Monthly Archives: April 2019

Do we need an Aspberger’s Teenager to tell it as it is…?

There are parallels between the denial on climate change and the need for a sustainable health service. The problem is that politicians are never willing to stick to an “unpalatable truth”, and the media are always willing to find a strap line that undermines any controversial aspect of change. The world is not celestial. We need compromising honesty in dealing with the reality and hard truths of this world. Health is little different from Social Care… Calls for increases in higher rate taxation usually result in more perverse activity above present levels, so it would have to be a tax on everyone. Co-payments for health would be a form of “deserts related” rationing, but the issue has to be faced. Nicola Bartlett reports in the Mirror that Norman Lamb suggests a “Tax on over 50s”. – and predictably John McDonnell slams Tories’ proposal to bring in a tax on ageing in order to fill a £2.75billion funding gap

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Greg Hurst in the Times reports 29th April 2019: Call to fund elderly care with new tax

Tax rises should be introduced to fund a system that provides a standard level of social care for all elderly people in England in the same way as the basic state pension, a senior Conservative has said.

The Tory MP and former minister Damian Green added that older people should be encouraged to top up their care by paying for additional elements.

In a report for the Centre for Policy Studies think tank, Mr Green calculated that introducing a free entitlement to basic care at home or in a residential home would cost about £2.5 billion extra a year.

To pay for this he suggested that the winter fuel allowance, a tax-free payment of between £100 and £300, be withdrawn from pensioners who pay higher rate income tax. This would raise about £350 million a year. The rest could be funded with extra money from the Treasury’s spending review or, in the longer term, by imposing an additional national insurance rate of 1 per cent on the over-50s. This would mean that older taxpayers paid an extra £308 a year and would raise £2.4 billion.

The report suggested that a standard entitlement to universal social care would include a set number of hours of care at home per week or a bed in a care home with a minimum level of service, with people able to make top-up payments for extra services.

The Financial Times: Why UK is struggling to fix a mounting social care crisis

…A consultative social care “green paper” has missed a series of purported deadlines. Once promised “by April” officials now say only that it will appear “at the earliest opportunity”. …

…The King’s Fund, a leading health think-tank, last year projected that demand for social care would rise by about £12bn by 2030/31, growing at an average 3.7 per cent a year. With expenditure growing at just 2.1 per cent a year, the shortfall will be £1.5bn in 2020/21 and £6bn by 2030/31, at current prices. According to those familiar with the process of drafting the green paper, however, it will not propose a single definitive solution. The government’s caution is rooted in experience. The Conservative manifesto for the 2017 election said that people would have to pay all of their care costs until they were left with just £100,000 of assets. After an outcry, and warnings from her own backbenchers about a voter backlash, Mrs May said she would impose a cap on the total cost of social care bills facing middle class households. It is unclear whether a ceiling will be included in the green paper.

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Will short term governments ever agree to long term genetic testing?

Will the state health services agree to spend money for the really long term? The evidence from other areas of health is that short termism trumps every time. First past the post systems particularly avoid longer term investments. Yes, we could develop the ability described, but the chances of doing it are very small. Aside from the political aspects, there is the ethical issues raised by various bodies and charities. The potential could be rationed away, which could lead to the testing going “private”. In this event the richer families would avoid genetic disease in their offspring, whereas poorer people would cause a continuing drain on the state resources….

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Imram Ranzam reports in the Sunday Times 28th April: Testing couples’ DNA could wipe out genetic disease.

People should test their partner’s DNA before starting a family to minimise the risk of inherited disease — and may have to decide to stay childless, according to a senior Harvard professor.

About 5% of babies have inherited conditions — such as muscular dystrophy, cystic fibrosis and sickle-cell anaemia. There are about 7,000 such conditions, all due to parents being badly matched genetically.

In an interview with the science magazine Discover, George Church, a professor of genetics who was one of the architects of the human genome project, argues that the world could be rid of such diseases if couples took DNA tests before having a family.

To eliminate the conditions, millions of couples would be advised not to have children, to use IVF — so embryos can be screened — or to consider genetic testing of their unborn baby with a view to termination.

While testing might be expensive, Church points out that the illnesses last a lifetime and cost millions to health providers, such as the NHS. “It [testing] will go exponential quickly,” he said.

In Britain, genetic diseases are a growing problem among some Asian and other ethnic communities where it is common for cousins to marry. A report from Bradford city council said such relationships were a significant factor in deaths from genetic abnormalities.

