Monthly Archives: April 2019

The service quality is falling, and staff are leaving

Across the four health services staff are demoralised and leaving. Bullying is endemic, and Scotland and its midwives are at least is trying to address this more actively.  Staff numbers are at their lowest, and Brexit will only make this worse. Most pregnancies are now to women over 30, and such a large proportion are “high risk” that midwifery led units are probably destined for extinction…. The NHS England site mouths platitudes like “participation is important”… for NHS staff, but those employed no longer believe it.

Bullying and Maternity Care Plans in Scotland (Nursing Times 15th April)

Laura Donnelly in in the Telegraph 27th March 2019: The number of NHS staff quitting over long hours trebles in the last 6 years.

Jane Dalton reports for the Independent today : One in four wards has dangerously low numbers of nurses..

Meka Beresford and Oli Cole report in RightsInfo: NHS Staff Shortages Could Double Without ‘Radical Action’

The NHS in England could be short of 70,000 nurses and 7,000 GPs within five years unless urgent action is taken to address a growing staffing crisis, according to analysis by three leading health think tanks.

A report by The Nuffield Trust, Health Foundation and King’s Fund warns that existing nursing shortages could double and the shortfall of family doctors treble, without radical action.

The analysis says that urgent measures must be adopted in a new NHS workforce strategy to prevent the shortages from worsening, with a combination of international recruitment, student grants and innovation needed…..

The NHSExecutive website reports 8th April: Widening pay gap between private and NHS staff ‘risks damaging the health service beyond repair’

Second class citizens – in Wales?

Chris Smyth reports in the Times 15th April 2019: English hospitals begin to ban Welsh patients in funding row Thousands of Welsh patients could be banned from English hospitals as a funding row escalates.

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Conservatives have demanded that the Welsh government “pay up” while NHS insiders expressed frustration that politicians are “just throwing rocks at each other”.

Last week the Countess of Chester Hospital NHS Foundation Trust said that apart from emergency or maternity patients, it would no longer treat people from Wales because they did not bring in as much money as those living in England. The Welsh government said that the decision was unacceptable.

Hospitals are paid a fixed fee by the NHS for each patient they treat. In England the tariff was raised this month as part of a budget boost. Wales opted not to increase rates, widening a gap that means English hospitals get paid about 8 per cent less for treating patients referred from Wales.

This is a particular issue in Chester, a few minutes’ drive from the border, which gets a fifth of its patients from north Wales. Deficit-reduction targets set by NHS England have made the hospital more reluctant to take lower-funded patients.

Nigel Edwards, chief executive of the Nuffield Trust think tank, said: “This has been bubbling for some time. Wales was not felt to be paying its way . . . It seems [unclear] why one set of people should be subsidising another.”

Latest data shows Chester admitting or discharging 81 per cent of A&E patients within four hours, compared with 63 per cent in Glan Clwyd and 57 per cent in Wrexham Maelor, the two closest Welsh hospitals.

Mr Edwards said that the Welsh government had previously relied on the fact that English hospitals preferred a lower rate to no money. However, rising waiting lists have meant that Chester feels confident of filling its beds with higher-funded English patients.

As well as patients crossing the border to the closest hospital, those in Wales needing specialist treatment are often sent to Liverpool or Bristol. With four million patients on English waiting lists, other hospitals could also switch to more lucrative patients if Wales continues to pay less. “I suspect it could well escalate,” Mr Edwards said.

Darren Millar, acting health spokesman for the Welsh Conservatives, said that the Welsh government “should get out [its] wallet and pay up”, adding: “It’s astounding that for every pound spent [on the NHS] in England, Wales receives £1.20 — 20 per cent more — and yet it wants to spend less. It’s ridiculous.”

A Welsh government spokesman said: “The English tariff increases include costs previously covered fully within the English NHS system, and we take the view [they] are not chargeable to Welsh NHS organisations.”

NHS England said: “[We] have been speaking to the Welsh government about this issue, as there is no reason why NHS hospitals in England should run up debts in respect of treating unfunded Welsh patients.”

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

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

We should argue for a re-unification of the UK health services.

Health and other Insurance and the Risk to Liberty.

The idea of a large mutual for health insurance came from Mr Aneurin Bevan in the Beveridge report.
Do we agree with the loss of liberty in order to reduce premium?, and rationed covertly, more and more people, will either pay or buy insurance products. The differential means that, like Obamacare, the 4 UK Health Services end up taking on the worst risks, which then makes demand higher and outcomes worse. In the US this is part of what is destroying what was intended as a seismic change in health care.
and on NHSreality
The whole principle of insurance is that we mutualise risk. In a hypothetical world, where companies can measure lifestyle and other risk factors, premiums can be varied according to risk profile.
Taken to its ultimate extreme, this individualises and de-mutualises risk: “Thereby undermining the whole basis of insurance”.
Do readers agree or disagree?
There are competing Liberal principles represented here.
Do readers support the loss of liberty needed to reduce individual premiums?
Do readers favour the increased education and autonomy represented by the ability to reduce premium?
Do we believe that the de-mutualisation of risk becomes individual, which undermines the social “good” of Insurance.
Do we agree with more and more information being collected by insurance companies?
I know the Liberal party argued against devolution.

Most doctors  agree that the de-mutualisation of the UK, from one NHS to 4 dispensations, is a negative for health. We should argue for a re-unification of the UK health services.

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