Monthly Archives: September 2018

The 3 myths of the NHS…..& …No learning from other countries – no co-payments, and more scandals..

With Mr Cable suggesting we “Tax the rich” more, and without means tested co-payments for health, as a reasonable additional method of rationing, NHSreality wonders if this is a policy that will win the votes of non members?

Bagehot in the Economist 28th June 2018 opines:

The three myths of the NHS- The National Health Service is a great institution. It is also the subject of fairy tales

There is little mention of the underlying ideology, and the fact that morale is so low because the staff cannot buy in to the prevalent philosophy. However, the correspondence (see below) challenges Bagehot. The first is another expression of denial. The second is the reality of other systems which discourage dependency and encourage autonomy through co-payments. Do we need to “test” our politicians? Do they know that there are better outcomes elsewhere? Of course they do: that’s why they all go privately.

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THE National Health Service’s 70th birthday is turning into an extravaganza. The government has given the service a £25bn ($33bn) present to mark the anniversary, which falls on July 5th. The BBC broadcasts daily encomiums to the wonders of free health care. Jeremy Corbyn, Labour’s leader, wore a large badge celebrating the NHS’s birthday at prime minister’s question time.

The NHS is the most popular institution in the country. In a survey by Ipsos MORI last year, 77% of respondents believed that it should be maintained in its current form and 91% supported its founding principles, that health care should be free at the point of delivery and funded by general taxation.

It is so popular because it is more than just a public service. It is also an embodiment of British values at their best: compassion and decency; waiting in line rather than barging ahead; being part of a national community rather than a collection of self-seeking atoms. These values were central to Britain’s conception of itself in 1948 when the Labour Party founded the NHS as part of its New Jerusalem. Many people cling fiercely to the health service today precisely because it is a reminder of a more egalitarian society and an antidote to our self-seeking times.

Walter Bagehot, the great 19th-century editor of The Economist, argued that the British constitution was divided into two branches: the dignified, which represents the nation in its symbolic form, and the efficient, which gets the work of the world done. The NHS is the most-loved British institution because it straddles this divide. It is dignified because it represents Britons’ collective view of themselves as a decent bunch of people, and efficient because it treats more than 1m patients every 36 hours.

The fact that the NHS spans the dignified and efficient divide not only explains why its birthday is being celebrated with such enthusiasm. It also explains why so much of this enthusiasm is coupled with nonsense and exaggeration. It is hard to remember a time other than a royal wedding when so many commentators have uttered so many half-truths—or indeed non-truths—with such grave conviction. Three myths are particularly cloying.

The first is that Labour summoned up the NHS from thin air; that before 1948 the poor died in the streets but after 1948 they were suddenly equipped with new hips and false teeth. In fact, the government inherited a rich patchwork of charitable hospitals, school medical services and employer- and government-subsidised health care. The 1945-51 Labour government didn’t build a single new hospital or add significantly to the number of doctors. Its achievement was to nationalise a patchwork system and make it free at the point of delivery.

The second is that the NHS is a unique embodiment of compassion. Aneurin Bevan, the health secretary who created it, sold the NHS as proof that, even as Britain was ceding global leadership to America and the Soviet Union, it was still a superpower in one vital area. “We now have the moral leadership of the world, and before many years we shall have people coming here as to a modern Mecca, learning from us in the 20th century as they learned from us in the 17th century,” he declared. But there was far more than morality at play. The service’s roots are in the “national efficiency movement” of the Edwardian era. The 1905-15 Liberal government introduced medical inspections for schoolchildren in 1907 and national health insurance in 1911, among other reforms, because, in Lloyd George’s words, “The white man’s burden had to be carried on strong backs.” After 1948 the NHS was part of a warfare-welfare state that spent 10% of GDP on defence and maintained a large conscript army because it worried that war with the Soviet Union was imminent.

The NHS does a middling job of turning compassion into care—certainly better than America, but worse than several continental countries that rely on compulsory insurance backstopped by the government. The Nuffield Trust, a health think-tank, points out that Britain has markedly fewer doctors and nurses per person than similar countries, and fewer CT scanners and MRI machines. It also has higher rates of mortality for problems such as cancer, heart attacks and strokes. On the positive side, it is excellent at providing long-term care and value for money.

