I’ll pay later, and possibly with my life.. NHS trusts face a record £6bn backlog of repairs…

If there are 60 million souls in the UK (I know its more) the £6,000,000,000 bill equates at £100 each man woman and child. And you can be guaranteed its an under estimate. The trouble is that I don’t have the option to pay now, and prevent deterioration. I’ll pay later, and possibly with my life.. while successive governments think, and deny. Capital projects are decreed by devolved government in Wales, Scotland, and N Ireland, but centrally in England. 

The Times reports 23rd October 2018: NHS trusts face a record £6bn backlog of repairs

NHS trusts are sitting on a record-high backlog of almost £6 billion worth of repairs or replacements that need carrying out, official figures show.

About £1 billion of the outstanding repairs are “high risk”, meaning that they could result in “catastrophic failure, major disruption to clinical services” and are “liable to cause serious injury and prosecution” if they are not addressed immediately. Examples of maintenance required could include upgrading software on medical equipment, maintaining generators and boilers and ensuring the structural integrity of buildings.

In the year to March there were 17,900 incidents across England in which patients were harmed or put at risk of harm because of infrastructure problems, according to the data from NHS Digital. This is an increase of 800 in a year. Clinical services were delayed, cancelled or otherwise affected because of problems with buildings or facilities on 3,835 occasions, an increase of 1,500.

Chaand Nagpaul, chairman of the council of the British Medical Association, said that there was an urgent need for extra funding to address the NHS’s “impoverished infrastructure”.

The repair bill has risen every year since 2011-12, when it stood at £4 billion, while costs for outstanding high-risk works have more than tripled over the same period. NHS trusts spent a combined £404.5 million trying to reduce the backlog last year but the bill rose by more than £400 million.

Siva Anandaciva, chief analyst at the King’s Fund, a health think tank, said: “Deteriorating facilities and unreliable equipment can expose staff and patients to increasing safety risks, and make NHS services less productive as operations and appointments may be cancelled at short notice.”

For the past four years the Department of Health and Social Care has transferred money from the capital budget to use on day-to-day spending. A spokesman said: “Investment to tackle this maintenance work has increased by 25 per cent from £324 million in 2016-17 to £404 million in 2017-18. We are also investing £3.9 billion into the NHS to help transform and modernise buildings.”

General News regarding the 4 UK Health Services in last 2 weeks.. Worse and worse…

Readers might well ask “What is the legal situation regarding rationing?” Well, as long as its called something else, prioritisation, restriction, limiting or excluding, trusts can, within certain limitations, ration health care. The risk of anarchic rationing by post code was exposed by NHSreality last week. (NHS rationing and the Law by Warwick Heale in Devon) The risk is getting higher….. and as each week draws nearer to Brexit day, UK citizens might wish to consider how they can reduce risk. Private insurance is all very well for “cold care” (Non urgent) but emergencies are unpredictable, A&E s are understaffed, and capacity is limited as well as funding. The safety net which was there when I qualified in 1974 is well and truly holed. I strived to find “good news”, and note the savings on syringes and gloves.. but this is child’s play compared to the waste elsewhere. The return of fear and the ultimate lottery in health care has arrived. The average citizen/punter will not recognise the problem until they or their next of kin are ill….. The current funding and the system for funding health overall is a political decision. The need for change is paramount, but in the Brexit limbo iceberg of today, no important changes are likely. Its going to get worse…

NHS rationing and the Law – by Warwick Heale in Devon

Gareth Iacobucci in the BMJ reports 16th September: GP exodus could force hundreds of practices to close in next five years, royal college warns

and on 2nd October David Oliver reports:  The crisis in care home supply

Mark Smith for Walesonline 22nd October reports: Welsh NHS boss quits and is moving to England to get better cancer care for her husband –  Prof Siobhan McClelland says she has lost faith in the Welsh NHS

and the Welsh Health Minister “rejects her claims” in the Mail

Michael McHugh 22nd October 2018 in the Belfast Telegraph: Cancer treatment in Northern Ireland receiving ‘sticking plaster’ approach, says campaigner – Co Down woman blasts care available to patients

and Northern Ireland health service facing resourcing crisis amid 1,800 vacancies – health chief Valerie Watts – An extra £100 million has been set aside to overhaul the system as part of the DUP’s confidence and supply agreement.

and MP’s ‘real concern’ at disparity in health service between Northern Ireland and UK

In BBC Scotland Glen Campbell reports 16th September: Health board says Brexit poses ‘very high’ risk of disruption after August : NHS Scotland works up ‘detailed’ no-deal Brexit plan

BBC News Holyrood Louise Wilson 22nd October: Statements on abuse, NHS and P1 assessments – Worse waiting lists, waiting times, cancer waits, and outcomes wompared to England.

