Just for Health – “MPs must be brave and tell us we were wrong”

The idea that a political opinion on Brexit might be in this website did not occur to me – until I thought about the link between wealth and health. Matthew Paris opines in the Times 29th December: “MPs must be brave and tell us we were wrong“, and points out that we are already in the last chance saloon as far as the timetable, already concertinaed by Mrs May, is concerned. “There are only a few weeks left now for the vast, sensible majority in the Commons to acknowledge that voters were wrong”.

Ok, so it applies to more than health: the risk of war, trade, fishing, defence, the young v old divide (who’s going to die first?) and to a liberal Europe united in ideology and philosophy, apart from political, fiscal/monetary and linguistic union. But NHSreality says that, just for health, its worth thinking again. This does not mean that the other omissions such as honesty and rationing, fear and bullying, whistleblowing protection and graduate entry to medical school don’t need addressing. But Brexit overrides all of these in immediacy.

An ennui hangs over British politics and the prime minister is depending on it. Like a thin, wearisome fog it does not quite obscure but it blurs and greys, softening edges and dulling our reactions as we head into the new year. Brexit? Oh, for God’s sake. Haven’t we done enough of that?

No we have not. These very few weeks ahead, these weeks when change is still possible, await, still fluid, before everything fixes. Yesterday I watched a grim little video from the Home Office telling EU citizens legally resident here that they will have to make a new application to confirm their status. The Leave campaign promised this would not happen. I felt, again, so ashamed of where our country could go.

These are the last days and this is the last time when, looking back and perhaps by then impotent, we shall understand it still remained possible to stop this thing. Little more than three weeks are left for MPs to choose. It is so important that at this critical stage moral courage does not ebb.

In all animals, including the human kind, the anaesthetic power of an imminent and, once taken, final step is curious. An approaching moment of truth has a weird potency to tip us straight from “not yet” to “too late”. The approach up the aisle to the altar is hypnotic. Mad wars, marriages and investments have been entered upon for no better reason.

We’re very close now to tipping over the edge: an edge which (as I wrote here last week) will be no cliff but the start of a decades-long and one-way slide down a long and gentle slope, pushed by a generation of foolish old men who will soon enough be waving goodbye to the younger generation they’ve been kneeing in the back. MPs must think again before it’s too late. Westminster needs one big, final slap about the face, one big inrush of cold air into the festive torpor.

I exclude from this discussion that minority of parliamentarians in all parties who genuinely want a “proper”, “clean-break” Brexit. There is no arguing with faith. But it’s doubtful their numbers amount to so much as a quarter of today’s House of Commons. Among commentators too much time has been devoted to reading the runes of their various undertakings to sink (or not) Theresa May’s European exit deal — and, to be sure, if they act as a bloc they can.

But life is too short to deconstruct the mental processes of Peter Bone, MP. I’m permanently wary of relying on Brexiteers’ pledges to block the prime minister’s chosen path because were I them I would fear it could prove the only Brexit available. They may well cave in, to live today and make trouble on the other side of March 29.

Nor should we waste time beating our fists against Jeremy Corbyn’s “irresponsibility”, “procrastination” etc. Fate has handed this leader of the opposition a rare gift: the chance to see the achievement of something he has always wanted, but which he knows may prove a vote-loser — but with the Tories, not his own party, blamed for it. “After you, Theresa,” makes so much sense for Corbyn that he must be discounted as an ally.

So put aside Corbyn and the old-fashioned hard left. Put aside the Tory “European Research Group” zealots. It is to the rest, the more than 400 MPs who are deeply uneasy about where we’re going, that we must turn. Where are they?

Let them try this simple thought experiment. The UK does not have to hold a referendum before entering or dissolving a major international treaty. So imagine our government had been minded to leave the EU with no referendum. Having negotiated draft terms, they now present parliament with essentially Mrs May’s proposals. These are (remind yourself) that unless or until we can work out something better, we remain an economic satellite of the EU, unable to strike our own trade deals, but losing our place on European decision-making councils, our membership of its trans-national projects and institutions. “Here’s my plan,” says the PM to parliament. “Shall we proceed?”