The final myth is that the Conservative Party is perpetually bent on selling off the NHS to the highest bidder. There may be a few ideologues on the right who dream of replacing the health service with an insurance-based system or an American-style public-private mix. But they are outliers. Conservative right-wingers have shied away from acting on their principles. One of the first big boosts in NHS spending came in 1962 when Enoch Powell, an early champion of the free market, splashed out on 90 new and 134 refurbished hospitals. Mainstream Conservatives like the NHS because it gives the government a way of controlling health spending and ensuring value for money. Easy on the champagne

It may seem a bit churlish to turn up to a birthday party and spit on the cake. Myths can serve a useful function in boosting morale, particularly when morale has been eroded by a decade of austerity. But the myths that surround the NHS have also done harm. They have given the Labour Party an excuse to demonise Conservative reforms as “backdoor privatisation” rather than subjecting them to serious criticism. They have discouraged the NHS from learning from other countries. They have made it impossible even to think about boosting NHS revenue by charging patients a nominal sum for visiting the doctor. They may even have allowed scandals to go uncovered because nobody can bring themselves to blow the whistle on saintly NHS workers. Britain is right to celebrate a service that provides all Britons with free health care at a reasonable cost. But they are wrong to treat the NHS as an object of awe rather than a human institution with all the imperfections that being human entails.

Bagehot suggested that any discussion of boosting its revenue by “charging patients a nominal sum for visiting the doctor” is off the cards because of the Labour party’s desire to “demonise conservative reforms”. An alternative view is that bitter experience has taught the public that nominal fees soon begin to grow at an exponential rate to painful levels. Charges for prescription drugs being a good example. “Free at the point of delivery” is a red line that all voters of all persuasions know must be held at any taxation cost. P Corser Selborne Hants.

Bagehot created some of his own myths about the NHS. Edwardian health reforms did not provide the roots for legislation that created the NHS in 1948. Medical inspections of children were precisely that: to tell their parents that their child needed a doctor. Treatment still had to be paid for. Free (or subsidised) health care appeared much later. And Nation Health Insurance, “employer and government subsidised health care”, offered only minimal GP careto a minority of the working population, namely low-waged blue-collar workers. Maternity care aside, the scheme offered nothing to their wives.

The Edwardian reforms were aimed at promoting the physical well-being of the male workforce and armed services. The principles of the NHS were different, based on equality. Why else would you dedicate equivalent medical resources to post-menopausal women? Moreover, thanks to the Trreasury’s parsimony, NHI never developed in the way it did in Germany. There, a Bismarkian Health=Insurance scheme expanded to provide universal cover, the foundations of German Health Care today. Prof Noel Whiteside, Institute for Employment Research, University of Warwick.

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An online complaints box cannot replace structured, professional, trustworthy, depersonalised, “Exit Interviews”.

There are many “ideas about healthcare” and the TED talks is a good place to start.  The letter following from the president of the Royal College of Anaesthetist points out that this “..clearly affects all health and social care workers and more needs to be done to tackle it”. In the absence of exit interviews, and without these being conducted by an independent Human Resources company, NHSreality feels that staff will be slow and reticent to use an internal facility. Things have got too bad. But the suggestion at least acknowledges the reality of the problem of NHS staff morale, and bullying.

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Richard Ford in the Times September 10th reports: Got a gripe? NHS staff to have their own online complaints box

NHS staff will be able to voice complaints and express frustrations about their jobs and bosses in an online service set up by the government to tackle poor morale in the health service.

Staff will be able to use the Talk Health and Care digital platform on their phones and tablets after it is introduced today by Matt Hancock, the health secretary. He wants to hear first-hand from those working on the front line of the NHS, who are the most qualified to advise on what needs to change.

“Millions of hard-working health and care staff turn up to work every day to meet any challenges tirelessly, with unending compassion,” he will say. “But they don’t just do this for money or other contract benefits. They do it to improve and save the lives of countless strangers, and in return it’s only right that they are valued, supported and developed. Too often health and care employers, despite the NHS being the world’s fifth largest employer, don’t get this right. It’s time we hear from health and care staff about what they really have to say about the jobs that are at the heart of this country.”

Mr Hancock has expressed concerns at the high number of bullying and harassment claims from staff and wants to ensure that these problems are not “put into the too-difficult pile” by bosses.

The health secretary will make his announcement during a visit to Southmead hospital in Bristol where his sister, Emily Gilruth, 41, was treated after she was seriously injured in a fall while competing at the Badminton Horse trials last year. She was in a coma for four days after hitting her head. He will meet and thank doctors, nurses and care staff for saving her life.

The most recent NHS staff survey found that 15 per cent of staff had experienced physical violence from patients, relatives or the public, with that figure rising to 34 per cent for ambulance staff. About 28 per cent of staff (47 per cent at ambulance trusts) experienced harassment, bullying or abuse from patients, relatives or the public.