ITV News reports something good: NHS saves £228m on syringes and disposable gloves!

and there are “not enough showers or toilets” in a Broke Trust.

Jamie Doward in the Observer Sunday 21st October: Ten NHS trusts ‘wasted £235m to hire private ambulances’ – Union anger over bill for outsourcing while service starved of cash

Dennis Campbell Sunday 21st October: NHS £20bn boost risks being spent to pay off debts, experts warn – PM urged to write off £12bn in hospital overspending or extra healthcare will be unaffordable

BBC News 22nd October 2018: Hugh Pym: NHS: Will this winter be even worse?

Martin Shipton for Walesonline 28th September: Welsh councils demand health cash is spent on schools and social care – Local authorities want the Welsh Government to give them some of the extra money that is coming to Wales as a result of NHS funding rises in England

Cathy Owen for Walesonline 18th September: Iceland is giving NHS staff free ice cream and pizza – Workers who have signed up to the supermarket’s Emergency Services Bonus Cardiff will benefit

Will Hayward 24th September 2018 for Walesonline: Doctor suspended for conning Welsh NHS out of £55,000 – There was a recommendation that Dr Chun Ooi be struck off

David Williamson for Walesonline: GPs in Wales are getting a major pay hike – what the 4% deal means for staff  – Doctors are delighted but dentists are upset

Richard Youle 3oth September: Health board wants to ditch Welsh-only name because it thinks it’s putting people off working there – But it fears ending up being called Healthy McHealth Board, if it lets the public vote for a new name, following the Boaty McBoatface debacle

Mark Smith and Ruth Mozalski: Deaths of 26 babies being investigated by Cwm Taf health board

A review has found 43 maternity cases where there was an ‘adverse outcome’ since the start of 2016

Adam Hale 9th October: NHS managers ‘used names of U2 band members to cover £700,000 fraud’ – The trio allegedly helped secure payments for building work which had ‘major deficiencies’ and cost £1.4m to rectify

Strand News Service: Boy left brain damaged by ‘negligent care’ at Welsh hospital is awarded millions in compensation  – The boy, who is now eight, suffered ‘catastrophic injuries’ in the first few days of his life

Doncaster, which cannot attract doctors easily. is taking matters into it’s own hands: NHS Trust looks to Doncaster school for future staff (BBC News 19th October)

NHSreality wonders if it was a doctor who first saw the young man in Tonbridge Wells: Tunbridge Wells man died after misdiagnosis of sepsis symptoms (BBC News 18th October)

And in the Isle of Wight: Isle of Wight hospital trainee doctors ‘left alone’. – Hospital patients on the Isle of Wight suffered as a result of trainee doctors being left to make decisions they were not qualified to make, inspectors said.

BBC News 22nd October: King’s Lynn QE hospital head quits following ‘inadequate’ report

Dennis Campbell on 21st October in the Observer: NHS £20bn boost risks being spent to pay off debts, experts warn – PM urged to write off £12bn in hospital overspending or extra healthcare will be unaffordable

Are we to expect rationing by anarchy? Will we repeat the lessons of the past?

NHS rationing and the Law by Warwick Heale in Devon

 

Are we to expect rationing by anarchy? Will we repeat the lessons of the past?

Tom Whipple in the Times 18th October 2018 reports: Lifesaving drug Spinraza, rejected for NHS, wins $3m prize

On the same day Chris Smyth reports: Hospitals earn £70m by making staff pay to park

and Alex Ralph reports: Stockpile now, medical supplier tells customers

What is the common theme in all these reports? The inability of the state to provide everything? NHSreality’s theme is that rationing has to happen, in any health system. Its just that it should be honest and overt, rather than dishonest and covert. Car parking is free in Wales, which means the doctors avoid subsidising their trust, and after a time, when their patent is near to expiry, new drugs are usually accepted. But the problems of systematic rationing could seem insignificant to the problems of anarchic rationing. If there’s no agreement on Brexit, patients with chronic conditions could be in trouble with the “just in time” supply system operating currently in the UKs 4 health systems. Rationing by anarchy is not a method I was expecting when NHSreality began…

…..Doomed to repeat? Lessons from the history of NHS reform: Nuffield Trust essays on what to expect from the imminent review.

