supposed to be invested in schools projects), a cheap, populist cheer is enjoyed at the expense of administrative logic, and the bits of public policy that do not have ringfencing or an earmarked source of tax revenue tremble.

If it is right to tax sugary drinks, they should be taxed irrespective of where this particular money ends up. If school projects need an extra billion they should get it, regardless of whether or not sugar is taxed. If the public reject higher taxes, responsible politicians should not defer to imaginary ropes tying some taxes to some purposes, or fencing off others from cuts; they should make their own judgments where the axe should fall.

And in the end they will. “Emergencies” and “crises” will arise and earmarks, links and supplements will be blown away like cobwebs. Telling the public otherwise is a deception, and politicians know it. So a new health tax would be just that: a bit extra for a bit extra to lift a bit of pressure from politicians for a bit of time, until events intervene. And every time that happens, fiscal vows ring just a bit more hollow than before.

Philp Aldrick in business section of the Times 26th May: “….. who will dare make the (right) call?”

Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

What would the world’s best health system look like?

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Brexit is bad for our health Experts call on health professionals to back demand for a ‘people’s vote’ to protect public health

History tells us there are a few main ways for a country to get poorer. War, external and civil, revolution, and devolution, and we are devolving from the EU. Since wealth correlates closely with health, we all have an interest.

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BMJ Leader 26th May 2018: Brexit is bad for our health – Experts call on health professionals to back demand for a ‘people’s vote’ to protect public health

https://eurekalert.org/pub_releases/2018-05/b-bib052118.php

Brexit is bad for our health and can be prevented, argue experts in The BMJ today.

The risks of Brexit to our health and our health services are becoming starker. This should concern us all as health professionals, whatever deal is finally brought before parliament for approval.

In January 2018 the UK government’s own estimates of the impact on economic growth were leaked.1 Ministers dismissed concerns about the scale of the impact, arguing that the leaked documents didn’t include their preferred option. This gap has now been filled by the think tank Global Future. Its report includes the estimated economic effect of this “bespoke deal,” conveniently expressed in terms of NHS funding.2 It says that the “Norway” option, by which the UK would remain in the European Economic Area, would reduce public finances by a figure equivalent to 9% of the NHS 2018 budget. The “Canada” option, involving a future free trade agreement, would see funding cut by 31%; no deal by 44%; and the government’s preferred option—if it is achievable, which most commentators doubt—by 22%. These figures should be seen in the light of estimates that the NHS will need £25bn (€29bn; $34bn) more than currently planned by 2022-23, to make up for the reduced annual increases since 2010.3 Over and above the direct effects of budget cuts, there are also severe threats to the supply of health workers, access to pharmaceuticals, medical isotopes,4 health technology, and much else.5

Meanwhile, improvements to health are stalling, with several years of austerity taking its toll. The social safety net is stretched. A faltering post-Brexit economy is likely to make this worse. The most vulnerable, including the growing numbers who rely on food banks,6 will be first to bear the brunt of inevitable national food shortages.7

As if in a parallel universe, the prime minister, Theresa May, has bowed to pressure and promised a long term funding settlement for the NHS.8 How this will be afforded and at what level remains unclear.

How will a final decision on Brexit be reached? There is now growing support inside parliament for a “people’s vote,” with a referendum not on an abstract question but on the details of any deal negotiated by the government. This would include a “no Brexit” option. Recent amendments passed by the House of Lords effectively set a deadline of 30 November for a vote in parliament. This would leave enough time for a people’s vote before the Brexit deadline of 29 March 2019. But the latest opinion polls give little hope of a convincing result from such a vote, in either direction. If the outcome proved as narrow as for the 2016 referendum, little would have been achieved.

Parliamentarians are at last becoming aware of the threats that Brexit poses, set out clearly in a growing number of select committee reports.910 But when it comes to claims about the impact of Brexit on the NHS, almost no politician is believed. By contrast, doctors and nurses enjoy a uniquely privileged position of public trust.11 Whatever our views as individuals, or how we voted in the 2016 referendum, we can no longer escape the fact that Brexit in any form so far discussed is bad for health. Nor can we ignore the increasingly well evidenced concern that, in terms of basic stewardship, the state seems headed towards abrogation of its duty to look after the needs of its citizens, individually and collectively.

Time is short. We have barely five months to mobilise public opinion to make MPs sufficiently confident in a conclusive result to demand a people’s vote. UK health professionals have supported calls for a “do no harm” amendment to protect public health in the EU Withdrawal Bill.12 We can do more. As public health advocates we can document the impact that the threat of Brexit is already having on NHS patients and staff, with increasing accounts of shortages of health workers. As citizens we can lobby our MPs. Some can spread the message through social media. As professionals we can share the facts with each other, and with our patients and the wider community.