Some Jewish communities face similar issues. About 20% of Ashkenazi Jews are carriers for at least one severe recessive genetic disorder, such as Tay-Sachs disease.

Lauren and Richard Kayser, a Jewish couple from north London, learnt they were carriers only after their daughter, Lia, was born three years ago. She was given the all-clear but the couple chose to use IVF when they added to their family. Twins Macy and Ruby are 10 months old.

Jnetics, a charity set up nine years ago to help prevent and manage Jewish genetic disorders, charges £190 a person so that would-be parents can assess the risk.

Katrina Sarig, executive director, said: “Genetic testing has been a game- changer in our community and . . . what we’re doing is transferable. It’s empowering to know what we are carriers of if we are able to do something about it.”

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Axe the pension caps that make the NHS sicker….how long will it be before the different Regions pay their doctors differently?

James Coney in the Sunday Times 28th April 2019 opines about pension caps perversely encouraging early retirement and / or avoiding overtime. Axe the pension caps that make the NHS sicker…

His reaction is reasonable and pragmatic, but the reason that doctors are paid better than they might be is because there are too few of them. The result of under capacity is that the employee calls the shots. In a world shortage he/she can take their labour away to another country or dispensation. With 4 dispensations in the UK, how long will it be before there is a differential in payments to doctors? If this happens will there be greater payment for doctors who work in unpopular areas?

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Axe the pension caps that make the NHS sicker…

It is, frankly, ludicrous that earning a couple of grand extra can leave you facing a £40,000 tax bill, yet that is the position one senior doctor found himself in.

Accepting a promotion and working overtime meant that he accidentally encountered a rule that cut the annual cap on what he could save for retirement from £40,000 to £10,000.

Breaking this rule landed him with the £40,000 tax bill and put him in a preposterous situation whereby the only way he could pay was to remortgage his house or lose a further £100,000 from his pension.

This valuable NHS worker is not alone. If doctors don’t have the spare cash available to pay the tax bill, they have to borrow it or use a system that allows them to take the money from their pension pot. For a 45-year-old who goes on to retire at 60, this “scheme pays” option will lose them £2,900 a year at retirement, according to the financial planner Tilney Bestinvest. If they die at 85, that £40,000 will have cost them about £100,000 once inflation is factored in.

So it is understandable that people affected by the lifetime and annual caps on retirement saving should decide that the best option is not to work extra hours. No extra pay, no extra tax.

It was in December that I first wrote about the problems created by the caps for the NHS, which is desperately short of staff in some areas. Those initial complaints have turned into a full-blown crisis.

We have George Osborne (again) to thank for this mess. The drastic limits on pension saving were set — under the guise of fairness — when he was chancellor. They were phenomenally poorly thought out, having become simply a tax on aspiration and sound investing.

Some suggest that the best way to end the pensions mess would be to give everyone a flat rate of tax relief, but that could create a multibillion-pound headache for public sector schemes that rely heavily on employer’s relief to keep them funded.

Osborne’s successor, Philip Hammond, has done almost nothing on the personal finance front, so now is the time to prove his worth. These pension caps need lifting — not just for doctors but for everyone — before this crisis in the NHS leaves us all feeling sick.

26th April Doctors Union warns Chancellor on pensions FT 

….The BMA – which represents 125,000 hospital consultants and family doctors –  has warned Philip Hammond that doctors will reduce their NHS working hours “unless there is tangible reform to the NHS pension scheme”.

Concern about doctors’ pensions has increased significantly since the introduction of the tapered annual allowance in 2016.

Nick Bostock in GPonline 26th April 2019 reports Experts back “Radical Change” to stop pension tax draining GP workforce 

Proposals to halve doctors’ pension contributions through a ‘partial pension’ scheme do not go far enough to stop punitive tax charges undermining the NHS workforce, experts have warned……

The NHS executive calls it a “punitive tax”.

Perfect storm’ brewing over NHS pensions IPE.com26 Apr 2019

Government ‘ignoring BMA warnings’ as pension taxes force doctors to … GP online25 Apr 2019

Laura Miller on 9th April 3, 2019 reports: in Telegraph Money Pensions reports: Pension tax row risks “absolute crisis” with one in 10 NHS doctors quitting.

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Despite “run through” blackmail, a large majority of doctors are opting out and taking a career break.