Nearly a quarter (24 per cent) had been harassed, bullied or abused by their colleagues and 12 per cent felt that they were victims of discrimination, a figure that rose to 24 per cent for black and minority ethnic employees.

The Talk Health and Care platform, an in-house service available to the NHS’s 3.1 million staff, will allow them to offer views on improving their shift patterns, juggling home and work lives, speeding up the use of helpful technologies and training and development.

Ruth May, executive director of nursing at NHS Improvement, welcomed the service, saying that it would “help the NHS listen to and support its staff, so that they feel happy, healthy, safe and valued”.

Sean O’Sullivan, head of health and social policy at the Royal College of Midwives, said: “We welcome any initiative to get the views of midwives and NHS staff.

“They will often have solutions to problems they face and ideas for delivering safer and better care. What is important is that this is a real exercise in engaging with staff and that the government act on what staff tell them.”

Mr Hancock has previously been a digital minister and became the first MP to launch his own smartphone app earlier this year. When the app was found to collect its users’ photographs, friend details and contact information, Silkie Carlo, director of the privacy rights group Big Brother Watch, called it a “fascinating comedy of errors”.

Sir, Matt Hancock’s work to develop a digital platform so NHS staff can voice their concerns is a welcome move to better understand poor morale and bullying among our doctors and the wider healthcare staff. (“Got a gripe? NHS staff to have their own online complaints box”, Sep 10). The Royal College of Anaesthetists’ own surveys show that poor morale (and to a much lesser extent, bullying) can be an issue across all grades of our members, but it clearly affects all health and social care workers and more needs to be done to tackle it.

One immediate step that the government could take to improve the welfare and morale of NHS staff is to ensure that all hospitals have adequate rest facilities. Thousands of NHS staff do not have a dedicated room to rest at the end of their shift, and tired doctors and other frontline clinical staff are at risk of being killed and injured in accidents while driving home exhausted. This needs to be urgently addressed.
Dr Liam Brennan

President, Royal College of Anaesthetists

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There are thousands of “ranting doctors”, but they keep their rants to themselves. Times for honest and open “exit interviews”.

Whistleblowing in the US – helping to change the organisational culture? No comparison with state owned organisations.. Exit interviews better and less destructive..

NHS pays £100,000 a day for mistakes. We do have a choice, and we dont have to wreck it..

Once again, reporters are omitting to mention that this “may” only be the figure provided by the DOH in England. There is no NHS, so what are the comparable figures for the 4 regions of the UK? Devolution has failed in health and education in Wales, which are more expensive and of lower quality than England. The litigation budget in Wales is extraordinary…. More and more people are aware of the safety net failures, and are paying for private care. No fault compensation is a reasonable way forward. Providing more home grown and trained doctors and nurses will also help…

See the source imageThe Times reports September 13th: NHS pays £100,000 a day for mistakes

Three patients a week are being compensated by the NHS after claiming that botched care left them without a limb, unable to see or suffering from cosmetic scarring.

In the past eight years the NHS has paid out compensation to 810 patients who suffered needless amputations, 340 who were left blind after poor hospital care and 269 who sustained cosmetic injuries as a result of negligent treatment, the latest figures show.

NHS Resolution, which resolves compensation claims, paid out £3.2 billion meaning the cases are costing the NHS more than £100,000 a day.

The biggest group of claimants was people who won legal cases against hospitals saying that negligent care meant they had to have an amputation.

The compensation paid out over the past eight years to the 810 people who had lost a limb totalled £2.2 billion, meaning that the average payout for the loss of an arm or leg was almost £300,000.

The average compensation cheque for loss of sight was about £250,000 while the average claim for scarring after cosmetic surgery was about £30,000.

Joyce Robins, of Patient Concern, a patients’ rights group, said: “It is absolutely unbelievable that you go into hospital for care and then you end up suffering more. Much of the problem is down to the system being overstretched. We just don’t seem to have enough people to look after patients.”

An official from the regulator, NHS Improvement, said: “Providing patients with high quality and effective care is a priority for hospitals.

The NHS successfully provides safe and compassionate care to hundreds of thousands of people per day, so incidents where this doesn’t happen are thankfully very rare.

However, it is vital that when they do, hospitals investigate and take action to improve.”

See the source imageThe blame game. The proliferation of compensation claims – needs a “no fault compensation” cure, possibly through a social insurance fund.

Fully home grown doctor workforce – Medicine thrives on experience from abroad. There is irony in a short term recruitment solution ..