 

Back to the future: Look again at what we used to do well – before it’s too late.

The care of Doctors, and their ability and time to care needs to improve. So does continuity of care….  This is not the work of one leader, or one health minister, although it is tempting to allocate blame.

Iona Heath (BMJ 2018; 362: k3187) writes a seminal and thoughtful essay: Back to the future – Iona Heath BMJ 2018.

Her last paragraph is worth reproducing, but before this she regrets the ending of continuity, and acknowledges the relative inefficiency of new pharma and technologies, Private Finance Initiatives, the conflict between the needs of society (populations) and individuals, and the need to reinstate teams that care for their patients, and for each other. She indirectly challenges the “free at the point of access” philosophy, pointing out that prescription charges and other co-payments are already in place (In England). She avoids talking about the merging of heath (free) and social care (means tested) and co-payments. She also fails to look at other systems, but her intent is clear. Look again at what we used to do well – before it’s too late.

….Things that should change

We all, professionals, patients, citizens and policymakers, need much more recognition of the limits of medicine and the intrinsic uncertainties of its practice. Applying general scientific truths to individuals will always have unpredictable results and, however sophisticated (and expensive) our technology becomes, all of us will sooner or later get sick and die. There is far too much false certainty in our simplistic descriptions of cause and effect and, when things go wrong, this makes it much easier to blame clinicians struggling to do their best at the frontline of care.

The longstanding democratic deficit within the planning, organisation, and regulation of the NHS needs to be acknowledged and tackled, perhaps through a system of elected regional government, in parallel with the devolved national governments. The deficit is in no way resolved by the current system of appointing the great and the good to the boards of NHS bodies and creating patient participation groups, however dedicated and worthy, because none of the participants are in any way accountable to a wider electorate.

So, let’s hold onto the best, change with more caution and care, and celebrate the NHS at 70.

Adrian O’ Dowd reports: Doctors need to improve their conversations with dying patients, says RCP – BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4330 (Published 19 October 2018) Cite this as: BMJ 2018;363:k4330

Doctors need to speak to patients with terminal illnesses in a timelier way and handle conversations with greater compassion and confidence, says a report from the Royal College of Physicians.1

The report, which examined why clinicians find it difficult to talk to patients about death, found that some doctors thought that death could be perceived as a failure and that modern medicine was expected to cure all ailments. However, evidence from patients and carers indicated that many people wanted to talk about death and that planning helped them feel more empowered about their care and decision making.

Almost half of all deaths in the UK are estimated to occur in hospital, and many patients admitted to hospital are in their last year of life. The college said it believed it was essential for doctors and other professionals to have the knowledge and skills to undertake sensitive conversations at an appropriate time when patients were ready.

The report was based on conversations with doctors at all levels, patients and carers, and medical organisations.

A range of clinicians from medical students to consultants said that they were uncomfortable about initiating conversations about the future with patients. Students and junior doctors had little practice with real patients and said that training did not prioritise the “soft” skills they needed.

Other barriers to talking about death included confusion over whether hospital doctors or GPs should be having the conversation, workforce pressures, lack of privacy, lack of prioritised time for conversations, and the need to be sensitive to different cultural and religious beliefs.

One key issue identified by the report was that healthcare professionals needed to begin conversations about planning for care at the end of life care nearer to when patients are given a terminal diagnosis. Early conversations give patients more choice and control over the remainder of their lives.

The evidence showed that patients who had these conversations and had care plans put in place had a better experience than those for whom the conversations came in the final days or hours of life.

The authors offer solutions and resources to help build clinicians’ compassion and confidence in this area of care and detail four case studies of hospitals that lead the way in supporting conversations about care at the end of life. The report highlighted the University Hospitals Bristol supportive and palliative care team for its Poor Prognosis Letter Project, a scheme that has enabled local GPs to identify patients approaching death more easily and earlier, so they can start discussing end of life care.

The Royal College of Physicians’ president, Andrew Goddard, said, “This report is a big step forward in helping patients, relatives, and doctors to talk honestly about death and dying.

