Monthly Archives: April 2019

The four GP dispensations / jurisdictions. Nothing “national” about GP contracts.

There is nothing “national” about the GP contracts around the UK. The only way to ensure adequate supply is to train enough. NHSreality believes we should aim at overcapacity to ensure both supply and financial control. The contracts seem to endorse “private practice” but at the same time stop GP premises being used at all for private activity. Will this include Insurance and DVLA medicals? We are all in the UK (just) and pay the same taxes, and yet we have dofferential, hidden, randomised post code rationing.

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The BMA in England has produced “A five-year framework for GP contract reform to implement The NHS Long Term Plan” but this does not apply to Scotland N Ireland and Wales, and indeed, it has not been agreed by NHS England in it’s entirety. Despite the lack of recruitment, loss and early retirement of GPs, the whole edifice is falling like a pack of cards.

Pulse commented on the headlines in January observing that this was the most significant reform since 2004. The comments on line are “looks like the exodus will continue” and “150K lloks like a lot but after tax and pension it’s a much more modest sum.” Another is “Well if you are close to the !%)K limit …. what will happen is GPs will simply stop doing NHS work”.

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In Northern Ireland the HSC (Health and Social Care) Board rules.

In Wales the GPone website from the Welsh Government supplies their details. In Wales agreement has not been reached on the litigation funding arrangements, which at present may be top-sliced obligatorily, and causing resentment. In Wales we even cerebrate a reduction in the degree of bankruptcy…   and the poorest standards in Bowel Cancer screening, results, and Waiting times.

The Scottish Government contract and website is different again

NHS England contract 2019 which all the headlines are about. They ignore the other 3 dispensations. The Medical Indemnity scheme is funded separately in England, and will not be top-sliced as threatened in Wales.

“A new state backed indemnity scheme will start from April 2019 for all general practice staff including out-of-hours.” (NHS England)

See the source image

See the source image

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

Camille Oung and Laura Schlepper outline four principles to underpin an ideal funding system. This blog links to a new, interactive tool which provides a guide to different funding options for social care, and reveals whether they meet our tests for a fair and viable funding system. Camille and Laura suggest that “no single funding scheme proposed to date meets all of the principles perfectly”. Why shouldn’t these principles apply to medical care? Surely an ID card with tax status and means is now essential….

Nuffield Trust Blog: What principles should underpin the funding system for social care?

NHSreality commented August 2018: The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

and in June and July 2018: Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions.

NHSreality is a “heretic”. The NHS has become the greatest cult of our time. As a “holy relic” it is granted immunity from meaningful change.. If social care is means tested, why not medical care?

May 2018: The dissonant ideology between social care and the NHS: “One is heavily rationed and means-tested, the other free at the point of use and tax-funded”.

December 2018: 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..

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Nuffield Trust Blog: What principles should underpin the funding system for social care?

It is widely accepted that for health care there is a collective duty – and thus a role for the state – to provide financial support for all. No such consensus exists when it comes to social care. Yet Sir Andrew Dilnot at our recent Summit reminded us that the structure of risk for personal care is no different from that for health: only a handful of us will have no need for social care, most of us will have some, and a small proportion of us will have extreme need and face ‘catastrophic costs’.

As the much-awaited green paper approaches, we have collected and reviewed the different funding proposals put forward over the last two decades and two things have become clear: they are numerous and they are varied. A fundamental question remains about whether policy-makers will reconsider the balance of responsibility for funding between the state and the individual.

Changing role of the state?

Sir Andrew suggests that the role of the state is changing, and auto-enrolment pensions are an example of that. The government has acknowledged the importance of saving for old age but, instead of addressing that directly, has opted to compel individuals to take responsibility for saving through private pension schemes.

This vision of the role of the state is mirrored in some of the more recently reported proposals that we might expect to see in the green paper. The details for proposals for an auto-enrolment scheme modelled on pensions for social care funding remain unclear, however. Would they operate as a form of voluntary insurance, or as an individual fund relative to the size of your income? Either way, it draws on a narrative of individual responsibility.

Applying the rationale of pensions to social care need is misleading. While a pension pot is designed to reflect the quality of life of people’s working years, a need for social care can arise irrespective of wealth.

Relying solely on the private market to provide appropriate products is also problematic. Experience suggests there is limited enthusiasm for financial or insurance products for social care. Creating an attractive offer is difficult, and demand from individuals is low. Private products are also prone to medical underwriting, favouring the young and healthy and excluding those of high risk.