The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

How much does NHS Wales spend? You can find out the basics, but not in comparison with England yet.

A plea for No-Fault compensation: please politicians, think long term.

This is starting to add up. Overseas patients, fraud and litigation… are costing us all dearly.

See the source imageThe Express Anna Behrmann in 2016 reports : NHS lines up £56billion of budget to pay for legal costs of negligence cases

THE NHS has set aside almost half of its entire budget to cover compensation payments and legal costs, it has emerged.

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Hospital job vacancies top 100,000 due to bad planning. NHSreality adds political short termism, & high sickness and absenteeism..

The bad planning is built into the system it seems, as successive and different administrations under ministers of health of many different persuasions have fallen into the same trap. Undercapacity. The 4 health services reports their staffing levels on different sites. It is accepted that the health services combined are the largest employer in the country, and have the highest absenteeism.

England, WalesScotlandN Ireland

The total full time equivalent workforce is unknown as so many are actually in the GIG economy, work part time, or are part of a  sub-contracted service. It is not all due to bad planning. Some blame must fall on our first past the post political system whereby no elected MP considers any problem solving with a time horizon longer than the next election. It is made worse by the largely female workforce, the part-time working, and the high sickness levels. 

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Kat Lay reports “on line” with a different heading on September 12th in the Times: National emergency risk as NHS vacancies top 100,000

More than 100,000 NHS jobs are unfilled and vacancies are increasing, according to the hospital regulator.

Experts said that there was a risk of a national emergency because of “a long-term failure in workforce planning”. The figures are part of a performance report from NHS Improvement in which it said that the underlying deficit in hospitals was £4.3 billion.

Some 11.8 per cent of nursing posts were not filled between April and June, a shortage of nearly 42,000. In London, which had the highest vacancy rate, the figure was 14.8 per cent. In England 9.3 per cent of doctor posts were vacant, a shortage of 11,500.

At the end of June there was a total of 107,743 vacancies, up from 98,475 at the end of March.

Siva Anandaciva, chief analyst at the King’s Fund think tank, said: “Widespread and growing nursing shortages now risk becoming a national emergency and are symptomatic of a long-term failure in workforce planning, which has been exacerbated by the impact of Brexit and short-sighted immigration policies.”

The report said that trusts had had to use bank and agency staff to ensure that posts were filled, spending £805 million on bank staff and £599 million on agency staff in three months, £102 million and £32 million over budget respectively.

Those costs were partly responsible for hospitals missing their savings target by £64 million, the regulator said, although it added that the plan had been “ambitious”.

The way vacancies are recorded has changed, but in 2008 the vacancy rate for nursing staff was 2.5 per cent and for medical and dental staff 3.6 per cent.

At the end of the first quarter of the financial year trusts in England were £813 million in deficit. The report included the sector’s underlying deficit for the first time, which reflects its financial position without taking into account one-off savings such as land sales or non-recurrent funding. That was £4.3 billion.

Sally Gainsbury, senior policy analyst at the Nuffield Trust think tank, said: “That means services were lacking the equivalent of 18 days’ worth of funding last year.”

The report said that A&E attendance was 6.23 million from April to June, 220,574 more than last year.

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

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

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

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Do we want reduced access and less efficiency? GPs are self employed, and they take dividends. Salaried staff are far less value to the state. Politicians are uninformed and short termist..

Successive increases in the health budgets in Wales have not helped….. Brexit will make it worse… We all seem agreed, so why not change direction?

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How should we care for our mentally ill children? Would society choose more risk for closer care?

Jonathan Owen for the BMJ reports 4th September 2018 (BMJ 2018;362:k3769 ) : Children are still being forced to travel far for mental healthcare and a map in the printed article shows the few centres capable of looking after these difficult children. There is another on the internet..

There are so many risks associated with teenagers with anorexia and eating disorders. The level of supervision needs 1:1 staffing or even more, and there is always the blame culture looking to find a scapegoat if things go wrong. The state safety nets it’s risk with fewer centres which are properly managed and staffed. The public, and parents (before there is a disaster) always prefer closer care. This is the same argument which is going on writ larger in rural areas when considering A&E and inpatient specialist services. With not enough money and not enough staff we have to compromise. The number of children with cancer each year (1300) only just exceeds the number with mental health problems (1039 – see below), and no parent rejects travelling for the best cancer treatment. Why should they resent the travelling for mental health? The reason is that mental health care is not short, or time limited, it is chronic and usually repetitive. By the time mentally ill children present there is a deep seated problem in non-compliant patients, often manipulative, and sometimes dysfunctional families. Accidental suicidal attention seeking is possible.. Cancer on the other hand has compliant patients and families…. Would society choose more risk for closer care? Prevention might be a better approach, with more family therapy options, at local level…. Given the number, this is reasonable rationing of resources. Will the situation be made worse when we have to call people “fat” rather than “obese” because we GPs need better language? (New drive to encourage doctors to write to patients in plain English)