“We must minimise the barriers in our systems and culture that prevent this happening. This is not just about palliative care in the final days but about having a series of conversations much earlier after a terminal diagnosis.”

Continuity of care in General Practice

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

GP Occupational Health – too little too late. Lack of trust may ensure the service is ignored.. Say goodbye to continuity of care…

New Models of Primary Care and the future of general practice: less continuity of care… bigger surgeries…. more foreign trained doctors?

GP A&E Triage – would be a good idea if we had planned for the numbers needed. We have not.. and GP partnership and continuity of care is in decline

Selecting doctors, and portfolio careers crossing from primary care to Hospital.

How do we end the culture of fear? Doctors and families must be able to work together for safer care….

Some countries are honest…. NZ has to ration dialysis

UK governments need to take note of the honesty of others.

Radio New Zealand reporter Gill Bonnett on 13th August 2018 reports: “We have had to ration dialysis” – Immigration NZ 

Some New Zealand dialysis patients have had their treatment rationed because of ineligible patients turning up for emergency care, according to government documents

However, the Ministry of Health says New Zealanders who need dialysis are not losing out due to ineligible kidney patients putting demands on the health services and Immigration New Zealand told RNZ there was no evidence treatment rationing was “currently happening”.

Documents obtained by RNZ from Immigration New Zealand (INZ) include slides from a presentation by its chief medical officer on the costs and demands on the health system, made in a meeting with the Immigration and Protection Tribunal last year.

Two pages discussed how some kidney patients were dying faster because their dialysis treatments had been cut back to allow urgent treatment of foreign patients.

Under the heading ‘Health Screening; Concerns’, one slide said “we have had to ration dialysis due to lack of resources to deal with demand.”

“When we get ineligible overseas patients turning up we are obliged to treat them urgently but we are often full in which case we will reduce the dialysis our existing patients are having in order to fit everyone one.”

INZs chief medical officer said at times staff said they have had to reduce dialysis sessions to twice a week and patients “get sick and die quicker” at that level.

INZ director policy integration and immigration Nick Aldous – in response to RNZ questions about the presentation – said there was anecdotal evidence of ineligible kidney patients, but did not say when it happened.

“The scenario [in the two pages] was based on anecdotal evidence from an earlier point in time. We don’t have any evidence that this is currently happening.”

The Ministry of Health on Monday said there was a small number of ineligible patients receiving dialysis but this doesn’t affect treatment for New Zealanders.

“People who need dialysis are receiving it according to clinical need.

“Dialysis services are under pressure because of the growing population as well as obesity and type 2 diabetes,” a spokeswoman said.

Patients ineligible for publicly funded healthcare include tourists, except for those from the UK and Australia, which have reciprocal health agreements with New Zealand.

However, detailed immigration medical assessments before visas are issued are not compulsory for many temporary immigrants.

And ineligible patients do not have to pay for healthcare costs upfront.

Official information

Slides from the INZ presentation, obtained under the Official Information Act, refer to the world-wide numbers of diagnosed diabetes cases, many of which come from New Zealand’s immigrant source countries in Asia and the Pacific. There are also a number of undiagnosed cases.

The slides also looked at the cost of mental illness among immigrants on the health system.

“We have had to stop training patients for home dialysis which has meant more hospital beds full up and at times we have had to limit patient dialysis sessions to two per week per patient.

“The minimum acceptable standard is three sessions per week, below that, patients get sick and die quicker.

“But we have had to ration dialysis due to lack of resources to deal with demand.

“So the care our patients receive is impacted when we are working above our capacity.”

Kidney Health New Zealand’s national education manager, Carmel Gregan-Ford, said dialysis was rationed a few years ago but she has not heard of it more recently, although ineligible patients are still an issue.

“I have people who ring me on the 0800 line who are telling me, coming from overseas, telling me they’ve got friends coming next week and they need a place to dialyse,” she said.

“And I say to them you can’t come, there’s nowhere you can dialyise and they’ll come anyway and present to emergency clinics and hospitals and they have to be dialysed, so I don’t know how that can be prevented.”

Immigration ‘scenario’

Immigration New Zealand director policy integration and immigration Nick Aldous said the presentation – referred to in the official information – was given in mid-2017.

He said the slides were part of a “scenario” designed to provoke discussion about health service costs and demands.

“It uses dialysis treatment as one example for the scenario.