What would an ideal funding system look like?

Our collection of proposals underlines the multitude of potential ways to fund social care, some of which could be applied in combination. While there isn’t one perfect approach, we have come up with four principles that should be central to an ideal funding system.

1. Does it raise money for now and the future?

An effective approach to funding needs to inject additional money into a system already struggling to maintain existing standards.

The current means-tested approach does not provide a route to securing additional funding, as it relies on covering costs through a mix of local authority funding and personal contributions that are dependent on income and assets. Proposals to raise the level of income at which individuals have to fund themselves (the ‘floor’, currently set at £23,250) would raise costs for local authorities, without injecting additional funding. So too would setting an overall cap (as proposed by some) on what individuals can be expected to pay.

Looking to the future, the funding system must also make sure it can accommodate the growing need for care, as demographic change means that a system in which only working-age adults contribute is unlikely to be sustainable in the long term.

Tax increases and extending national insurance contributions beyond the state pension age are two schemes that offer the potential to reduce the short-term funding gap.

In contrast, some of the individual insurance-based approaches proposed would require contributions over a longer period before having full impact, and would need to sit alongside other mechanisms to ensure short-term funding increases.

2. Does it pool financial risk?

Risk pooling provides protection against the lottery of catastrophic care costs by redistributing revenue to those with the greatest needs. It provides security to all, and ensures the whole population has equitable access to care, regardless of wealth.

While all funding systems based on insurance and taxation have an element of risk pooling, some perform better than others. Universal mandatory contribution schemes, such as general taxation or national/social insurance, have the greatest potential to protect the largest number of individuals. They distribute cost across the whole of society and therefore offer at least some protection to all.

In contrast, voluntary auto-enrolment insurance models run the risk that those who are already struggling financially may opt out, leaving their future needs unfunded.

3. Is it fair?

There is growing evidence to suggest that those with lower socio-economic status are more likely to experience high needs, but are less able to pay the associated costs. A fair funding system would address these inequalities and minimise the burden on individuals. In a universal, mandatory system, for instance, everyone contributes in line with their level of wealth, and everyone has equal access according to their level of need, not their level of contribution.

But, of course, ‘fairness’ is complex and multidimensional. Our current system is beset with regional variations, so a fairer approach would respond to the fact that wealth and care costs vary regionally. Collecting and redistributing money at a national level minimises local disparities.

Intergenerational fairness is a further dimension. An ageing population puts more financial pressure on younger generations, leading to the suggestion that a fair model should see people continuing to contribute beyond state pension age.

4. Is it understandable and transparent?

Many people believe that social care is part of the NHS. They are consequently not aware of a need to save for their future social care needs, and by the time they or a relative develop a need, it may be too late. The current means-testing system is also complex and poorly understood by those navigating the system for the first time.

A reformed funding system will need to be clear about what is being contributed, by whom, and how it is being redistributed. Only an understandable and transparent approach to funding can hope to engender public support for, and ownership of, a reformed social care system. The funding mechanism most likely to gain most public support is one that is familiar to people.

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No Out of Hours service for taxpayers in Pembrokeshire. Be prepared to camp wherever you are sent…

As readers know there is no NHS, and in Pembrokeshire citizens who pay their taxes have no  GP Out of Hours Service/ Doctors on Call – in Pembrokeshire County …  

If you are elderly, or have young children, it looks as if you will have to camp in Casualty, and even that is poorly staffed, incompletely covered, and failing. NHS 111 is an appalling service. Confidence is failing, and private care will have to step in when the demand for it occurs. If there are deaths this might be sooner rather than later.

ITV news reports that for the second week running “GP shortages mean Out of Hours closures. 5th April 2019.

and prior to this, on 29th March: Out of Hours GP service closed again at Withybush Hospital this weekend.

For those who don’t know the area, the nearest (and also failing) DGH is 35 miles and many agricultural vehicle obstructions away, in Carmarthen. The situation is akin to the loss of services in Chester, except this is worse: it is access to emergency care rather than cold planned care that has been rationed out by successive administrations (of all colour).