Do you imagine a single MP in any party would vote for it? Would a single newspaper, a single media commentator, a single think tank or research body, recommend acceptance? Of course not. All sides would throw up their hands in horror of such a mad idea.

So it’s all about the 2016 referendum, isn’t it? MPs are being asked to approve a huge change for our country in 2019 that they would never have dreamed of touching, were it not for a referendum in 2016. Fair enough, but be honest about it: we’re doing it because the voters asked us to. We do not, however, believe the voters reached the right decision.

Why does this era have such difficulty in saying that last sentence? Surely the whole idea of representative rather than “direct” democracy is to provide counterbalance against a sometimes faulty popular judgment.

Everybody knows that the people can sometimes reach the wrong conclusion because we know that we ourselves sometimes do so. Who doubts that popular opinion in the 1930s was wrong to favour appeasing Germany? Who doubts that in the 1950s the public were wrong to cheer on politicians towards the Suez debacle? The public, for a while, have been wrong about many great issues: slavery, hanging, flogging, the imprisonment of homosexuals. So if you believe in democracy you should believe in so much that must come with it: persuasion; a little foot-dragging; re-thinking; give and take on both sides. Politics negotiates with popular opinion: it doesn’t just take dictation.

Our present impasse offers unusual scope for negotiation with the electorate. We did instruct government to negotiate Brexit but there’s no reason why, nearly three years later, we can’t be asked to judge the result. Are so few MPs ready to square up to their voters and use the language of second-thoughts?

I worked for the Commons of 1974 and was a member of the Commons of 1979 and 1983. Today’s MPs are as bright or brighter, as honest or honester, and wonderfully more diverse, than those earlier parliaments. But, then, we believed in ourselves. Perhaps we were too pompous. But there needs to be a reserve of self-respect if not self-regard among today’s parliamentarians. Grave decisions face them over the coming days; without self-belief, they may not rise to the occasion.

 

Can the NHS be saved? Only with different local and global thinking, and changing the “rules of the game”.

All of us in the caring professions know the answer to this question, and indeed that there is no “N”HS any longer. The Guardian knows the answer….. Iain Robertson Steel, a retired medical director acknowledges the problem (But suggests no answer/solutions), but on 26th April  in the Western Telegraph I suggested a “fourth option” for people in Pembrokeshire.  This last is only for local needs, and a letter suggesting a global rethinking was in the Western Mail 25th Jan 2018 is at the bottom of this post. What can save the 4 health services is not clever reorganisations, but an honest debate on overt rationing, and making it clear to everyone what is not available free, for them. ( Changing the rules of the game )

Can the NHS be saved? The Guardian – Dennis Campbell – 

…the Guardian’s health policy editor Denis Campbell spent a day in King’s College hospital in London. He found staff and patients who are devoted to the NHS but who can also clearly see what is needed in order to sustain the service for future generations.

A long-term plan designed to secure the future of NHS England has been delayed once again by Brexit. But as Britain’s health service heads into its annual winter beds crisis, the Guardian’s Denis Campbell visits King’s College hospital in London to find out what staff and patients need for the future – and how much it will cost. 

“The Welsh NHS and social care is a shambles and no longer sustainable or fit for purpose.” Dr Iain Robertson Steel in the Western Telegraph 7th December.

Health service needs to be remodelled Western Mail 25th January 2018

From the perspective of west Wales there is no British health service.

I do not have access or choice to anywhere outside my own rural trust (Hywel Dda) unless the service needed is not available here. Even a second opinion has to be within the same trust.

There are four, and possibly five health services if Manchester is included. The WHO has said it will no longer report on an “NHS”.

The lack of choice, the covert rationing, and the unequal access to tertiary centres, primary care, and palliative care threaten to bring on civil unrest.

A Welsh mutual of three million people cannot offer the same quality of healthcare as one of 60 million. Even if the Welsh Government has tax-raising powers, there are not enough taxable earners to rise above the decline.

We seem to have forgotten the power and improved health outcomes in large mutuals. Since the UK’s health service has to be refashioned, now seems a good time to unify again, and re-establish the same rights across the country.

Increasing taxation to pour more into a holed bucket should not appeal to most taxpayers.