Despite “run through” training blackmail, a large majority of doctors are opting out and taking a career break. The Foundation Programme was first proposed by England’s Chief Medical Officer, Professor Sir Liam Donaldson in 2002…. Some countries, (India) use financial measures to entice their doctors to work for the state for their first 5 years. Doctors can be posted to unpopular outlying areas, so they try to avoid this, and even borrow to pay their way out. The “Perverse outcomes” of the foundation programme could only have been avoided by overcapacity of doctors and it has been through many administrations that places have been rationed.

Since “run through” training (GMC)  was advanced, and the penalties for “uncoupled training” were made clear at the start of the “Foundation Programme”, the profession have felt bullied, and coerced into a narrow based training, rather than the broad based training of yesteryear.

Knock on effects mean that opening up an abdomen often needs several specialities present. The convention of Human Rights states that a person may elect to take his skills to anywhere that wants and allows him, and in Europe this is part of the free movement of people in the European Convention of Human Rights. SO blackmailing doctors to stay in the UK, for fear that they will not get posts on their return, has backfired. The profession as a whole has voted with it’s feet. There is a world market in doctors, and medics reserve the right to take their trade where they wish. A perverse outcome from the wrong incentive at the wrong time…

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The BMJ Editorial by Jennifer Cleland, John Simpson, and Peter Johnston “Doctors opt out of training after foundation years,” (BMJ 2019;365:l1509 )

The UK’s inflexible training system looks increasingly unsustainable

There has been an explicit assumption in the UK that doctors will seamlessly progress upwards through the postgraduate training pathway. This was perhaps the case in the early years of the UK’s foundation programme (the first two years of generic training following medical school)—in 2010, 83% of foundation year 2 (FY2) doctors progressed directly from foundation to specialty training, including primary care. By 2018, however, that figure had fallen to 38%.1 Nearly two thirds of UK medical graduates now opt out of the training pathway at the first natural opportunity.

Most doctors who opt out return to specialty training within three years.2 This suggests that the break from formal training is the postgraduate equivalent of gap year—a time to recuperate from intense educational experiences, resolve uncertainties about the next steps in life, and make a curriculum vitae more competitive.345 Qualitative research suggests these are common reasons for not entering specialty training after FY2.5

Taking dedicated time to plan a career that may last more than 40 years is sensible. That doing so does not align with our current training system suggests a need for change. This is already happening. Doctors are opting to work overseas for a year or two, or take a “service job” (a post which is not linked to a formal training programme) to gain experience. Academic or clinical fellowship posts are also proliferating.2 These posts are designed to support medical education and other areas of activity, such as quality improvement, usually combined with some clinical service—often supporting rota gaps. These posts work for individuals, and also work for the NHS by keeping early career doctors in the UK.

But they are an isolated solution that could cause ripple effects throughout a complex training system.6 Fellowship posts, for example, are largely funded with money saved from unfilled specialty training posts. The two options compete for funding and are at the mercy of shifting trends. Fellowships will be a sustainable option only if they attract independent funding as, in the current system, an increase in the uptake of specialty posts would decrease the funding available for fellowships.

More fundamental changes to postgraduate training should consider the following: the interactions between individuals and the system at different points in the pathway; how different elements of medical education and training relate to each other and to the wider social and political landscape; and how systemic changes may benefit training and, ultimately, healthcare. Research shows, for example, strong connections between admission decisions by medical schools and the choices made by FY2 doctors about both specialty and place of work.78

The relation between medical school admissions policies and medical workforce planning is not simple or linear.9 Shifting the focus of admissions, however, from a stifling emphasis on high academic achievement10 to a model better aligned with social accountability would be a good first step towards a better match between the two. Such a model would select a mix of students with the personal attributes and motivation to train and work in the NHS, across the full range of localities and specialties. To facilitate this change, selection policies should consider the views of a broader cross section of stakeholders, including representatives from community and hospital medicine, employers, patients and the public, and government.11

Similarly, medical education and training in the UK involves many separate systems, including medical schools, the Foundation Programme, postgraduate training providers such as Health Education England and NHS Education for Scotland, and the royal colleges. All must work together across boundaries to ensure a smooth transition between foundation and specialty training. Consider, for example, the potential value of aligning medical school admissions (such as dropping the high academic requirements) with increases in intake (through government reform) and royal colleges rethinking how training programmes are constructed, assessed, and regulated.