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Dennis Campbell in the Guardian 29th August reports: Children forced to travel hundreds of miles for NHS mental health treatment

Exclusive: NHS England figures reveal some under-18s sent as far as 285 miles for inpatient services

Children and young people with serious mental health problems are receiving treatment as far as 285 miles away from their homes, despite a pledge to end such practice, because bed shortages in some areas are so severe.

Experts say sending highly troubled under-18s to units far from their family and friends can be frightening for them, reduces their chances of recovery and increases their risk of self-harm.

In all, 1,039 children and adolescents in England were admitted to a non-local bed in 2017-18, in many cases more than 100 miles from home, figures collated by NHS England show. Many had complex mental health problems that often involve a risk of self-harm or suicide, such as severe depression, eating disorders, psychosis and personality disorders.

Patients from Canterbury, in Kent, were sent 285 miles for inpatient mental health care, those from Cornwall and the Isles of Scilly 258 miles and those from Bristol 243 miles.

Bed shortages meant that in 119 of the NHS’s 195 clinical commissioning groups (CCGs) at least one patient under-18 was sent out of the area for care last year, the statistics show.

NHS England has acknowledged that the separation from relatives and isolation that very vulnerable patients experience during out-of-area placements can be damaging.

Its own policy states that in order to maximise the chances of recovery, “patients should be treated in a location which helps them to retain the contact they want to maintain with family, carers and friends and to feel as familiar as possible with the local environment”.

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New technologies and rationing by post code/region. New treatments and assessments are not available to all UK citizens.

Its good news that we can embrace new technology, and quickly, but the decision raises other issues. Mainly to do with rationing honestly… Other new technologies will follow (Hope of cure for men with aggressive prostate cancer) but whilst there are 4 different health systems, and announcements only apply to one of them, we in Wales will wonder if we can afford what England can. Only this week a friend went to London for a new prostate cancer assessment test (mpMRI) which is not available in Wales. (Sign the petition on line) ( He went Privately) Assessment and staging of Prostate Cancer is essential, and there are far more sufferers than there are with leukaemia.

Paul Kelso for Sky News reports 5th September: NHS England nets ‘game-changing’ childhood leukaemia treatment

The therapy – which has a list price of £282,000 per patient – is currently only available in Europe as part of clinical trials.

The Times also reports: Game-changing NHS treatment to save children with leukaemia

The Telegraph: NHS to fund “game changing” personalised cancer drug.

But can we afford these treatments without rationing the high volume and low cost treatments? How does such technology fit in with “personal health budgets”?

High Tech advances hit NHS funding. A proper debate wont happen however.

Interesting suggestion low cost for high volume treatments to be excluded… GPs will take no notice as their job is to put their patient “at the centre of their concern”.

World class cancer care (and Mental Health care) is possible, if we ration the high volume low cost treatments…

The cost of high tech treatments – that if these become “universal” then the low cost high volume treatments need to be paid for.

Trials of personal budgets will have long term perverse outcomes in an ageing society. Health costs are rising, and geographic variations will become greater….

Wales ‘behind’ in technology to detect prostate cancer – BBC News

Prostate Cancer breakthrough with a more accurate test (Scotland)

PET scans for prostate cancer (Birmingham)


Health Services Data collection: Tribalism has ruled so far….

At first glance it seems incredible that there is no joined up combined data set for the 4 UK health services. The media and the press don’t help with headlines that indicate that all 4 health services are impacted by a decision, when it is actually only NHS England. The proposal was rejected in Pembrokeshire in 1996. Even today, some 22 years later, there is no comprehensive information available to the Out-Of-Hours (OOH) doctors or paramedics or nurses. Resistance to change at the time was due to fears about workloads in transferring from one system to another, and no compensation or mitigation was offered. |Today all GP computer systems are excellent. Any one of them would be better overall in A&E and Casualty departments. It would then be “demanded” by the wards, radiology and laboratory, physiotherapy etc. Managers could ask the system for waiting lists “real time”, and for operations and other outputs. Complications, infections, and complaints could also be recorded, along with waiting times and waiting lists. NHS Digital may cover all 4 jurisdictions….but much of it’s news headings relates to England only. Missing notes (commonplace) would only happen if all system was down.. Are you ambitious to be famous? Do you trust the confidentiality of health records?