“This scenario was based on anecdotal evidence from an earlier point in time.”

According to Ministry of Health guidelines, district health board renal services must all offer home dialysis.

The National Renal Advisory Board published guidelines on access to renal replacement therapy which says that home dialysis is most cost effective and provides people with the best quality of life.

In 2016, there were 2750 dialysis patients in New Zealand, but there is no data on how many were overseas’ patients.

About 400 people died while on dialysis in New Zealand that year.

It is not clear how many DHBs are affected, and by how much overall, although the three Auckland DHBs receive partial compensation from the Ministry of Health for the cost of treating ineligible patients for all health conditions, where the immigrant or tourist has not repaid that debt. Last year that was $5.5 million.

On notice

The comments on health rationing were made at an annual training session of the Immigration and Protection Tribunal.

The tribunal, which can overturn deportation on humanitarian grounds, had until last year commonly been granting immigrants needing dialysis temporary visas on appeal, to allow them to continue their treatment.

But in a decision in June last year, it put future appellants on notice that they should not presume that would continue and said it was preferable that they put their cases to the Immigration Minister.

And since then it has ruled in two cases that immigrants had exceptional humanitarian circumstances but said that was outweighed by the public interest in minimising health costs and upholding the integrity of the immigration system.

The most recent one, in April, ruled that a Fijian man married to a New Zealander but who failed the visa requirements and was going to be deported, can stay for a year so that he can sell land he owns to pay for dialysis or a transplant.

In a statement, INZ said it introduced eMedical in 2014, an immigration health screening system that allowed for greater oversight of applicant health information, better decision-making on applications, and the monitoring of health changes over time.

It said it had a Memorandum of Understanding with several district health boards, which allowed DHBs to confirm the eligibility of patients for treatment, and had been working with DHBs to improve understanding of the criteria for eligibility, and how they were applied.

– Editor’s note: This story has been updated with additional responses from government agencies and clarifies that treatment rationing isn’t happening currently, but has happened on a small scale in recent years.

Advances in Diabetic care are rolled out at different speeds in different post codes.

There is a history of rationing new advances in medical care differently in different post codes and regions. Some things are too important for this type of random care. If it was open and honest, and announced in advance, for some cheap services rationing is appropriate: but of course it is not allowed to be talked about. The perverse incentive for commissioners to get away with what they can is too great..

Judy Hobson in the Mail in 2010: The alarm that can save diabetics’ lives (so why is the NHS rationing them?)

Faith Eckersall reports in the Daily (Dorchester) Echo 12th October: Diabetics to confront councillors over postcode lottery – DORSET diabetics – including some children- will be part of a delegation at the county council on Wednesday to campaign for new testing technology free on the NHS.

Currently people with Type 1 diabetes must use the painful and inconvenient pin-prick method to check their blood sugar levels but Flash, which must be paid for in Dorset, works on a pain-free patch and scanning device.

The protestors are angry that despite the government’s NICE drugs and medicine rationing committee approving the use of Flash Glucose Monitoring on the NHS, Dorset Clinical Commissioning Group has not made it freely available, as has happened in adjoining health areas.

The CCG is running a six-month pilot of the Freestyle Libre blood glucose monitoring device for 200 people in three specific groups of diabetic patients in the county. But protestors point out there are 5,000 diabetics in Dorset who could potentially benefit and say no further testing or pilot is needed.

Diabetes UK south west regional head, Phaedra Perry, said: “The Dorset Clinical Commissioning group should make Flash available immediately to all people with diabetes in the area who can benefit, and not to just a very limited group of 200 patients for six months.

“Commissioners here are out of step with neighbouring CCGs which have agreed to prescribe it. Dorset is one of very few areas in the south west where Flash is not available and is effectively imposing a postcode lottery on diabetes technology.”

Changing a culture of fear, bullying and gagging…… Start again with local pride….

NHSreality feels that the culture in Westminster reflects the culture in the nationalised industries as a whole, and the health service being the biggest. It is also the biggest bully, with most fearful staff, and who feel most gagged… Starting again using local pride may help, but some areas may fail to recruit… Perhaps these should be the first to be released from the shackles of Political Interference. Co-payments should be allowed.