Change may be unpalatable, but the alternative is to continue with the current state of affairs—an inflexible training pipeline that fails to supply enough doctors to meet growing demand and fails to meet the needs of doctors in training. Acknowledging that systemic and structural problems exist is the first step towards developing effective, system-wide solutions.

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Poverty and Wealth, and pregnancy rates. Will the slave society mean that Middlesborough et al supply the future low paid workforce?

The Economist in an article on 20th April reports on the state of childbirth demographics, and the differences between rich and poor areas.  Surprisingly, Wales is improving compared to the North East and even in Breast Feeding, although the length of time this applies to is not recorded in the Guardian figures…. How many of the IVF conceptions (3% of all) are private and how many public? The health divide ….. The Economist says it explains: Why the middle-aged are replacing teenagers in maternity wards – The conception rate is rising for women over 40, even as it crashes among under-18s.

There are many interesting graphics below, and the Teenage Pregnancy Rates in England and Wales) are most interesting. They do not include Scotland and N Ireland. Presumably Scotland similar to Wales, and N Ireland will have many, and fewer terminations because of their archaic laws.

Since most pregnancies are “high risk” in older first timers, will this mean that midwifery led units disappear? They should. (The risks in having babies in rural areas – midwifery-led units questioned by consultant.)

Will the slave society mean that Middlesbrough et al supply the future low paid workforce?

Maybe Later baby – The Economist 20th April

…. The conception rates of the youngest and oldest mothers are now close to converging (see chart). Middle-aged maternity may soon be more common than teenage pregnancy.

Advances in health care help to explain the convergence. Although assisted conception accounts for only a small proportion of pregnancies, it is growing more popular and more successful. Between 1991 and 2016, birth rates from in vitro fertilisation treatment increased by more than 85%. In 2016 more than 20,000 babies were born following IVF (out of a total of 696,000 births that year). About three-fifths of women who use it are 35 or over. Demand is likely to increase as women learn of others whose treatment has been successful. Ms Fenelon was inspired by a magazine article about egg-freezing……
Patrick Butler in the Guardian 2018: New study finds 4.5 million UK children living in poverty

New measure by Social Metrics Commission aims to focus political attention on the issue

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David Oliver: Are we seeing value based rationing clearly?

David Oliver opines in the BMJ: Are we seeing value based rationing clearly?

When will the debate on rationing take place ?

Leaders of public healthcare systems must make tricky decisions about prioritising resources, and they need public and professional engagement for this difficult role. Even a deluge of extra funding, after a relative drought of flat increases, wouldn’t magically wash away this need, but a recent report by the Medical Technology Group left me wondering whether England’s NHS is getting it right.

The report examined rationing of elective cataract surgery, using data from freedom of information requests sent to clinical commissioning groups (CCGs) in England. In total, 104 groups included elective cataract surgery on their list of “procedures of limited clinical value.”1 Of these, 76 used a “visual acuity threshold” before patients could be considered for cataract surgery, meaning that surgery is considerably delayed or not currently offered. A previous Royal College of Ophthalmologists survey reported that around two thirds of eye departments had moderate visual acuity thresholds to ration the procedure.2

In response to the Medical Technology Group’s report, the umbrella body NHS Clinical Commissioners said that its member organisations had to make “tough choices”3: implementing the National Institute for Health and Care Excellence’s (NICE) guidelines was “not mandatory.”4 The Guardian reported that 95 CCGs now restrict hernia repair, and 78 restrict elective hip and knee replacements.1 But cataract replacements provide a good lens for the broader issue.

Unwarranted variation in surgery rates should be explored using approaches such as Getting it Right First Time.5 But cataract surgery is not high cost per patient (although around 400 000 people a year undergo it)4: the NHS tariff prices it at £667 to £1363, depending on the procedure.6 In addition to its effects on the lives of people with worsening vision, delays in cataract surgery have been shown to increase the risk of falls and injuries, which carry their own costs to patients and services.7

NICE guidelines8 don’t advocate rationing or restricting cataract surgery on the basis of visual acuity, and the Royal College of Ophthalmologists has criticised using visual acuity thresholds to decide rationing.9 NICE states that cataract surgery is “one of the ways in which the NHS can transform our lives.”10

Although NICE is sometimes criticised for recommending treatment the NHS can’t afford or implement, cost utility and cost effectiveness are built into its methods. Its recommendations can be challenged by judicial review, and CCGs can be challenged in the courts for failing to provide NICE standards of care.11

The policy emphasis on “value based” healthcare is growing, where value is defined in terms of spending on outcomes that matter to patients.12 Initiatives such as Choosing Wisely, Realistic Medicine, and Prudent Healthcare are embracing this approach.131415

I don’t perceive that the NHS’s mechanisms and joined-up policy have caught up with its ambitions around value based healthcare. In a whole range of treatments or services, we haven’t consistently studied, measured, or described the outcomes that matter to patients, so we lack the tools for the job.