We need a new health insurance system (the original NHS was insurance based) and the caring professions will remain cynical until what replaces “in place of fear”, avoids bringing it back.

Dr Roger Burns

Haverfordwest

Pembrokeshire GP urges a “fourth option”. Western Telegraph 26th April 2018

The finances are in such a mess, that local post code and unexpected rationing is everywhere… The “Rules of the game” need to be changed…..

Changing the rules of the game

 

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Distracted by Brexit… There is plenty of evidence that Social Care is breaking down, and with the loss of the opportunity to import EU workers, the staffing issues will only get worse. Government in Westminster, following reports from Wales and Scotland, has promised a review of the funding of social care (and by implication, Health as the budgets are being combined), but they have failed to do this in their own time line which was before Christmas. A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. Even the IFS (Institute for fiscal studies) admits its a bust.. 

We have to earn profits as a nation to afford social care and health care, but the current account deficit is getting worse, despite the promise from Brexiteers that a lower pound would help exports. (Huge current account deficit is a worrying backdrop as Brexit nears – Oliver Kamm in the Times 24th December 2018). 

The media’s failure, and the political denial will get worse. NHSreality predicts that when the health and social care review is published, that it will try to pretend that we don not need to ration health care. It will ignore the fact that social care is means tested and health care is not, and it will allow post code blurring of the margins between these two. 

Paul Johnson in the Times 24th December opines in  Vital social care needs are ignored in obsession with short-term expediency  “….This is a long-term failure of government. It is a perhaps a sign of the fact that we have come to expect nothing better that I have seen little or nothing in the mainstream press in the past few weeks bemoaning yet another failure to deliver on a promise simply to publish a set of policy ideas for consultation. Perhaps we have just given up…” (Full text below)

Jan 2018: Parliamentary Review of Health and Social Care in Wales Final Report

The Nuffield Trust: Health & Social Care in the UK | Research Reports and Analysis

Charts and Infographics (Nufield Trust)

NHS deficits  (Nuffield Trust)

The Institute of Fiscal Studies reports 2018: A review of the Department of Health and Social Care’s Funding …

Jan 2018 in the Guardian – Delay in the Green Paper…

The Berwick report in 2013 criticised the lack of “compassion”, and it has got worse since then.

Vital social care needs are ignored in obsession with short-term expediency – Paul Johnson in The Times 24th December 2018

The whole article is below:

Paul Johnson Vital care needs ignored

As Robertson Steel said in his valedictory piece, its all down to politicians and the “rules of the game”.

Dr Robertson Steel letter (exit interview) for Western Telegraph in Pembrokeshire

Scotland’s Health Services are bust. No wonder the reporter suggests a visit to Delphi…..

On October 14th Gillian Bowditch reported in Scotland for the Sunday Times: Scots NHS bosses are at heart of Greek tragedy – Management exodus is predictable given the self-inflicted financial wounds – 

It is up there with spinning hair into gold. Accepting a position as an NHS manager is a job at which Sisyphus himself would balk. It used to be a task that was merely thankless; these days, it appears to be verging on the impossible.

Last week it was revealed that seven NHS chief executives had resigned in a matter of months, and that almost half of Scotland’s health boards were losing their most senior manager. Some have jumped, others have been pushed. Most are reported to be leaving without another job to go to.

NHS Grampian, NHS Tayside, NHS Borders, NHS Highland, NHS Orkney, the Golden Jubilee National Hospital and the State Hospital are looking for new bosses. If you are applying for the role, take your pick.

Do you go to the board that was forced to raid the charity teddy-bear fund to pay for a new IT system? Or do you opt for the one where bullying is said to be endemic? In terms of prudent financial management, there is not much to choose between them. Fiscal incontinence is a recurring theme.

The crisis in NHS management is entirely predictable and, indeed, predicted. Every health care system in the world is under pressure, but in Scotland, several factors have conspired to create the perfect storm.

Scotland splashes out on services such as free prescriptions and free care for the elderly, which England deems unaffordable. At the same time, enforced annual efficiency savings of 3% for several years in the face of growing demand for services have resulted in a system with little or no slack. Successive governments’ faith in stricter financial controls has ultimately proved to be naive.