So why has it not happened? Will all 4 health systems agree? Tribalism has ruled so far…. both in GP and in Hospital systems, which are all different!

There is a new incentive to make it happen: the potential profit in data mining, and the Health Services, if put together, cover a large population. Apart from England the numbers are small, but the power of the combined 4 systems is high. Regional Innovation hubs (Walesincluded?) may help….                (NHS England chief executive Simon Stevens has said the NHS needs to recommit to exploiting the potential of anonymised clinical data for driving research and innovation.

Stevens announced that the NHS will set-up two to five regional Digital Innovation Hubs, each covering regions of 3-5 million people.  “We need to advance on exploiting anonymised clinical data.”) When the system does work we will all wonder why it took so long and so much money to get there.

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Philip Aldrick in the Times 5th September reports: NHS set to be offered a ‘fair share’ of data profits

Companies using NHS patient records to build the next generation of healthcare tools will have to demonstrate that any commercial gains they make are shared “fairly” with the NHS, ministers will say today.

The Department for Health has drawn up a code of conduct for technology firms that use the NHS’s “unique” data to train their algorithms.

The code will establish commercial principles to ensure that the NHS shares in the financial gain from any innovative treatment or device created with the help of its data. It also will ensure that patient records are used solely to improve health outcomes.

Britain is at the forefront of advances in artificial intelligence healthcare, with companies such as Google’s Deepmind and the UK-listed Sensyne Health mining electronic health records to build tools that can transform patient outcomes. Deepmind has built algorithms that are better than doctors at spotting eye disease and is developing diagnostic tools that catch critical illnesses early.

Under the code of conduct for data driven technologies, companies will be asked to “enter into commercial terms in which the benefits of the partnerships between technology companies and health and care providers are shared fairly”. All health records must comply first with data protection regulations that protect privacy.

Lord O’Shaughnessy, parliamentary under-secretary of state for health, said that NHS data was “like oil” and should be considered a form of capital. “AI needs data to work on and the NHS, because of the way it was set up, has this unique longitudinal data set of 60 million people alive today,” he said. “When NHS data goes into create an algorithm and the company owns the algorithm, does the NHS get a fair share for the contribution that the patient data has made to that algorithm? Patients want to know that NHS data is generating benefits for patients directly. This has to be valued and there has to be a sense of a fair distribution of benefit.”

The government will consult the private sector about potential partnership models, but Lord O’Shaughnessy said that the benefits could be through “discounted use or free use” of the tools for the NHS, or equity partnerships and royalty streams, as Sensyne has pioneered.

Ministers emphasised that the highest ethical standards would apply and that only companies that could show potential health benefits would be granted access to the data. The code would be voluntary but “at some point we will need to think about how accountability becomes tougher”, Lord O’Shaughnessy said. He said that the government “does not want to discourage innovation”.

One proposal is that devices and treatments developed in line with code of conduct receive an NHS kitemark. The code of conduct is set to be formalised at the end of the year.

The minister emphasised that consented and anonymised patient data was already being used for research purposes and by companies such as Deepmind. “The question is not whether, it’s when and how,” he said. “People are very aware that if you are working with the NHS you have to play by the rules. We need trust so people don’t opt out because they believe the benefits are fairly shared between the hospital and the private operators.”

Then there are confidentiality issues. The minutes of the Independent Group Advising on the release of data (IGARD) minutes are dry but lead to an understanding of the issues.

GPs could be forced to switch IT systems under new NHS Digital contract

Untrustworthy staff – continuing saga of data collection failure blights the Health Services potential. GPs cannot have had enough say and power in planning…

Health Secretary pledges to overhaul NHS IT system

It is a small risk (of fraud), but mainly notes missing is incompetence. Best keep a running file of your own notes.

The potential risk for blackmail – think about your medical records when you are young. Are you ambitious to be famous?

Not hacking it… Sangfroid?

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Coroner considers fresh inquests into150 deaths

Tribalism is endemic in the health services. How to prevent it involves a much more sophisticated level of training, more communication skills and more teamwork focus. In a university world where city based girls dominate medical school entry, we need to get more balanced focus on team activities. And of course there are politicians who need the same training in avoiding disruptive behaviours…

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Nigel Wray (Saracens) sports foundation) funds a charity which focuses on the gang culture, and aims to replace this with team culture. 

