Monthly Archives: July 2018

Stress in work – do we have less than the US, and is this partially due to the safety nets of our 4 health services?

In  the \economist July 21st Bartleby describes a new book by Jeffrey Pfeiffer, a professor of business at Stanford, “Attitudes in the American workplace”. The stress that kills American workers”, is a thoughtful assessment of un-to-date facts.. Do we have less stress than the US, and is this partially due to the safety nets of our 4 health services? Our health services have the highest rate of sickness and absenteeism of any organisation in the world!

HOW much golden leisure can you expect at the end of your working life? The OECD has calculated for how many years people in its member countries are now likely to be drawing their pensions, starting not from their official but their actual retirement age. It found that men could look forward to between 14 and 24 years in retirement and women between 21 and 28 (see chart 6). In many countries that was half as long again as in 1970, and in some of them twice as long. And the figures are probably an underestimate because they are based on life expectancy as it is now, not as it will be in future.

Retirement has been overdone. The original idea was that people should enjoy a bit of a rest after a life at work, but nobody imagined that the rest would stretch to almost a quarter-century. Some countries have already raised their official retirement age; others are debating whether it still makes sense to have a specific retirement age at all. One widely touted idea is to phase in retirement over a number of years. It does not seem like a good idea for people to be working at full tilt one day and twiddling their thumbs the next.

From an economic point of view, getting people to work for a few more years would solve many of the problems associated with ageing populations. By carrying on, those workers will not only save the public purse money by not drawing a pension but will also continue to pay taxes and social-security contributions, so those extra years are doubly valuable.

Moreover—though it seems an outlandish thought in the middle of a deep recession and rising unemployment—ageing populations are likely to cause labour shortages. In some countries and some sectors these are showing up already. In Germany, where the labour force is due to start shrinking from next year, a study by the Institute for the German Economy in Cologne identified a shortage of about 70,000 engineers in 2007, a rise of nearly half on the year before. The obvious place to look to fill such gaps is among well-qualified older people, and indeed the institute found that companies had stepped up their recruitment of engineers over 50.

Many countries already have laws to prevent discrimination on age grounds. America led the way with its Age Discrimination in Employment act in 1967, designed to make sure that the over-40s (greybeards of their day) were given the same job chances as younger people. Among other things, it prohibited reference to age in job advertisements. The act has since been amended a couple of times and now rules out mandatory retirement on age grounds for most jobs. That seems to have helped keep older workers in jobs.

The European Union in 2000 issued a directive that obliges member countries to ban discrimination in employment on a number of grounds, including age. France imposes a tax called the Delalande contribution (now being phased out) on employers who sack older workers. Although this can be quite hefty—up to a year’s pay—it does not appear to have saved many jobs. Rather, it has discouraged employers from hiring older workers.

Various countries have concocted an alphabet soup of initiatives and pilot projects to get older people into work and keep them there, with mixed results. Advocacy groups for older people such as America’s powerful AARP, and a growing number of similar organisations that are springing up in other rich countries, have helped to raise awareness of the issue. But survey after survey finds that where employers have a choice, they prefer to hire younger workers. Are they right?

On the face of it, there are plenty of reasons to plump for youth. In most countries, pay goes up as workers become more experienced and productive, and then declines again towards the end of their careers. But in some places—for example, France, Germany and Spain—pay just keeps rising. So even assuming that workers remain just as effective as they get older (see below), at some point they end up being too expensive for what they offer.

But employers are also doubtful that older workers can still hack it. Vegard Skirbekk of the International Institute for Applied Systems Analysis near Vienna has reviewed a large number of studies about the relationship between age and individual productivity and found a fairly broad consensus that productivity in many jobs declines substantially in mid-working life….

…Show me the colour of your carrot

But even if employers were happy to keep or recruit older workers, how enthusiastic would those workers be to carry on? That would depend on the circumstances. In the past few decades, when pensions in most rich countries were reasonably generous and early retirement was positively encouraged, only the most workaholic (or improvident) continued working. But now that money is getting tighter and early-retirement deals are off, the balance may well have shifted.

Most of America’s baby-boomers now say that retirement is not for them, partly because they fear they may not be able to afford it and partly because they actually like work. In Europe too there has been a change of heart from the retirement-minded 1980s and 1990s. In a recent FT/Harris poll 45-60% of respondents in the big European countries favoured working longer for a bigger pension (except in Germany, where only about a quarter wanted to carry on). But many older people would like a less onerous workload than they had at their peak, perhaps working part-time.