Ministers will point to an increase in overall staff numbers, but when you break down the figures, administrative staff outnumber doctors and non-nursing medical staff by two to one. The NHS is being managed to death.

But the most pernicious factor has been the decision by government to interfere with the Barnett consequentials. Under the Barnett formula, if Westminster adds £10m to the pot, Scotland gets £1m without asking for it. The understanding has been that if the cash is generated by healthcare south of the border, it is spent on healthcare in Scotland. This link was broken for the first time under the SNP, and it has been broken more than once.

NHS spending in Scotland at £13bn a year accounts for about 40% of the total Scottish budget. The government insists it is committed to protecting the health service with record investment, and that it will increase the frontline NHS budget by almost £2bn by the end of this parliament.

According to the Conservatives, however, HM Treasury figures have shown a 9% increase in health spending in England compared with a 3.4% increase in Scotland between 2011-12 and 2015-16. Last year, Scottish health boards were asked to save £500m, 4.8% on average and a 65% increase in real terms on 2016.

We have now reached a point where the new health secretary, Jeane Freeman, has been forced to declare a £150m fiscal amnesty for badly managed health boards. In an acknowledgement that some health boards will never be able to repay their brokerage loans, which have been stacking up over time, she has abolished all the debt in a single sweep. There will be a clean slate for 2019-20.

It may be a pragmatic gesture, and the accompanying decision to move to three-year rolling budgets will give able financial controllers more flexibility. But boards unable to manage an annual budget are unlikely to find they can manage a three-year budget. It is also a slap in the face for managers in more prudent health boards who have absorbed huge amounts of stress to balance the books.

There is a democratic deficit within the NHS. The culture within management is often unhealthy, as shown by the regular concerns about bullying. NHS Highland, where four senior doctors have signed an open letter calling for intervention, and NHS Tayside are just the latest to have their dysfunctionality exposed. Senior managers, many of whom have come up through the nursing ranks, often act as though they are accountable to nobody.

At the same time, Scotland has a health service that is tightly controlled by politicians. Clinicians and managers are used to edicts from on high that increase their workload, distract doctors and nurses from the core job, rarely deliver the intended results, and come without any funding.

In an article I wrote for The Sunday Times in 2011, I quoted Margaret Hannah, then deputy director of public health in NHS Fife. At the time the Scottish NHS was facing the dreaded annual 3% efficiency savings.

“The evidence of history suggests this level of financial restraint within the NHS will prove impossible,” Hannah said at the time. “The sums will not add up. And the consequence may well be dramatic, enforced, permanent cuts in services in two or three years from now. Without radical innovation, this is a system in a state of terminal collapse”.

Sisyphus may find running the NHS beyond him, but you don’t have to be the Oracle at Delphi to work out what happens next.

 

The Brexit deadline and the Health Services planning – standards and services are going to get worse..

All four UK health services have been asked to plan ahead. Whilst everybody’s attention is elsewhere, the collapsing standards, in both delivery and training, are affecting morale very deeply. Many doctors and nurses are using their qualifications to travel – away from the UK where they feel more valued. In a “world market” this is inevitable.. the only rational response is to train more people in our own country. Meanwhile,, it’s going to get worse. We don’t just need to ration around the March deadline, we need to ration continuously…… Watch for an expansion of private care, including emergency departments, and extension of the demutualisation of the former “N”HS.

Andrew Gregory reports 23rd December in The Sunday Times: NHS told to review operations and staff holidays as Brexit deadline looms

The government has ordered NHS chiefs to “review” the holidays of more than 1m staff as it urges hospitals and GP practices to “ramp up no-deal preparations” for Brexit.

Every NHS organisation has been told to appoint a senior official responsible for contingency planning “as soon as possible”, according to guidance from the Department of Health and Social Care. They have also been instructed to see how many operations are planned for the final weekend of March and “be ready for further operational guidance”. The 34-page document, seen by The Sunday Times, is stark and detailed. It sets out action that NHS service providers should take to prepare for a no deal — in areas including staffing, regulation, finance and the supply of medicines.

In one section, providers are ordered to “review capacity and activity plans, as well as annual leave, on call and command and control arrangements around March 29, 2019”.

