Monthly Archives: December 2018

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:

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.


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



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.

Image result for mind the health gap cartoon

Some tips to avoid waiting to see your doctor……. but it is going to get worse, and more expensive whatever.

A relative had to call the doctor for a urine infection. It was painful, they had a fever, and yet no treatment was available without an appointment, and a sample of urine for culture. The urine was lost, and they went privately because there was “no other way” to get treatment! This cost time, energy and £65, but to the English Health Service it has cost another disillusioned taxpayer. Stories abound about poor access, delayed investigations, and subsequently poor outcomes. The shortage of doctors has been predicted for more than a decade, and the poor manpower planning that has led to those doctors we do have being “part time” is understandable for all of us close to the profession and the service. Disillusion is not confined to the public, but is endemic in the caring professions…. hence early retirement and emigration, and changes of career. Poorer parts of the UK will be more affected, as when there is undersupply doctors will choose to work in more affluent areas with better schooling and infrastructure. These areas will also have more people prepared to pay for the private option. Just as dentistry has “gone private”, so Primary Care (G.P.) is facing the exact opposite of the National, fair, mutual service(s) that Aneurin Bevan enabled in 1948. We are bringing back fear, rather than replacing it.

Some tips to avoid waiting to see your doctor…….

Write your symptoms down on headed paper and deliver it ( by relative if necessary ) as the doctor will have to read the letter, have it scanned into your notes, and act on it accordingly. The envelope should be addressed to your preferred or normal doctor, but make it clear that any doctor will be adequate. If you think it urgent mark the envelope as such, but be aware that GPs have been excused form being an emergency service. ( A true emergency, as defined by the state(s) and not by the patients, needs a 999 call, and attending A&E. ) Verbal messages over the phone are not recorded in a standardised manner, so recording is different in each practice. Emails either direct to a practice, or from receptionists receiving messages, are not necessarily copied into notes.  Access is going to get worse, and more expensive whatever: there are just not enough doctors for the next 15 years..

The “ideal” concept, as originally envisaged has died. We have to ration health care, so better that rationing is overt rather than covert. It must be universal for big expensive services such as cancer care, and heart surgery, but it may have to be local (post coded) for smaller items and services which are not expensive or life threatening. My personal preference is for means tested health care in the same way as we have means tested social care. This would allow combining budgets without internal argument. All that remains is for the press and the politicians to reach this conclusion. The bad news is that this will take decades, and many deaths.

The prospect of a “telephone app” doctor does not convince me at all. Advertisements in London have small print saying that, to access this service, you will need to re-register. The old adage of History, Examination and Investigation is being replaced by History, Investigation and then possible examination but by a different doctor. I predict: No continuity of care. No trust. Waste by over investigating, and then by litigation costs. What better incentives to go privately if you can afford it? What better way to destroy the health services by making them unofficially “two tier”?

Sarah Baxter reports that: “Doctors are quitting and surgeries are threatened. Services need radical reform” in the Times 11th December 2018.

Scary news. More than 350 GP practices may close next year and millions of patients face a three-week wait to see their doctor. To be frank I thought everybody in Britain, like me, was already obliged to book an appointment three weeks in advance. So whenever my children, say, need prompt attention for an ailment that might be serious but probably isn’t, I send them to one of those private walk-in clinics for £65 that you can find around the back of central London railway stations.

Not everybody has that opportunity, but I felt ashamed about running to the A&E after my son was prescribed a couple of Nurofen for a neck injury on the football pitch that turned out to be nothing. Equally, I’m not prepared to wait three weeks for an examination. I did try to change surgeries, but was told by a nearby GP practice that its situation was far worse……….

My NHS clinic is Theresa May‘s ideal – if only I could see a GP (The original Times article)


Sir, You report that, in the past year, 9.3 per cent of patients waited more than three weeks for an appointment (“Millions of patients face three-week wait for GP”, Dec 7). While it is undeniable that there are serious resource shortages at GP practices, there is much that patients can do to improve the performance of their GP service. In my local practice, patients fail to turn up to 5 per cent of booked appointments without giving prior notification. During the course of 12 months this wastes 50 per cent of the time of one whole doctor.