The service in West Wales is now an official failure… but nobody is admitting their complicity in this disaster. The Post Code lottery is worse for distant and remote places. We are expecting a decision on a new hospital… 

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GP shortages this weekend mean that out of hours services in Carmarthenshire and Pembrokeshire will be closed intermittently. 5th April ITV News 

Hywel Dda University Health Board says they are continuing efforts to fill the shifts but expect the following disruptions:

  • Withybush General Hospital – closed 12am to 8am on Sunday.
  • Prince Philip Hospital – closed 2pm on Saturday until 8am on Sunday.
  • Glangwili General Hospital – closed from 10:30pm on Saturday to 8am on Sunday.

Analysis by Health Reporter James Crichton-Smith:

The fact that Hywel Dda is struggling to fill its GP out of hours rota is not a new one.

Health boards across Wales regularly have gaps in GP out of hours cover and Hywel Dda has previously warned of a shortfall at weekends, like it has this afternoon.

Read more:

Staffing problems and poor morale affecting GP out of hours

Health Board has had no doctor available overnight

The cause is a simple, and familiar, one. There simply aren’t enough GPs in Wales.

Efforts are ongoing to try and change this. The Welsh Government has its Train. Work. Live. campaign – and it has been getting results.

But training new GPs and attracting them to Wales takes time. The challenges are in the here and now.

August 2013:A series of intellectually and ideologically bancrupt administrations has led us to a GP recruitment crisis.

April 2019: GP suicides: LMCs call for action to reduce “appalling” numbers

March 2016: Top GP warns of threat to NHS as BMA calls emergency conference

August 2014: Recruitment rationing: GP magazine calls on political parties to support general practice

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The Liberal conflict around vaccination. We should exclude children from class without Measles vaccination. We should give HPV boys as well. How do we counter uninformed dissent?

Vaccination is accepted as a communal “good” by most of us. But there are groups who are choosing to exclude themselves, as well as groups who are excluded by the state on the grounds of cost effectiveness. Research has demonstrated for years that we should vaccinate both sexes (Rubella and then HPV) and there is a good case for excluding children from school if they are not fully vaccinated for infections diseases.. Research has also shown that herd immunity counts most in protection, and that individual immunity is less important. In other words, if you are the only child in a class not vaccinated you are very likely to catch the disease.

Measles is a killer. Before Bill Gates recognised the importance of the “cold chain” (refrigeration temperature) being preserved, corruption and inefficiency ensured most vaccines were useless in the third world. Improved delivery systems, checks and electricity supplies will ensure vaccination delivery gets better in the future. 

Meanwhile, it is not surprising that families losing children to diseases such as TB and Measles even though the children were vaccinated, are cynical about vaccinations. 

In a liberal democracy with strange groups exercising their “rights”, we need to consider carefully the risk to the other members of a class if a child is unvaccinated. A small loss of liberty for an individual/family can be justified if the risk reduction for the whole group/class is more important.

For HPV and its vaccine there is less risk, but when ill the disease (cancer of the cervix, mouth and anogenital area) is more lethal. Especially if a patient rejects cervical smears. It is reasonable to have a choice here, but doctors will usually elect to have their own children vaccinated (privately). Is there a message here? (Who should have the HPV vaccine? – NHS)

In truth, the vaccine resistance movement represents a larger “lack of faith” in the world’s leaders. The larger question is whether there is something wrong with our democracies that encourages uninformed dissent.

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11th April: School Exclusions During Oakland County Measles Outbreak

8th April: Unvaccinated students excluded from Birmingham middle school with .

14th March: New York measles outbreak: Judge upholds ban on unvaccinated …

Measles order in NYC: Unvaccinated students to be excluded

New York measles emergency declared in Brooklyn BBC News9 Apr 2019

4th April BBC News: Measles: How a preventable disease returned from the past

New York parents hold parties to deliberately catch the disease Measles! – The Mail

Measles outbreaks across England – GOV.UK

NHSreality: HPV Vaccination rationing – sexist, non-universal, and not learning from other countries 13th June 2016

Good News: HPV vaccine could be given to boys as well as girls in UK 30th November 2013

Dr Miriam Stoppard in the Irish Morror: Lift the ban on boys having the HPV jab

Repeating mistakes and false rationing. Vaccinations lead the way.

The potential for ID cards in accessing health, and progressive redistribution

In the Times 10th April:

Anna Nadibaidze: Voters are looking for extremes as the prospect of EU elections 

Ruth Fox and Joel Blackwell Hansard Society Audit: The public think politics is broken, and are willing to entertain radical solutions

Heart attack victims wait an hour for ambulances. West will be worse for outcomes..