The document adds: “There is no ask [sic] to reduce capacity or activity around this time”, but with the caveat “at this point”.

Some NHS officials were dismayed that the guidance had arrived so late. It was issued on Friday afternoon — three months before Brexit Day and just before Christmas, as winter pressures begin to bite.

“We needed this in September, with six months to go, not December 21,” one official said.

NHS groups across the country face complex challenges if there is no Brexit deal.

Hospitals in Kent fear that gridlock on the roads around Dover could stop doctors and nurses getting to work. There is also concern about whether deceased patients can be moved quickly enough to body storage facilities.

NHS officials in London are worried about an exodus of social care workers from the EU after Christmas, which could have a significant impact on the health service. Saffron Cordery, deputy chief executive of NHS Providers, which represents NHS trusts, said: “Obviously, it’s immensely helpful to have guidance from government on how trusts should start to plan for a no-deal Brexit.

“Trusts have been keen to receive this for some time and were expressing concerns as far back as the summer about the need for national guidance.”

The health department said: “We are working closely with NHS trusts, relevant companies and their supply chains so patients can continue to access healthcare services and medical supplies in the same way they do now.”

A naturalised and retiring consultant airs his views – the implications are stark. We have not trained enough doctors, and we could lose many of those we have attracted.

A letter in the BMJ : Uncertain times for EU doctors

I qualified as a doctor in Italy in 1982 but felt I wanted to gain some experience in a different healthcare system. In January 1985, I moved to the UK with my then Italian girlfriend who is now my wife. My first proper job was in Stockport as a pathology SHO, whilst my wife started a paid PhD in electronic engineering at the University of Manchester.

I would not have come to work here if the UK had not been part of the EU. The recognition of my medical qualifications and the fact that no work permit was required, for both myself and my girlfriend, were important factors in our decision. Perhaps more importantly, I did not feel I was a migrant.

At the time, I was an EU citizen moving into a fellow EU country under freedom of movement. I then worked as a microbiology registrar in Oxford and as a senior registrar in London. In 1996 I took on a microbiology consultant post in Sunderland, where I have worked since.

By this stage it was apparent we would not go back to Italy, so both myself and my wife acquired British nationality in order to have the full right to vote and to feel full members of British society.

All four of us, including our two sons, have dual British and Italian nationality. I define myself as a British Italian and have now spent more than half of my life in England.

After the Brexit vote in June 2016 I was gutted. I felt as if I had been personally rejected from my adoptive country. Had I made the wrong choice when I moved to the UK in 1985? Two German colleagues of mine, both consultants in my hospital, left in 2017 to go and live in France. This is not really an option for me as I am close to retirement and my two sons have grown up and work here. Although I am sure had this happened some years ago then this may have been different.

Initially, I did not quite understand why Brexit had happened. When I moved into the UK, I did not feel the local culture was very different from my culture; maybe my lasagne recipe is slightly different, but the fundamental values and professional standards are the same.

It is discouraging to think that maybe I was wrong about this. Perhaps all this time myself and others like me were perceived as EU migrants and ultimately, as a problem. I personally think we all have to do our bit to improve society. As a result of Brexit, I have now joined a political party and have started campaigning for a People’s Vote.

I am retiring next year but I am going to carry on doing things with others, hoping to achieve a greater good. I find all of this helps with morale. Despite what our Prime Minister recently said, I do not think I jumped any queue in 1985.

Dr Giuseppe Enrico Bignardi is a microbiology consultant working in Sunderland.

The thin edge of the wedge. Is private A&E going to thrive and become the shape of the future? Aneurin Bevan, what would you do?

Chris Smyth of The Times reports on the first Private A&E in London, (The private A&E will see you right now) and the leading article on the 15th derides the change. This development has been predicted by NHSreality for some time now, and the two tier unofficial health service is here. Politicians and the Media seem to conspire in a collusion of impotence. Is health just too toxic a subject for UK citizens to address? Nobody copies us now, and those that did have realised their error and changed the funding basis to be founded in reality rather than in the clouds.….”