We cannot address the culture of fear without better management and it cannot come from inside. Even if the skills were there, which they are not, the staff would not trust them. We need an outside provided HR company to do “Exit interviews” on all staff and board members, and to report dispassionately and in a depersonalised way, at regular intervals. Somehow this needs to be amalgamated into an annual public report for localities, and regionally, and nationally. We need to hear the views of all staff who leave a job, move departments, or retire, or emigrate.

But then, you and I know what the result will be….

So at the same time, because we know the outcome, we need to be planning the changes necessary to reverse the decline. I admit that I cannot see the way forward, especially when the official line is “everything for everyone for ever” and no overt rationing applies. We are creating a dependency culture. We are discouraging autonomy. In work with the GIG economy we are creating a slave culture. I see several “Spartacus” like revolts ahead, and the destruction of the whole state health and social care empire unless we have much more honesty and much better leadership.

If we apply zero budgeting and allow local trusts to run themselves without any government interference, restraints, or banal performance indicators, we will get large differentials in health care, but morale will rise. Staff can feel involved and “begin to enjoy themselves”.  After a time best practices will emerge, and convergence of standards, but this will take a decade(s). Meanwhile we need to lift the restriction on medical school and nursing training places, so that we have an excess of staff, even allowing for the dropout rate. We need to acknowledge that no state cannot keep up with the advances in medical science, (see The NHS is being impeded by greedy drug companies ) and therefore we need to ration health care. Cradle to grave, without reference to means,……? The drug companies are out to make a profit, and it is not drugs which improve the health of populations. (See the USA) They do improve the outcome for individuals, but that is different. 

How we do this is the big debate which has not even started. NHSreality suggests means related co-payments, both for health and social care. Then there is the litigation…. without no fault compensation, the combination of reduced resources, short termism and declining standards (see baby death rate) will ensure more and more opportunities for citizens to litigate. Reducing tax relief on pension contributions is another tempting short term fix…  

Frances Gibb in the Times 15th October reports: NHS payouts to disabled children reach £100m in a day

Sofia Lind in Pulse 20th September reports: GPs should expect to be sued every 10 years, says defence organisation.

Tim Ship man reports in The Times 14th October 2018: Budget pensions threat to raise £20bn for NHS

Chris Smyth on October 15th reports in the Times: Baby death rate could soon be double that of western nations

The Guardian 15th October: Westminster MPs treated staff like servants, inquiry finds

BMA 20th September : Survey of UK doctors highlights blame culture within the NHS

BMJ October 12th: Creating joy in work is the only way to save the NHS

US Hospital to advise London on safety….. and what a terrible record their country has when treating populations

Traditional In-patient Hospices are not viable in small populations

 

 

Call to end NHS rationing of HIV prevention drug PrEP

Once we accept that we have to ration health care, we can start discussing how. Prevention can be expensive, and so can a lifestyle. NHSreality feels that means related co-payments would address this issue well, and even the poorest should pay something for prevention. Commissioners are not allowed to do this, anywhere in the 4 UK health systems, and the official line is that there is no rationing , and indeed we can provide “Everything for everyone for ever for free”.

The News and Star (Cumberland News) reports 12th October 2018: Call to end NHS rationing of HIV prevention drug PrEP

A charity has called for more gay and bisexual men to be given access to the HIV prevention drug PrEP, a year on from the start of a major trial into the treatment.

The National Aids Trust (NAT) said many men were being turned away from clinics, and some would contract HIV as a result.

Last year, a study funded by NHS England found that a quarter of new HIV cases in England could be prevented by giving high-risk men pre-exposure prophylaxis (PrEP) treatment.

The programme could save the NHS millions as a result of fewer men
getting infected and needing a lifelong supply of drugs to stop them
succumbing to Aids, researchers said.

The first clinic in the PrEP Impact trial opened on October 13 last year.

The three-year trial aims to provide PrEP to 10,000 people, but the NAT said all the allocated places for gay and bisexual men were filled by March.

Since then reallocation of places and a boost of a further 3,000 places on the trial has allowed clinics to reopen, but this provides only temporary relief, and it is expected that most clinic places will be filled up by early next year.

NAT chief executive Deborah Gold said: “PrEP is 100% effective at preventing HIV when taken as prescribed.

“NHS England’s decision-making process concluded that PrEP should be commissioned and just last month the cost of the drug has substantially reduced as a result of court judgments on the patent.

“It is therefore completely unacceptable for people in need of PrEP to be denied it by the NHS.