In the case of minor ailments, patients who agree to accept an appointment with a clinical nurse or agree to visit a pharmacy directly can improve the availability of doctors for more urgent appointments.
Richard Harvey
Oakham, Leics

Sir, Tony Blair made two big errors in his dealings with primary care: allowing GPs to opt out of 24-hour care and interfering with appointment systems that practices had fine-tuned to meet the needs of their patient population. As a result of being embarrassed on national television in a Q&A session with voters, he introduced a “one fits all” system incentivising practices to deal with all requests for an appointment within 48 hours. The only way this could be achieved was for practices not to allow booking in advance so the appointment book was empty at the start of each day. This created the rush hour at 8.15am and a lucky 30 got an appointment.

Any service where demand outweighs supply inevitably has a pinch point and in this scenario the bottleneck is at about two to three days. Urgent cases can still be seen on the same day and chronic conditions can wait a couple of weeks with no detriment to the patient. Illnesses such as sore throats, viral illnesses, diarrhoea and vomiting, etc get better without the need to be seen at all.
Dr Andrew Cairns
Petersfield, Hants

Sir, Maybe the delays in being able to see a doctor are not caused by, as you report, “the chronic shortage of GPs”. Out of the seven GPs in my doctor’s practice, six only work part time.
Douglas Stuart
Guildford, Surrey

Sir, It is not just general practice that is under enormous strain; patients across the country are also struggling to access NHS dentistry. More than half of NHS dental practices are closed to new patients and some people face a 90-mile round trip to get to their nearest surgery.

As chief executive of the largest provider of NHS dentistry in the UK, I see first-hand the acute shortage of NHS dentists, particularly in remote areas, and the impact this has on patients. The government urgently needs to train more dentists and, most importantly, allow high-quality clinicians from around the world access to work in the UK.
Tom Riall
Chief executive, mydentist

Sir I am lucky enough to be registered with a GP practice in west London which operates a system that ensures that medical advice can be easily accessed. Each weekday morning and four weekday afternoons a walk-in clinic is on offer where, as often as not, a patient is able to see the doctor of their choice without too long a wait. As well as this facility, an appointment — perhaps for a lengthier consultation — can be arranged using the phone, sometimes subject to a week’s delay. If this busy practice can achieve such a service, then why are not all practices aiming for such a system?
Sheila Keating
London W2

Image result for two tier service cartoonWorkload pressures and the GP shortage forcing practices … to close

GP surgery closures ‘will see 3 million patients lose out in the next year’ 



BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

Under the present funding rules, rationing of health services will need to be more severe, and more covert, in the devolved nations. NHSreality has warned about the problems of smaller mutual in health provision many times….. When readers listen to the debates next week, and think about their personal future, their chances in severe illness, and those of their nearest and dearest, they should think about this prediction… and this despite the figures on the infamous “red bus”…

Kate Whitfield reports in the Express 6th December 2018: Brexit news: How healthcare and the NHS will suffer, deal or no deal – BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

The report, titled “The NHS and Health Law Post Brexit: Views from Stakeholders and the Devolved Jurisdictions.” released on Tuesday, is made up of research and evidence from interviews around the UK. Concerns about the future of health care include staffing, shortage of medicines, public health, research and funding. Most worryingly, it appears devolved nations – Northern Ireland, Scotland and Wales – might be the worst hit.

Speaking at the launch of the report, researcher Professor Tamara K. Hervey said: “The risks of Brexit vary significantly depending on what kind of Brexit we have.”

However, she added: “No-deal is much worse for health and the NHS than the withdrawal agreement.”

So, whether Parliament votes the prime minister’s embattled deal through next week or not is likely to seriously impact the health sector.

Professor Hervey said: “There are major negatives no matter what kind of Brexit we look at.”

How will the NHS be affected?