Cardiovascular disease is the major killer in old age, Its essential for cardiovascular obstruction pathology that access to tertiary care is rapid. Not all District General Hospitals have access to round the clock tests and treatments for stroke and heart attacks. This needs to be addressed, but with old buildings. too few pep[le and too few radiology machines there is little chance of matching the best treatment and running it out across the country. Those living in rural areas with poor transport links will get inferior care. In West Wales the Air Ambulance service is a charity meaning it has low priority for government. Without a better service, either better roads or a comprehensive air ambulance, west will not be worst for outcomes…

Chis Smyth report sin the Times 16th Fwb 2019: Heart attack victims wait an hour for ambulances

Heart attack and stroke victims are among hundreds of thousands of patients made to wait up to an hour for an ambulance because the NHS has never met key targets.

Critically ill patients are waiting too long because new rules for dispatching ambulances struggle to pick out life-or-death situations, experts fear. Meanwhile, patients with non-life-threatening injuries routinely wait more than three hours for an ambulance, analysis of official data by The Times shows.

Ambulance targets were overhauled in 2017 and while the changes were largely welcomed, one contentious aspect was longer waits for some heart attack and stroke patients. Patients who are not breathing or unconscious are now classed as category one, with an ambulance expected to arrive within seven minutes on average. This target has never been

met.

However, other seriously ill patients, including many suffering heart attacks and strokes, are included in category two, where ambulances are expected to arrive within 18 minutes on average, with nine in ten arriving within 40 minutes. Neither target has been hit and in busy months one in ten ambulances has taken more than 55 minutes.

“These figures show the intense strain that many ambulance trusts are under,” Rachel Power, who leads the Patients Association, said. “Self-evidently, grossly unacceptable delays of many hours will put patients’ lives at risk.”

Chris Gale, professor of cardiovascular medicine at the University of Leeds, said that for some heart attack patients “every minute is critical. What you don’t want to do is lose muscle in the heart because you can’t regenerate that.” Patients with other types of heart attacks might not need immediate care but the professor, who is researching ambulance delays, said distinguishing between them was often only possible once they got to hospital. “The default should be if you’re having a heart attack it’s an emergency and you come into hospital,” he said. “These patients need to be in hospital straightaway.”

Taj Hassan, president of the Royal College of Emergency Medicine, said: “There needs to be greater transparency around the data to understand where the safety bar should be set.”

One in ten patients considered stable — classed as the lowest category four — wait more than three hours. A target to get to nine in ten patients in this time has been met nationally in five of the 18 months it has been used.

An NHS spokesman said: “The new ambulance response standards were introduced after the world’s largest clinical trial and with the support of patient groups and NHS staff. Over the last year, average response times for the most critically ill patients have fallen by 14 per cent and we will continue working with ambulance trusts to make further progress towards the new standards over the coming year.”

You can’t get no satisfaction – and its going to get worse….

The 4 health services need money, especially if they are “free at the point of access”, and cradle to grave, without reference to means etc. Unfortunately we in the profession know this is unsustainable and hence the problems at Chester – refusing Welsh Patients. The money moves with the patient all around the 4 Health Services, so no wonder the commissioners refuse second opinions from outside their trust (These are the only ones that matter), and refuse inter trust transfers and referrals whenever possible. Just like in Dentistry, private services are going to thrive, whether GP advertising is banned or not… Cutting referrals means more private care.. 

The fines for long waiting lists have to be more than the cost of extra contractual referrals! Commissioners will coolly calculate the difference and lives will not be considered. 

We shame Aneurin Bevan’s ideal and even Stephen Hawking realised this.

Nick Triggle for BBC news 7th March reports: Satisfaction with NHS ‘hits 11-year low’

and this is particularly true in the Walsh border area around Chester.#

The Chester Chronicle reports: Satisfaction with NHS “at lowest since 2007”.

Public satisfaction with the NHS has fallen to its lowest level in more than a decade, despite the Government’s announcement of a funding boost, new research suggests.

Just over half of people (53%) in 2018 said they were very or quite satisfied with the way the health service is run, the British Social Attitudes (BSA) survey found.

This is down three percentage points from 2017 and the lowest proportion since 2007, according to analysis by the King’s Fund and Nuffield Trust.

In 2016, 63% of people were satisfied, compared to 65% in 2014.