Is Primary care to follow dentistry? Rather than Denplan, will GPplan to be marketed soon? The whole aspect of removing fear has been denied. We are bringing back fear… Those interested might like to read Bevans chapter 5 at the end of this post.

The Times view on private medical care: expansion signals a health service in trouble – It is the failures of NHS provision that are generating demand for private treatment

We report today that patients are increasingly turning to private provision for this care.

This is not only a rational decision for those patients who can afford private treatment for accident and emergency. It also has public benefits by easing pressures on the health service. Though it will be tempting for policymakers to rail against the emergence of a “two-tier” system, it would be more constructive if they focused on the failures of NHS provision that are generating the demand for private treatment.

The market for private provision of non-urgent operations is established. But demand for these services, generally known as casualty, emergency and urgent care units, suffered in the early years of this decade after the financial crisis of 2007-09. Even so, about 11 per cent of Britain’s population has some form of private medical insurance. The principal gap in these policies is that they do not provide cover for accident and emergency.

This is not because emergency treatment in the health service is so good that no one would want to go elsewhere. On the contrary, waiting times in hospitals are too long and getting longer.

We just cannot have Everything for everyone for ever. 

The Times article and leader are below:

Private A&E London Private AandE London

In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

Surgery waiting lists at ten-year high. The perverse outcome is a two tier society…

 

 

We are going to spemnd more and more on private health care…. if we can afford it.

Remember that governments priority is not the same as doctors. They treat populations. Doctors treat patients. So prevention is better than cure: does this mean we should allocate our resources differently? David Buck reports for the Kings Fund. 

The book Factfulness by Hans Rosling teaches us to be sceptical of single facts, and to ask more questions. But the headline from the Times (Below) could have read “Patients pay £1bn to choose their specialist, or to avoid complications, or to have surgery when they want it”. There are many reasons people choose to go private, and nobody (I hope) is suggesting choice is removed in the UK. This would simply drive the services offshore… there is always a perverse outcome in health. Of the 3 health services which used to fund everything free 30 years ago, Scandinavia and New Zealand have accepted that this is an impossible aspiration. £1bn means £500 each (average). This is less than 1% of the total health budget across all 4 health systems. But we are going to spend more, and an unofficial two tier system is evolving. 

Only this week I have seen friends with problems that need surgery, and one of these is in my view an emergency with neuro-compression signs. Yet the Welsh Health service (post codes) can only offer an operation in a month, having delayed for 3 already. Nobody, surgeon or administrator has suggested that there might be another region with a shorter wait, or more capacity to fit him in. Choice is severely restricted in Wales… as the money moves with the patient. The operation is not available privately, so this is exactly the sort of thing the health services need to cover. The patient is still working, and should have ten more years of work possible….

Chris Smyth in the Times 13th December reports: 

Private Patients spend £1bn to jump NHS queues (whole article)

The NHS budget, and how it has changed. The Kings Fund.

When the NHS was launched in 1948, it had a budget of £437 million (roughly £15 billion at today’s value). For 2015/16, the overall NHS budget was around £116.4 billion. NHS England is managing £101.3 billion of this. For more detail on the NHS budget, visit the GOV.UK website.

 

Poor handovers and rota gaps are a sign of problems with training, says GMC

As standards fall, and numbers of staff prove inadequate, thr quality of those being trained may also fall. Add to this the importing of doctors from overseas, especially form countries who really need them, and reducing the standards of both language and qualification needed, as well as letting in unqualified [suchiatrists, and we have a recipe for steep decline.

Poor handovers and rota gaps are a sign of problems with training, says GMC BMJ 2018;363:k5104

Junior doctors who experience problems with handovers and rotas may not be getting the quality of training and support that they should be, the General Medical Council has said.

The two aspects of work were highlighted in the GMC’s 2018 national training survey as pressure points which were signs of heavy workloads and could affect patient care.1

The survey was sent to all doctors in foundation, core, and higher specialty training programmes and 51 956 trainees responded (a 96% response rate).