Chris Smyth on August 31st reports in the Times: Coroner considers fresh inquests after 150 deaths at St George’s Hospital heart unit

A coroner is investigating dozens of fatalities at a heart surgery unit to see whether new inquests are needed after a review found that rivalries among surgeons had contributed to higher death rates.

Doctors at St George’s Hospital, southwest London, are braced for cases to be reopened and have been told to get better at reporting deaths amid concern over cardiac surgery mortality rates. More than 150 people have died at the unit after surgery in the past five years.

Relatives asked Fiona Wilcox, the senior coroner for Westminster, to investigate further after an internal report exposed “toxic” bickering between rival camps of surgeons. Staff spoke of a “dark force” in the hospital but the report’s author, Mike Bewick, a former deputy medical director of NHS England, said that he was unable to investigate claims of incompetence, cover-ups and cronyism.

The Times has learnt that health inspectors made an unannounced check of the unit in recent days to investigate claims about patient safety and cover-ups after revelations in this newspaper.

St George’s, one of Britain’s biggest teaching hospitals, is under pressure to allow a full external investigation after a former cabinet secretary said “there can be no confidence in its ability” to investigate itself satisfactorily.

In a letter to The Times, Lord Armstrong of Ilminster, head of the civil service in the 1980s, argued that a recent court case had shown that “the management is itself part of the problem” and only an independent inquiry could get to the truth.

In the court proceedings, a judge ordered Marjan Jahangiri, a heart surgeon, be reinstated at St George’s. The decision to suspend her was disproportionate and evidence from the chief executive “wholly inadequate”, Mr Justice Nicklin said in an interim judgment.

Dr Wilcox has written to St George’s saying that she has received multiple communications from relatives in relation to deaths after cardiac or cardiothoracic surgery following Professor Bewick’s report. “I understand that from that report that difficulties in the department may have contributed to some post-cardiac surgery deaths,” she wrote.

She requested “a list of patients whose deaths may have been so affected that I may ensure coronial investigation has been undertaken, or if inquests have already been held that such matters were properly explored”. She adds: “It may be that further investigations and inquests are required.”

The hospital has submitted a list of all those who died after heart surgery in the past five years, more than 150 people. Nationally about 2 per cent of patients die after heart surgery but St George’s was twice alerted to higher-than- expected figures, averaging 3.7 per cent.

Senior doctors have told colleagues in messages seen by The Times that “we should expect that further inquests may be required for historical deaths” and that the coroner’s team “believe that there may have been an under- reporting of deaths in some areas”.

Doctors can report deaths to coroners if they are unexpected or unexplained, or if patients died during operations or before coming round from anaesthetic. Doctors at St George’s have been told that they must ensure that deaths of patients who have had, or were waiting for, cardiac surgery are reported.

It has also emerged that the Care Quality Commission made an snap inspection of the hospital’s cardiac surgery unit last week. Bosses have been asked whether the hospital’s culture gets in the way of action to resolve problems.

A spokesman for St George’s said: “We have provided the Westminster coroner with the information she has sought and will fully co-operate with her. We would emphasise that the cardiac surgery service is safe. The Royal College of Surgeons has stated that the treatment provided at St George’s is within the UK standard and has never been below this. We fully agree with Professor Bewick, however, that significant improvements are needed, and we are taking urgent actions to deliver this.”

The trust said an external inquiry was not needed because after Professor Bewick’s review “the trust is focused on implementing its findings as rapidly as possible”.



Do you carry a transplant donor card? Have you told your next of kin and children? Former cancer patients should not be excluded from being donors, of both blood and organs.

There is a terrible shortage of donors. Previous suggestions by NHSreality have been to reduce tax on motor bikes, and to encourage a default of opting in. It seems that the latter has not increased the donor rate in Wales, which has had a default opt in for several years. In some countries you have to be a blood donor to get a drivers licence… It seems the most important thing is to communicate your wishes to relatives and your primary medical team. IN addition, being a blood donor should be encouraged more. The 4 health services need more donors, and since so many of the population will have had cancer in 20 years time, we should review the evidence that these people should be excluded from being donors, of both blood and organs.

Transplant patients miss out due to would-be donors not telling their families An estimated 3,000 transplants were blocked by relatives last year. William MacLennan reports I news reports 3rd September 2018.