“NHS England and local authorities must urgently agree a national PrEP programme to start as soon as possible in 2019.

“The Government should play its part by increasing funding to public health so that we maximise the sexual health benefits of the PrEP programme.”

NHS England initially refused to pay for PrEP, arguing that responsibility for HIV prevention lay with local authorities.

It agreed to fund the study at selected clinics after a High Court judge upheld a judicial review application challenging the legality of the original decision.

The treatment involves a pill containing a combination of two anti-HIV drugs, emtricitabine and tenofovir, taken daily or around the time of sexual activity.

A spokeswoman for NHS England said: “While it would be wrong to prejudge the PrEP Impact trial, it is already expanding with the number of places available increasing this year by 3,000 to 13,000.

“The NHS will look at evidence from the trial to expand prevention services in the most effective way.”

170,000 victims, and nobody takes the blame!! Typical of a nationalised health service…

Just as we need to change the onus of proof on Agricultural products, we need to do the same with non drug medical products. The licensing of the mesh repair products is a case in point, and all 4 health systems should be ashamed of not reporting side effects and complications systemically (all together). The reporting of such problems is just one reason for a large mutual in health. Devolution means smaller numbers and lower standards. The commissioners and the Trust Boards are all to blame, but so is central government. Will any careers be finished? They should be.. Mesh is a foreign body, and as such the default is rejection, and possible infection.

Hernia mesh complications may have affected up to 170 000 patients, investigation finds ( BMJ 2018;362:k4104 )

Up to 170 000 patients who have had hernia mesh operations in the past six years could be experiencing complications, yet NHS trusts in England have no consistent policy for treatment or follow-up with patients, an investigation by the BBC’s Victoria Derbyshire programme has found.

Around 570 0000 hernia mesh operations have taken place in England over the past six years, figures from NHS Digital show. Leading surgeons think that the complication rate is between 12% and 30%, meaning that between 68 000 and 170 000 patients could have been adversely affected in this period.

Patients who had had hernia mesh operations told the programme about being in constant pain, unable to sleep, and finding it difficult to walk or even pick up a sock. Some patients said that they felt suicidal.

The Department of Health and Social Care and the Medicines and Healthcare Products Regulatory Agency (MHRA) continue to back the use of mesh for hernia repair. The use of surgical mesh for stress urinary incontinence is under ongoing review after it was suspended in July in response to pressure from campaigners and MPs.1 Campaigners are calling for a similar review into the use of hernia mesh.

Owen Smith, a Labour MP who chairs the all party parliamentary group on surgical mesh implants, said that he feared the UK could “potentially have another scandal on our hands.”

He added that the MHRA was not doing enough to listen to the experiences of patients affected. “It reflects the flawed system we have in place,” he said. “Neither the regulators nor the manufacturers have to follow-up on problems.”

Ulrike Muschaweck, a private hernia surgeon, told the programme that she used a suture technique instead of mesh for most hernia operations, but this method was dying out because young surgeons were rarely taught it. She said that she had performed 3000 mesh removals because of chronic pain—after which only two of the patients had not gone on to become “pain-free.”

Suzy Elneil, a consultant urogynaecologist who was a leading voice in the campaign to halt the use of vaginal mesh, said that the mesh used in hernia was the same product. She estimated that treating those who have had complications with hernia mesh would cost a minimum of £25 000 (€28 000; $33 000) a patient—a similar amount to that predicted for vaginal mesh complications. This includes the removal of the mesh, a further operation to treat the hernia, and follow-up care. She said that the manufacturers should be covering the cost rather than the NHS.

The Royal College of Surgeons pointed to a 2018 study, which found that both mesh and non-mesh hernia repairs were effective for patients and were not associated with different rates of chronic pain.2

A spokesperson for the college said that “complications range dramatically from minor and correctable irritations to the more serious complications highlighted [on the] programme. Complications can also occur with non-mesh hernia repairs and by not operating on a hernia at all.”

They said that the college and regulatory authorities would continue to listen to patients’ experiences. “It remains vital that surgeons continue to make patients aware of all the possible side effects associated with performing a hernia repair,” the spokesperson said.

Kath Sansom from campaign group Sling the Mesh told the programme that a lot of the studies into complications were flawed or had short follow-up times. Quality of life questionnaires, for example, asked only about whether the hernia was fixed and not about new onset pain or other complications.