Japan, where it is customary to work well beyond the official retirement age, has found ways to allow people to step into less demanding roles. For example, at the head office in Tokyo of Hitachi, a giant global electronics company, over two-thirds of those who reach the company retirement age of 60 apply to be rehired. The company can usually find jobs for them, explains Takane Miwa from the company’s human-resources department, but often in a different division, sometimes part-time and always minus their former job title and seniority. The company pays the employee about 80% of his previous salary, which includes his public pension and a government subsidy, so it gets him at a bargain price.

Most other rich countries have not been good at making use of older people willing and able to work. The names of a few companies that have consistently recruited staff past retirement age—mostly retailers such as Britain’s B&Q and America’s Wal-Mart—pop up time and again, but the list never seems to get much longer. In the absence of a good choice of jobs, some newly retired people manufacture their own, turning themselves into self-employed consultants to do much the same thing as before, though perhaps at a less punishing pace.

It is worth bearing in mind that if many more older people were to stay on in the formal economy, some of the things they now do outside it and without monetary reward would fall by the wayside. Many newly retired folk sign up for voluntary work, and many more get drafted into family duties, looking after grandchildren or frail old parents. Such unpaid work does not show up in the GDP figures. If the people who do it held down regular jobs, much of those things would have to be paid for—or would not get done at all.


A recent article in the BMJ pondered “Why Doctors Don’t take Sick leave”

In Search of the Perfect Health System – a new book reviewed

Grieving for the NHS. The softer specialities and locums. Ration for higher earners, and where insurance could cover.

Cornwall and Barnsley have worst morale and absenteeism

Bad News: Sharp rise in sick days taken for mental illness – especially in the Health Service Trusts

The NHS in the age of anxiety: rhetoric and reality—an essay by Rudolf Klein





Beware the tyranny of the mob. Brexit will harm those suffering from rare diseases.

If we are lucky we have a common condition, for which there are treatments and targets. But the health mutual is for everyone, no less those unlucky enough to have a rare disease. The power of numbers: a EU mutual of 400m people is much stronger and offers more choice than one of 60m (England) or 3m ( Wales). The post code lottery works against the smallest and more remote parts of the UK. Shame on the politicians who, in a representative democracy, should tell the mob when they are wrong. The FT is correct: “Nowhere has the value of a single market been seen more clearly“.

Jonathan Leake reports in the Sunday Times 22nd July :Brexit threatens rare‑diseases care for 100,000 British children

Britain faces expulsion from a medical network that helps to identify and treat conditions that affect tens of thousands

Britain faces being thrown out of a Europe-wide network for treating rare diseases — depriving 150,000 UK citizens, two-thirds of them children, of their best hope for treatment.

Six British medical experts, each head of one of the 24 specialisms covered by the European Reference Networks (ERNs), were this month stripped of their leadership roles, in preparation for the UK’s likely departure from the system next March under Brexit.

The ERNs link medical experts across the EU to treat people suffering from diseases whose rarity makes it difficult for any single country to build up specialist treatment centres. Each of the 24 networks covers a specific category such as childhood cancer, inherited liver disease, or babies born with heart conditions.

About 1m patients benefit each year, with 150,000 Britons seeking diagnoses and treatment from overseas while UK doctors offer similar assistance to EU nationals.

“My son has a genetic disease unique in the UK,” said Louise James, 40, from Bristol, whose son Scott, 8, suffers from multiple epileptic fits every week. “He has a mutation on his X chromosome which was identified by a geneticist in Siena, Italy. The European collaboration is his only hope of a treatment and Brexit means that is all now at risk.”

Rare diseases are those affecting fewer than one person in 2,000, with 80% due to unusual gene mutations that tend to cause lifelong degenerative illnesses. Each may affect a handful of people but the number, 7,000-8,000 known diseases, is so great that 6% of the population are affected by them.

It was the scale of the problem that prompted the European Commission to set up the 24 networks. Each network lets experts across the EU exchange medical imagery, patient notes, genomic and other data, and to discuss therapies. Such collaborations have also led to patients travelling between EU countries for specialised treatment.