Satisfaction with how the NHS is run is at its lowest since 2007 (PA Graphics)

 

(PA Graphics)

Ruth Robertson, senior fellow at the King’s Fund, said she was “surprised” by the results of the survey, in the year the NHS celebrated its 70th anniversary and was promised an additional £20.5 billion per year.

“We didn’t see this ‘birthday bounce’ that you might have expected in satisfaction,” she said.

The survey of almost 3,000 people in England, Scotland and Wales was carried out between July and October, after the funding announcement.

The main reasons people gave for being dissatisfied with the NHS overall were long waits for GP and hospital appointments (53%), not enough staff (52%), a lack of funding (49%) and money being wasted (33%).

More than two-thirds (71%) of those who were satisfied with the health service said it was because of the high quality of care, while 62% said it was the fact it is free at the point of use.

Older people were happier with how the NHS is run than younger people, with 61% of those aged 65 and over satisfied compared to 51% of those aged 18 to 64.

“Despite the outpouring of public affection around the NHS’s 70th birthday and the Prime Minister’s ‘gift’ of a funding boost, public satisfaction with how the NHS is run now stands at its lowest level in over a decade,” Ms Robertson said:

“In the short term at least, the promise of more money doesn’t appear to buy satisfaction.

“The public identified long-standing issues such as staff shortages and waiting times amongst the main reasons for their dissatisfaction and cash alone will not solve these.”

Satisfaction with GPs has hit its lowest level since the survey began (PA Graphics)

Satisfaction with GPs has also dropped two percentage points to 63%, the lowest level since the survey was first carried out in 1983.

Professor John Appleby, director of research and chief economist at The Nuffield Trust, said: “This may reflect continued strain on general practice, with mounting workloads and staff shortages and the evidence shows that people are finding it harder to get appointments than before.

“The NHS long-term plan expects even more of general practice – these problems will need to be addressed quickly if that vision is to be made possible.”

The analysts cautioned that there may be a “lag” before the money pledged by Theresa May has an impact on satisfaction levels.

However Ms Robertson added: “Two of the factors that people are telling us are big drivers of their dissatisfaction – waiting times and a lack of staff – are things that aren’t actually addressed in the long-term plan.

“We are waiting for the workforce strategy to come out to deal with the crisis we’ve got around workforce, and a review of waiting times as well.”

A spokesman for the NHS said: “For the third year in a row, public satisfaction with the quality of NHS care has improved and satisfaction with inpatient services is now at its highest level since 1993, however the results as a whole understandably reflect a health service still under pressure.

“The Long Term Plan sets out an effective blueprint for making the NHS fit for the future as funding comes on stream and does so on the back of the public’s enduring support for NHS services, with increasing satisfaction scores in the survey for both outpatients and inpatients.”

The Health Service is no longer National, and there is blatant finacial rationing because Wales has not paid up!

April 5th Chester Chronicle: English health trust accused of using Welsh patients as ‘bargaining …

BMJ 3rd April: David Oliver: The revolving door to the NHS lobby

The Guardian 31st Jan 2019: NHS England to ban GPs from advertising private services

The Herald Scotland 1st April: Margaret Taylor: It’s unforgivable for MPs to fiddle while our NHS burns

26th March 2019: CCGs continue to offer cash rewards for GPs to cut referrals

The Independent 15th February 2019: Tens of thousands of cancer patients left waiting months to start …

 

 

Covert and post coded randomised rationing of dementia care..

The daily mail claims there is a deliberate bureaucratic block on spending money on dementia. The implication is that these citizens, at the end of their lives, don’t matter. After all they often don’t have the mental capacity to vote, and they don’t have the life expectancy, so the combination means their votes don’t matter. The votes of their relatives do matter, but somehow relatives learn to live with this post code random rationing. It will be even more random in the other jurisdictions: these figures apply only to England.

Image result for dementia cartoon NHS

On Tuesday April 2nd the Times published: Dementia Care is not good enough across half of NHS but it was not on line (It referred to the Daily Mail):

“Dementia care is not good enough in half of NHS local healthcare groups according to official ratings.

One in three patients does not have a diagnosis with large variations across the country..

Experts have accused the government of losing focus on dementia as the number of patients continues to rise. About 850,000 Brtions have dementia… Analysis on the Daily Mail website shows  19 clinical commissioning groups that fund care locally are rated “inadequate”, and 66 as “requires improvement”. This compares with 43 rated “good” and 52 “outstanding”.