In a statement, the MHRA said: “We have not had any evidence that would lead us to alter our stance on surgical mesh for hernia repairs or other surgical procedures for which they are used. The decision to use mesh should be made between patient and clinician, recognising the benefits and risks in the context of the conditions being treated and in line with NICE guidance.”

An MHRA spokesperson added, “We encourage anyone—patient, carer, or healthcare professional—who is aware of a complication after a medical device is implanted, to report to us via the yellow card scheme, regardless of how long ago the implant was inserted.”

Ethicon Proceed Hernia Mesh Lawsuit Filed Over Unreasonable Risk Of Failure, Injury

… following hernia repair with an Ethicon Proceed patch have resulted in a product liability lawsuit against the manufacturer

Information on Bard Hernia Mesh Problems to be Presented to MDL Court

…

Hernia mesh operation ‘made me contemplate suicide’ says father-of-two, 57

This was caused by what should have been a simple 45-minute operation to fix a hernia … of patient filed lawsuits. “For the ..

If Nurses fill the gaps left by the shortage of GPs, this will be the start of private practice in many towns..

Most GPS will be too busy to read or reply to Mr Darzi. As a retired GP I feel I have to reply. The letters from the Times’ replies are in the pdf below.

It seems a little ironic for a surgeon, who deals with operations and definitive outcomes, to comment on General Practice. The good GP uses time as a diagnostic tool, lives with uncertainty and handles patients with multiple symptoms and often multiple diagnoses.

Failure to train enough doctors is one problem. Training a disproportionate number of females to males is another. Making the job more and more desk bound and administrative is another. The shape of the job has changed a lot, but given time, appropriate training, and backup of a good team it would still attract. GPs need broader training especially so that all of them have the same opportunities in Paediatrics and Psychiatry, and Old age medicine and rehabilitation.

Doctors are trained to think laterally and make a diagnosis. The training takes a long time but why has only 2 out of 11 applicants been successful over the last two decades? Rationing places at medical school has now killed the goose that laid the golden eggs of efficiency. Nurses will probably refer more, request more tests, follow up more, and may well make more mistakes. The litigation will follow…

And will this mean that unpopular areas retain GPs, whilst unpopular ones have Nurse Practitioners? A health divide if ever there was one, and an encouragement for private practice.

Ara Darzi opines in the Times 9th October 2018: Nurses can fill the gaps left by the shortage of GPs

Primary care and public health are becoming even more important as the population ages, diseases change and the need for long-term community care grows. Yet at the same time, this work is becoming increasingly unpopular with doctors.

To add to the problems of retaining GPs, a survey of general practice trainees carried out this summer by the King’s Fund, a health think tank, found that only a fifth planned to be working full-time a year after qualifying. The proportion planning to be working full-time after ten years was the same.

This is an astonishing vote of no confidence. Like many of their generation, young GPs want a portfolio career. They want to be involved in research and education; the prospect of owning and running the same practice for the next 30 years is a million miles from what most hope to do with their lives. They are not alone. Surveys show a similar trend across the world, with fewer than 10 per cent of physicians choosing family medicine in some countries.

Here, then, is an opportunity for nurses. Advanced practice nurses, also called nurse practitioners, are as effective as doctors at many tasks and, according to one study, could take on 70 per cent of GPs’ workload. Their main areas of expertise are in the management of long-term chronic conditions such as diabetes; they can diagnose, treat, prescribe and refer patients to hospital, and admit them if necessary. There are limits to their responsibilities (they don’t treat children under five or expectant mothers and they can’t sign sick notes) but they are acceptable to the public, take less time to train and cost less than GPs.

A report by a group of international experts, to be presented at the World Innovation Summit for Health in Doha next month, which I chair, will argue that nurses are poised to become the dominant force in primary care. They tend to live in the communities they serve, understand the local customs and culture and are well placed to detect early signs of disease and help tackle the wider social determinants of health.

There is a growing recognition that nurses are well suited to provide the sort of patient-centred care that is needed to look after the rising numbers of people with chronic diseases such as cancer, heart failure, diabetes and dementia.

There are barriers. Improved education, recruitment and commitment from employers will be required. But if we are to solve the crisis in primary care, we must urgently look to positioning nurses as the new gatekeepers of the NHS.

Professor Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London

Doctors to see groups of patients – is probably madness. The fox is waiting..

Letters in reply to Mr Darzi