We haven’t seen enough political accountability, public consultation, involvement, or oversight in rationing decisions. And, for elective procedures such as cataract surgery—which don’t always offer the degree of benefit patients might hope for but can also transform their lives—we surely need informed, shared decision making based on conversations with individual patients, not the crude mechanisms of blanket bans and arbitrary cut-offs.

Gary Young in the Guardian 29th March: Brexit has exposed our broken political system – a second referendum should be the start of urgent reforms

Peter Walker in the Guardian 23rd April:

System negates need for main parties to appeal to middle ground, report argues

Overseas staff are desperately needed. Why can’t we provide them ourselves? The populism and emergence of “fascist” tendencies will make things worse..

Lets start with the answer to the question first. There is rationing of training places in all specialities, in nursing and in paramedical training. We need to aim at providing an overcapacity, especially now that the work-life-years of the average health service staff is declining. All 4 health services are dependent on overseas staff… The same pressures from “populism” are on governments worldwide. We know about the USA and Mexico, which needs the Mexicans badly. In Australia the Human Resources Directorate reports that “Labour plans to tighten skilled worker visa laws”.

The post code lottery of our devolved administrations makes shortages worse in deprived areas. This encourages more populism and fascist tendencies ….

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The fascist tendencies in populism worldwide are worrying. This talk from Israeli Yuval Noah Hurari explains how to understand what is happening...

David Oliver in the BMJ 2nd Jan 2019 opines: Falling immigration could destroy the NHS  BMJ 2019;364:k5308

Workforce gaps currently pose a major threat to the viability of our health services, as noted in a joint 2018 report by the King’s Fund, Nuffield Trust, and Health Foundation.1

One in 11 NHS clinical posts is currently unfilled, rising to one in eight nursing posts.2 The report estimates that, without concerted action, the current shortage of NHS staff employed by trusts in England—already around 100 000—will grow to an estimated 250 000 by 2030.

Some of the proposed solutions have been put forward before, by organisations including NHS Providers3 and the Royal College of Physicians.4 These centre on training more staff at home and doing more to look after staff so that more of them stay in the workforce. But this will take years, so let’s get real……

Chris Smyth in the Times 24nd April opines: New migration plan puts hospital services at risk

NHS chiefs have warned the government that “destructive” post-Brexit immigrant plans could force some hospitals to close a quarter of services, leaked minutes suggest.

Health bosses have told senior civil servants that a strategy involving a £30,000 salary threshold for any workers moving to Britain would be “the most destructive policy for NHS recruitment” because of the service’s reliance on overseas staff.

The proposals are under attack from NHS and social care services, which are short of 100,000 staff. In a white paper published last year, ministers proposed that when freedom of movement ends, all workers wanting to take up jobs must earn more than £30,000.

According to minutes of a meeting in January seen by The Daily Telegraph, one NHS director told officials that the “£30,000 limit is the most destructive policy proposal for NHS recruitment I’ve heard of”, to which another person present added “and the entire UK”. The minutes also say that the policy will be particularly “awful for social care”.

The health service relies on overseas staff, with one in ten doctors and one in 15 nurses coming from other EU countries, and there are concerns that tighter immigration controls could worsen staff shortages.

A nurse’s starting salary is £23,000 and social care workers earn even less. Health think tanks have urged the sector to be exempt from post-Brexit salary controls as 90 per cent of staff earn less than the £30,000 threshold.

Caroline Nokes, the immigration minister, has acknowledged the problem, telling MPs last month that there is a “lot of concern” about social care in particular. She promised further discussion with unions and other bodies.

• Heather Blake, a director at Prostate Cancer UK, has warned that the charity estimates “thousands of men will miss out on the support they need because there are not enough clinical nurse specialists to support them”.

Doubling NHS surcharge “punishes” international doctors for working …

The BMJ9 Jan 2019