Clive Ballard, a dementia specialist at the University of Exeter, told the newspaper: “In 2012David Cameron made a commitment to takle dementia. The current figures show no subsequent progress. It feels very much like these pledges have been kicked into the long grass.”…..

In Camden (London) 91% are estimated to have a diagnosis, whereas in Cornwall on 52%…..

Fiona Carragher , of the Alzheimer’s Society, said: “It’s deeply worrying that the postcode lottery of care is continuing. People tell us they have to wait years for a diagnosis and have to fight the system to access support, advice and treatments.

“Some say their care plan is little more than a tick box exercise”.

Alistair Burns , National Clinical Director for dementia at NHS England said: “The long term plan prioritises further improvement, with GPs being given additional support to spot the tell-tale signs”.

 

December 17th 2018. Chris Smyth in the Times: Dementia patients have to move hundreds of miles for good care

A million older people live in places where most dementia beds are rated poor, forcing vulnerable patients to move hundreds of miles for decent care, The Times has learnt.

Large swathes of the country have fewer than one satisfactory dementia care home bed for every 100 people aged over 65, according to analysis. One in 14 older people has dementia and diagnoses are rising.

In Kensington and Chelsea, only 19 per cent of dementia beds assessed by inspectors have been rated good or outstanding, the lowest in the country. Campaigners have warned of a “broken system” for coping with dementia, which is the country’s biggest killer….

and in 2016: Dementia patients marooned in hospital

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“National” child database is actually Regional. What a shame that only England will benefit.

One of the four jurisdictions / dispensations in the UK (England) is setting up something that I at least assumed was happening already. That this new database excludes Scotland, Wales and N Ireland is evident. So will the press and media point this out? Of course not. The reality is that there is no NHS. What a shame that only England will benefit, and that the power of a large mutual is impossible..

NHS to launch world’s first national database on child mortality The Telegraph 30th March 2019

SBS news offers 31st March 2019: Health Dept opens UK child death database

Circumstances of all child deaths across England will be recorded in a new database in an effort to stop under-18s dying from preventable causes.

The BMJ News in 7 days in medicine offers: Child health . National child mortality database launches

The NHS is to collect comprehensive national data, standardised across England, on the circumstances of children’s deaths to help healthcare professionals learn lessons. The national child mortality database, funded by NHS England, will include data on the circumstances of the death alongside details of factors such as ethnicity, economic background, and other environmental aspects. It will also allow detailed analysis of groupings of children’s deaths, such as deaths from asthma.

 

Halfhearted support from Scotland. English Whistleblowers: “promises of protection are repeatedly broken”, meeting hears.

In Scotland the “whistleblower blast” is on 19th June, but there is no funding for the room Peter Gregson needs. For fundraising go here

He ends his message: “Please chuck in a few £. Then I’ll be able to afford to feed my children this month”. The petition is here

and the Scots are also looking at the Independent Contractor Model (GPs) after it has been cleaned out by understaffing and underfunding.

The health services are too proud and mean to contract out their human resources, but this is what is needed, along with a whole dose of repeated honesty, exit interviews, removal of targets, and giving the profession more powers over their own destiny..

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The BMJ opines: Whistleblowers: promises of protection are repeatedly broken, meeting hears BMJ 2019;364:l1482

There has never been a more dangerous time for frontline NHS staff to consider speaking up in defence of patients, a consultant surgeon who lost his job after reporting concerns about an avoidable death has told a meeting on whistleblowing at the Royal Society of Medicine.

All three levels of supposed protection—the NHS itself, regulators, and the law—are failing whistleblowers, Peter Duffy said.

Duffy, who reported his worries to the Care Quality Commission in 2015, won his case for unfair constructive dismissal at an employment tribunal last July. He was awarded £102 000 (€120 000; $135 000), which related to a dispute over pay, not his disclosures.

He told the meeting, opened by the RSM’s president, Simon Wessely, that he had been forced to resign from University Hospitals of Morecambe Bay NHS Foundation Trust in 2016 “for my own protection” and was “unemployed and, it seemed, unemployable.”

Since 2017 he has worked outside the NHS as a consultant surgeon at a hospital on the Isle of Man, living alone, while his wife, family, and friends still live in the Morecambe Bay area. “It really does feel like being two years into a 10 year prison sentence,” he said.