It found that of the 4712 (9.1%) trainees who said that their daytime workload was very heavy, 13% felt that handover arrangements did not always ensure continuity of care for patients …

Because they have not trained enough:

Government to relax immigration rules on overseas doctors

May heeds pleas from cabinet colleague to scrap ‘absolutely barmy’ caps on staff

The problem of non-attenders. There has to be a penalty… the denial of equal access to tertiary specialist care could be addressed by combining rural trusts, such as Hywel Dda, and Swansea.

Today in the Times 2 Letters: The good Samaritan approach that has led to a non functioning and disrespected system is the one below. The “hard cop” approach is first, and I have reversed the order that the editor chose! There has to be a penalty. In other countries there are much more financially affordable systems, and their life expectancy is little different. Putting state money into the expensive medical treatments (both in the developed & developing world) is of little benefit in extending life expectancy of the population, because we are at the top of the “gapminder” graph (real time today). Now look how the picture has changed in the last decade, since 2006. What makes populations healthy is wealth. We have enough money to afford an Irish or a Swedish style system, where there are co-payments for those earning enough, and punishments for abuse. The “hard truth” is that, without encouraging autonomy and discouraging paternalism, the health service is impossible to maintain. 

In the last two weeks the local Western Telegraph Newspaper has had two reports. One is with myself (Dr Rger Burns Illogical not tto have a hospital in Pembrokeshire, and Dr Robertson Steel, who mostly agrees with me. He wants reorganisation, but fails to address the issues around rationing and money. Dr Robertson Steel exit interview. The report is in fact a form of exit interview, and one wonders if he would have said it when employed, and kept his job. His article is titled “NHS challenges need to be faced by government”, but does not suggest how to combine a means tested social care with a free medical care, and make it work.

We already know that rural areas are being cheated when compared with cities, and now we know that life expectancy (In Scotland) is 5 years lower in the rural parts. Some of this is due to access, some to stoic people, and some to poorer education. But the denial of equal access to tertiary specialist care could be addressed by combining rural trusts, such as Hywel Dda, and Swansea. 

Notice the change in the slope of the graph (its nearly flat now(, and the lowest life expectancy (50 in the Central African republic) compared to 40 a decade earlier.

DOCTORS’ DILEMMA

Sir, In Sweden, if you fail to attend or fail to cancel an appointment with a healthcare assistant at least 24 hours beforehand, you can expect to be charged 100 SEK — or about £9. If you fail to cancel an appointment with a doctor, it’s 300 SEK. It concentrates the mind.
Michael Storey
Wokingham, Surrey

Sir, Some 25 years ago I analysed the “Did not attends” (letters, Dec 10 & 11) in my hospital outpatient clinics and a minority could be blamed on patient apathy. Many had serious other commitments but more had never received the appointment in the first place. Booking systems should write in an overbooking of 10 per cent. It’s good enough for airlines.
Dr Andrew Bamji
Rye, E Sussex

[PDF] Cancer Incidence and Cancer Mortality by Urban and Rural areas (2007) Wales

Daily Mail 12th December 2018: Living in the countryside gives you a ‘survival disadvantage’

The Times December 13th: Rural cancer patients less likely to live

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People living in rural areas are less likely to survive cancer than those in cities, according to a global review.

Researchers examining 39 studies found that 30 of them reported a “clear survival disadvantage” for rural inhabitants compared with those living in urban areas. Those living in the countryside were found to be 5 per cent less likely to survive cancer than their metropolitan counterparts.

The research by the University of Aberdeen suggested a number of reasons for the discrepancy, including transport infrastructure and distance from health facilities. As most services in developed countries are based in urban areas, it can be more time- consuming and expensive for rural people to travel for treatment, which may put them off seeking help in the first place or missing appointments.

Professor Peter Murchie, a GP and primary care cancer expert from the University of Aberdeen and the lead investigator, said: “A previous study showed the inequality faced by rural cancer dwellers in northeast Scotland and we wanted to see if this was replicated in other parts of the world.

“We found that it is indeed the case and we think the [5 per cent] statistic . . . is quite stark. The task now is to analyse why this is the case and what can be done to close this inequality gap.”

The university said that theirs was the first systematic review to consider this information on a global scale.

The team had previously found that those in the northeast of Scotland who lived more than an hour away from a treatment centre were more likely to die within the first year after a cancer diagnosis than those who lived closer.