The government has recognised the importance of ERNs. Theresa May’s Brexit white paper, published this month, says the UK should seek “continued participation”. There have been no formal discussions, however, and a hard “no-deal” Brexit would lead to the UK being excluded.

“As it stands Brexit will see the UK excluded from the entire rare disease treatment network,” said Professor Maurizio Scarpa, who was the EU-wide co-ordinator for the whole system until last month and who still heads one of the largest networks, for hereditary metabolic diseases, which has 43,000 patients, two-thirds of them children.

“This is bad for everyone. Six of the 24 networks are led by British experts and there are 32 UK hospitals and 150,000 patients already in the system. Brexit will exclude the UK from the EU so the six UK leaders have been asked to surrender their co-ordination roles and UK hospitals will no longer be part of the ERNs.

“We will try not to deny any help to UK patients but all the benefits of structure and leadership will be lost. The UK is a leading science centre so it is Europe’s loss as well as the UK’s. For some patients it will affect the chances of survival.”

The UK health department could offer no comment beyond what was in the Brexit white paper. The European Commission could also not comment while talks were in progress.

Those losing out could also include EU citizens referred to UK experts such as Avril Daly, 42, who has retinitis pigmentosa, a degenerative eye disease, which can be caused by defects in any of up to 200 genes. “My condition was diagnosed in Ireland but I had to go to Manchester to get a genetic diagnosis,” she said.

Dr Jayne Spink, chief executive of the Genetic Alliance UK, said: “Brexit is a huge threat to the European rare disease community — if negotiations fail to secure continued involvement in the ERNs for the UK, it will be patients and families who pay the price.”

Those families are already fearful. James said: “The impact Brexit is going to have on families like mine and the lives of children could be terrible. It seems to me that our politicians have forgotten the people they are meant to be serving. The children … need access to diagnoses and therapy and losing them will be life-threatening for many.”

In the FT: Brexit risks for UK rare disease sufferers must be addressed – Nowhere has the value of a single market been seen more clearly

Cancer survival rates revealed. Good News on prostate cancers – Bad news on rarer cancers

Restrictions on knees and hips are reasonable if the cancer treatments are taking priority in an imploding system.

Kat Lay reports in the Times on the |”Rationing of knee and hip operations”

This would be fair enough if it was overt, had been announced in advance, and was universal. As it is none of these, it brings back fear for those in the population who cannot afford private care, and they are the same people who will also get the heart attacks and other complications whilst waiting. When things get this bad, should those in work come ahead of those who are retired??

Increasing numbers of patients are being refused funding for knee and hip surgery, despite being told by their doctor that they need an operation, an investigation has found.

Almost 1,700 requests for such operations were turned down last year, 45 per cent more than the year before, according to research by The BMJ.

Ian Eardley, senior vice-president of the Royal College of Surgeons, said: “Hip and knee surgery has long been shown to be a clinically and cost-effective treatment for patients. We are therefore appalled that a number of commissioning groups are now effectively requiring thousands of patients to beg for treatment.”

The patients will have failed to meet certain eligibility criteria set by health bosses in their local area for the operation, which may include factors such as weight or smoking habits. Some areas have put forward controversial plans to offer patients hip and knee replacements only if their pain has reached a certain level.

The BMJ asked clinical commissioning groups, the GP-led bodies in charge of paying for NHS services in local areas, how many exceptional funding requests for knee or hip surgery they had received and rejected in the past two years.

In 2017-18, 1,675 exceptional funding requests by doctors on behalf of their patients were turned down, compared with 1,155 in the previous year. The proportion of rejected requests remained similar at about 10 per cent.

The request system was introduced in the 2000s to limit cosmetic procedures or fertility treatment but their use has been extended amid an NHS funding squeeze. GPs refer patients to specialists as normal but there is no guarantee that if they recommend a treatment it will be funded.

Mr Eardley said that the mechanism “seriously undermines the historic decision-making process; decisions about treatment should be made between a doctor and a patient, not by a panel that may not meet the patient”.

He added: “The use of funding requests means patients will spend more time in pain with potential deterioration of their condition, thereby generating further costs for a system already under acute financial strain.”

The BMJ research also highlights a postcode lottery. Buckinghamshire commissioning group had 1,298 exceptional funding requests for knee surgery last year and rejected 18 per cent, while Doncaster had 24 but rejected 23.