The report revealed a number of key findings:


Concerns around staffing are compounded by the already existent shortage of healthcare professionals around the UK.

Northern Ireland is a particular concern, already in the grips of a chronic staff shortage.

But cross-border care between Northern Ireland and the Republic is extra cause for concern: if the UK leaves without a deal and a hard border is re-instated, what will become of interacted healthcare services?


The possibility of shortages and the need for stockpiling has been discussed for some time now.

But here again, there are concerns about the devolved nations.

The findings state: “The key issue is the likelihood of multiple shortages taking place all at once, meaning that the normal responses are inadequate.

“The size of NHS England compared to devolved nations leads to worries about how professionals in Northern Ireland, Scotland and Wales


There are concerns about public health measures, such as combatting smoking, once the UK leaves the EU.

There are worries that, once the UK is no longer under EU regulation, commercial considerations may hold more influence.

The UK will also be leaving the European Centre for Disease Prevention and Control (ECDC) after Brexit, and the report urges the government to pursue a relationship.


The EU is involved in a range of vigilance systems that scrutinise health professionals, pharmaceuticals, medical devices, blood and tissue.

These measures facilitate the protection of patient safety, but may be at risk after Brexit.

Professor Hervey pointed out these dropped scrutiny measures could result in either “mistakes happening inadvertently” or “more powerful interests able to secure advantages” while the UK adjusts to the post-Brexit landscape.


The report finds that the loss of EU funding poses the biggest threat to Northern Ireland and Wales.

“The practical potential adverse impacts of this on health need to be addressed by policy makers in the immediate, intermediate and long-term period of Brexit,” the report said.

Download The NHS and Health Law Post Brexit


As standards fall – a rejection of volunteers…

It appears that amelioration of covert rationing by volunteering is not to be encouraged.

Image result for volunteer cartoon

Dennis Campbell in  the Guardian 4th December 2018 reports: Hospitals report warns against volunteers doing work of NHS staff – Study finds volunteers are vital but lack of clarity about limits of roles can lead to tensions

Volunteers play a vital role in hospitals such as by doing tea rounds and fetching medications but should never be required to do the work of trained staff, according to a report.

An estimated 78,000 volunteers perform a variety of roles in NHS hospitals across England. Richard Murray, the director of policy at the King’s Fund thinktank, which conducted the study, said that while it found frontline staff appreciated volunteers, that was “provided they were not being used as substitutes for paid staff”.

Patients appreciate the companionship, comfort and support volunteers can bring, according to the research. One of the almost 300 doctors, nurses and support staff interviewed said volunteers’ value lay in “bringing human kindness to a busy ward”.

Three out of four staff say volunteers help them care for patients, while almost a third believe they help free up their time to focus on clinical duties.

But the thinktank, which conducted the research for the Royal Voluntary Service (RVS) and the volunteering charity Helpforce, found that a lack of clarity about the limits of volunteers’ roles “could lead to tensions between staff and volunteers”.

Sir Tom Hughes-Hallett, the founder of Helpforce, said the ageing population meant hospitals would need greater numbers of volunteers in the near future, so the NHS should embrace their contribution.

Anna Chadwick, the lead dementia nurse at Mid Cheshire hospitals NHS trust, said RVS volunteers in its Leighton hospital in Crewe played a hugely valuable role. “The impact of volunteers giving their time to offer meaningful support to people who are unwell and often lonely and frightened is immeasurable,” she said. “The hospital environment can be overwhelming and a friendly face and chat can make the world of difference to a person’s experience.”

The NHS’s long-term plan is expected to map out how volunteers can help the health service and its staff cope with the challenges they face.

Matt Hancock, the health and social care secretary, said volunteers had been supporting patients in the NHS since its creation in 1948. “I want volunteering to be the norm across every NHS hospital, with volunteers given the tools they need to fit seamlessly into the organisations they are giving up their time to support, so that the public and clinicians can work side by side to deliver the best possible care to patients,” he said.

Image result for volunteer cartoon