His case showed, he added, that “we have NHS promises of whistleblower protection repeatedly broken, leaders who don’t show leadership, regulators who don’t regulate, guardians who don’t hold organisations to account, and a law which simply exposes whistleblowers to more hate, threats, intimidation, and allegations.”

He said that the law failed whistleblowers in at least three critical areas. First, the whistleblower was the one on trial, not the NHS trust and managers. Second, whistleblowers were “threatened with costs if they don’t drop the case.” Finally, for success in a claim of sacking on the ground of whistleblowing the law demanded an evidential link or “smoking gun” to link the whistleblowing and the sacking. “This evidential link is an almost impossible task, particularly with the NHS conducting a scorched earth policy to evidence right from the start,” said Duffy.

He advised potential whistleblowers, “If you speak up as a group, you are infinitely more powerful. My mistake was to go it alone.”

David Nicholl, consultant neurologist with Sandwell and West Birmingham Hospitals NHS Trust, asked how far the NHS had come since the report of Robert Francis’s Freedom to Speak Up review in 2015.1 “Not very far,” he answered.

Nicholl said that one hopeful sign was that the CQC had fined Bradford Teaching Hospitals NHS Foundation Trust in January for breach of the duty of candour because it had failed to tell a family within a reasonable time that there had been delays and missed opportunities in treating their baby, who had died.2

Peter Wilmshurst, consultant cardiologist at Royal Stoke University Hospital and a whistleblower who has reported several research misconduct cases to the General Medical Council, said that there was an inequality of arms because “the individual can never match the resources of the trust.” He added, “There are no effective sanctions for those who treat whistleblowers badly.”

Several speakers and delegates called for reform of the whistleblowing legislation the Public Interest Disclosure Act, which Duffy described as “full of loopholes.”

Nicholl said, “There are fundamental problems with the legislation. If there’s anything we can do to press on that, it’s absolutely vital.”

David Walker, medical director of the Morecambe Bay trust, said in a statement, “We strongly encourage staff to come forward if they think patients may be in any way at risk, so we can investigate and learn from any mistakes. He added that the concerns raised by Duffy had been thoroughly investigated at the time and that “the employment tribunal found there was no evidence that he was ill treated or suffered a detriment for raising those concerns.”

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Elderly go blind as NHS ignores eye surgery rationing advice

A leader and an article in the Times 6th April.

The Times view on cataract surgery: Correcting Vision

It is cost-effective yet many older people suffer needless delays

lmost one British person in five is aged 65 or over. An ageing population has distinctive health problems, of which none is more predictable than deteriorating eyesight. About 2.5 million people in England and Wales in this age group have impaired vision due to cataracts, which is a clouding of the lens inside the eye. Most cataracts are related to ageing, and surgery to remove them is among the most common procedures carried out by the National Health Service. More than 400,000 such operations occur each year.

Yet a survey conducted by the Royal College of Ophthalmologists suggests that tens of thousands of elderly people are struggling with poor vision because of unwarranted restrictions on cataract operations. Their plight is a very human cost of a drive for rationing that does not even make sense in purely monetary terms. Policy by local funding bodies needs to change. Cataract operations should not be rationed or restricted.

The demographic problem of ageing is not unique to Britain. Every healthcare system in the developed world is coping with financial constraints and the need to direct resources to their most pressing uses. Healthcare systems in some European countries address the issue by distinguishing between core procedures that are covered by insurance schemes and other services for which the patient must pay extra. The NHS, by contrast, relies on the National Institute for Health and Care Excellence (Nice) to advise health providers on what are the most cost-effective treatments.

In the case of cataracts, Nice has done what it was designed to do. It looked at the evidence and in 2017 issued guidance which concluded that cataract surgery was almost always an effective use of resources. By carrying out surgery early, the health service can save money in the longer term. Older people with poor eyesight are prone to fall and suffer injury. Far better, for them and for other patients, that they should be given treatment sufficiently early so they can continue to be safe and self-reliant.

Yet that guidance isn’t being implemented properly. When the advice was issued, the college surveyed eye units and found that two thirds operated rationing policies. These expedients are unjust as they build regional inequalities into the system. Whether an older person is entitled to a cataract operation at any particular stage in their visual deterioration depends on an accident of postcode. This is not how a health service should operate. It would not happen in an insurance-based system. It should not happen in a system like the NHS, free at the point of need.

Chris Smyth: Elderly go blind as NHS ignores eye surgery rationing advice