There are 6,133 people on the transplant waiting list, some of whom have been waiting years. NHS Blood and Transplant encouraged those on the register to make sure their families knew

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Thomas Conlin in the Times 3rd September reports: 3,000 transplants blocked by organ donors’ families

Families objecting to an organ donor’s wishes have led to about 3,000 potential transplants being missed in the past year, according to the NHS figures.

NHS Blood and Transplant has encouraged those who join the register to discuss their decision with their families. There are currently 6,133 people on the transplant waiting list.

Gareth Evans, 45, from Stockport, has been on the list for more than nine years and is among 280 people waiting for a new heart. “There are not enough people talking to their families and saying ‘I want to be an organ donor, you need to know my wishes’,” he told the Press Association. “If somebody saves a life while they’re living they are classed as a hero — the final thing you could do is be a hero, save people’s lives. There is nothing more marvellous than that.”

Anthony Clarkson, the interim director for organ donation and transplantation at NHS Blood and Transplant, said: “Gareth has been waiting a really long time, nine years is quite exceptional but people are still waiting two or three years as routine and as you can see from Gareth that is way too long.”

“This is why we’re trying to get the message out about organ donation. But the key is that you also tell your family because at the time when you’ve died and your family want to support organ donation, knowing that’s what you wanted to do, they will honour those wishes.”

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Performance related pay is risky, and has been rightly reversed for GPs and Primary Care. Will it work for Trusts and Hospitals?

If Health Service staff were subject to the same pressures as private industry, would there be better performance. The drivers for private industry are profit and expansion, but the drivers for health are care and outcomes. We already know that, if given the choice, local populations would choose more local care, and less life expectancy in emergencies. We know that GPs have resented and rejected “performance related pay” (PRP) and the QOF (Quality Outcomes Framework) is being dismantled. NHSreality doubts that the suggestion from Dominic King will have any long term effect, but if it means that staff who don’t perform move on, and that a job in admin or accounting in health is no longer a job for life, that may help. If meetings all resulted in outcomes and time lines with clear responsibility rather than perpetual delay and procrastination this would also help. Performance related pay is risky, and has been rightly reversed for GPs and Primary Care. NHSreality expects the culture of the organisation to prevent progress in this honest and well intentioned suggestion. It’s just playing games around the important decision: how do we ration healthcare honestly and fairly for the populations of the 4 UK systems? And given that citizens are under the same laws and tax systems, should these 4 rationing systems be different from each other?

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Philip Aldrick, economics editor reports in the Times 3rd September 2018: Pay NHS providers based on results, says Google’s Deepmind chief

Health officials should step up efforts to move the National Health Service on to a performance-pay model for service providers, the clinical head of the country’s leading health technology company has said.

Dominic King, who leads the health unit of Deepmind, Google’s artificial intelligence company, has called on the health service to “move to value-based and outcomes-based reimbursement”.

Deepmind is developing AI diagnostic tools that catch diseases early, promising to save lives and to reduce the crippling cost to the health service of treating chronic conditions. It has contracts with six health trusts and this month revealed that its algorithms could spot eye disease as accurately as humans.

Dr King said: “In the UK most technology providers, pharmaceutical companies and medical device manufacturers are effectively paid for a service, whether or not that service provides any positive benefit. Where we would like to get to is, if we’re preventing patients needing dialysis, being rewarded for the value gained from those improvements.

“That’s not how reimbursement works in most health systems. The NHS, in keeping with most health systems, wants to move to value-based reimbursements. It will probably move that way.”

The issue of payment models is significant because NHS England spent £13.1 billion on care provided by non-NHS organisations last year, 10.9 per cent of total expenditure, according to the Nuffield Trust. More than two thirds of that was from private providers. Many countries are hoping to move their health contracts from a fee model to a performance-based payment as they grapple with the escalating costs of healthcare.

Data-based health technology developers, such as Deepmind, are ideally suited for an outcomes-based reimbursement model, which in theory would ensure that payments deliver better outcomes in a cost-efficient manner. “A world of better health data would allow value-based reimbursement because you can [track performance],” Dr King said.

Cost efficiency will come into greater focus because the NHS must raise productivity in return for a £20 billion-a-year increase in funding from 2023, agreed as part of its 70th birthday present. The Institute for Fiscal Studies has warned that the NHS will need an extra £56 billion of taxpayer money by 2033 to cover the costs of an ageing population and to pay for advances in science.

Deepmind employs more than 100 people in its health AI business and is investing heavily in creating a world-leading company. It makes a loss but intends to build a “sustainable business — it is important to make this fund itself”, according to Dr King. He said that he wanted to build “a valuable service people are willing to pay for based on the outcomes we can demonstrate”.

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