If we knew that an infectious agent posed a serious threat to the health of our population and we could prevent it, then we would have no hesitation in demanding and ensuring that something be done. Yet when we are faced with clear evidence that political decisions will cause harm, many of us feel we should be silent. Ultimately, politicians decide, but we have a responsibility to ensure that they do so on the best evidence available, regardless of where the threat comes from. With Brexit, the evidence is now very clear.

Health is closely correlated to Wealth – If you are poor you get no choice (Wales), and live a shorter life, but if you are rich, or born abroad, you live longer and you do get choice! So much for equity…

Health is Wealth: How parts of Britain are now poorer than POLAND with families in Wales and Cornwall among Europe’s worst off

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Locked away – An alarming rise in mental-health sectioning in Britain

I have heard, informally, that the number of “emergency” sections, with only one doctor and a relative or social worker is also increasing. It would be interesting to know the numbers of such sections under the mental health act by each UK region for comparison. As it is we only have Englands’.

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The Economist April 19th 2018: Locked away – An alarming rise in mental-health sectioning in Britain

Fewer psychiatric beds and growing risk-aversion among doctors may be to blame

….The number of detentions under the Mental Health Act in England rose from 43,463 in 2009 to 63,622 in 2016. The process requires two doctors and one approved mental-health professional, like a social worker or nurse, to agree that a patient needs hospital treatment for a mental-health disorder, and that they may pose a danger to themself or others.

Experts admit it is impossible to know whether the increase is justified or not. But many are alarmed by its sheer speed. Some also worry that those with only minor conditions are being swept up in the rise.

What is behind it? One theory blames the underfunding of early-intervention services. These were set up by hospital trusts in the early 2000s, after which the number of detentions began slowly to fall. But since 2011 mental-health spending in Britain has fallen by about 1% in real terms, while greater public awareness of mental-health issues has stoked demand for services. As a result, mental-health teams are stretched. Someone with psychosis, for instance, should receive treatment in two weeks but may wait up to six months, says Will Johnstone of Rethink Mental Illness, a charity. In that time their condition may deteriorate, leading them to be sectioned.

Another factor is a long-term drop in the number of beds for psychiatric patients. A shift away from hospital treatment to care in the community saw the number fall from about 155,000 in 1954 to around 20,000 today. Most have welcomed the change. But a lack of beds raises the pressure to discharge patients early, meaning some need to be sectioned again. A survey by the Royal College of Psychiatrists in 2014 found that about a fifth of trainee psychiatrists had sectioned patients just to secure them a bed and care.

Doctors have also become more risk-averse, says Sir Simon Wessely, professor of psychiatry at King’s College, London, and the chairman of an official review into sectioning set up last year. In 2014 a Supreme Court judgment broadened the definition of unlawful deprivation of liberty. One effect is that some elderly folk with dementia, who had previously been kept in hospital with a bit of informal persuasion by doctors and relatives, are now being sectioned in order to avoid accusations of unlawful detention. A recent report by the Care Quality Commission, a watchdog, revealed that in some wards for elderly people, every patient had been sectioned.

Doctors also seem to be more nervous than before about suicide. In 2009 the National Health Service drew up a list of eight “never events”, errors so grave they should be expected never to happen, and which trigger an internal investigation if they do. It includes patients using curtain or shower rails to commit suicide in mental-health units. In January Jeremy Hunt, the health secretary, launched a “zero-suicide target” in hospitals. Such a focus may encourage doctors to increase the supervision of their patients by sectioning them sooner and for longer, rather than risking a death.

That risk-aversion may also harm the recovery of those detained, argues Ms MacDonald. She eventually recovered in a hospital which let her take up pastimes like embroidery and walking in the garden. Such activities calmed her down when she felt depressed. Yet stricter infirmaries did not allow them, for fear of self-harm.

The rise in sectioning has disproportionately affected ethnic minorities. Black people are four times more likely to be sectioned than whites. This long-standing pattern is partly explained by black Britons’ lower incomes, which are linked to poor mental health. But it is also down to discrimination and a lack of black people in senior roles in mental-health services, says Patrick Vernon of Black Thrive, a charity.

Sir Simon’s review will report its initial findings in the next few weeks and make proposals later in the year. Some will be quick fixes, but mental-health legislation can take decades to change because it is so complex, he warns. One hurdle is legal, since the rules on sectioning are tied to other laws, such as the Mental Capacity Act. Another is ethical, because of the need to balance individuals’ right to liberty against the state’s duty to protect them and others. And a third is scientific, as mental illness has many causes, from the genetic to the economic. The rise in sectioning may have been rapid, but anyone hoping for an overhaul of the system is in for a long wait.


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Being sectioned (England) – Royal College of Psychiatrists

The number of detentions under the Mental Health Act is rising – Full Fact

Mental Health Statistics (England only) – NHS 10th October 2017