The BMJ said there was emerging evidence that more patients were choosing to go private. Spire Healthcare reported a 12 per cent rise in revenue from self-paying patients last year.

The NHS is considering whether there should be standardised thresholds for patients to receive treatment across England but there are concerns that any such moves might restrict access.

The four-hour target of treating, admitting to hospital or discharging patients seen at A&E departments may be outdated, the head of NHS England implied yesterday. Simon Stevens said there that had been “significant clinical practice changes in urgent and emergency care pathways”. Performance measured against the target of dealing with 95 per cent of patients in less than four hours has slipped in recent years. In May only 86 per cent of patients were seen within four hours.


Repeating mistakes and false rationing. Vaccinations lead the way.

We have repeated our mistakes with HPV vaccine. We made the same mistakes with Rubella decades ago. \herd immunity is obtained with 84% cover. So only doing one sex is just plain stupid, and false economy\now 

My wife and I paid for our shingles vaccines, before the state subsidised age of 70.

Now Kat Lay reports in the \times 19th July: |U turn on giving cancer vaccine to boys. “Boys to be given anti cancer vaccine after all”.

Boys could get an anti-cancer vaccine given only to girls at present after government advisers changed their mind and said it would be cost-effective.

Teenage girls are vaccinated against human papillomavirus (HPV), a sexually transmitted infection that causes about 5 per cent of all cancers, in an effort to reduce cervical cancer rates.

Campaigners wanted the programme extended to boys on equality grounds and to protect them against other types of the disease including mouth, throat, penile and anal cancers.

Yesterday the government’s Joint Committee on Vaccination and Immunisation (JCVI) said that it would be worthwhile to do so, subject to ministers negotiating an effective rate on bulk purchase of the vaccine. The government will consider the advice.

Last year the JCVI said that boys were already given so much protection by the programme for girls that it would not be value for money to provide a “gender-neutral” approach. Campaigners argued that it did not protect men who had sex with men, or with unvaccinated women.

Andrew Pollard, chairman of the JCVI, said: “There is clear evidence that vaccinating boys would have a health impact, with anticipated reductions in rates of various cancers in men including penile, anal and oropharyngeal cancers, as well as further reductions in cancers in women by reducing their exposure to the virus.”

Campaigners called for a swift introduction of a programme for boys. HPV Action said: “It is entirely realistic for the vaccination of boys to begin by September 2019 at the latest”. A spokeswoman for the Equality and Human Rights Commission said it welcomed the JCVI’s recommendation.

The Times has already opined on the stupidity of the situation, and that doctors are choosing to have their sons vaccinated privately!


Brexit dividend for NHS is a fallacy, says OBR

Philip Aldrich in the Times 18th July 2018: Brexit dividend for NHS is a fallacy, says OBR

Britain’s fiscal watchdog has told the government there is no “Brexit dividend” to fund its NHS spending pledge.

The Office for Budget Responsibility said that last month’s promise to raise real NHS spending by 3.4 per cent over the next five years, costing £20.5 billion a year by 2023, would increase the national debt by 57.9 per cent of GDP, or £1.2 trillion in today’s money, by 2067.

Mrs May had said a “Brexit dividend, with us as a country contributing a little more” would cover the extra funding. However, the OBR said that the dividend did not exist, implying that the burden would have to fall on tax rises. “Brexit is more likely to weaken the public finances than strengthen them over the medium term, via its effect on the economy and tax revenues,” Robert Chote, the OBR chairman, said.

The country would recover its EU budget contributions but any talk of a dividend “ignores other Brexit-related calls on those savings”, he said.

The OBR’s annual fiscal sustainability report, which maps out long-term risks to the public finances, said that health spending was the biggest threat as an ageing population, technological advances and chronic diseases piled costs on the NHS. All else being equal, health spending as a share of GDP would almost double to 13.8 per cent over the next 50 years. As a result, public spending excluding debt interest payments would balloon from 36.7 per cent to 44.6 per cent of GDP, it said.

The Treasury issued a report that set out how it was managing the risks, vowing “to return the public finances to balance by the middle of the next decade”. It said it was investing in infrastructure, tackling tax avoidance and reforming the financial system to reduce taxpayer exposure to another banking crisis.