Drug firms collude to defraud the Health Services.

Prochlorperazine should be dirt cheap. At the old price of 10p each it was expensive, and now at 70p each it is astronomic. The drug has existed since I qualified, and no amount of increase in ingredient cost, or production process can justify this opportunity. The purchasing power of the English Health Service, ( as opposed to the other 3) is so great that all they need is good procurement management and supervision. It does not exist, just like exit interviews.

Other more expensive anti-nauseants are subject of much controversy already.

Billy Kember reports in the Times 24th May 2019: Firms ‘colluded’ to boost cost of drug for cancer sufferers

Four drug companies have been accused of colluding to force up the price of a medicine commonly taken by cancer patients by 700 per cent, costing the NHS millions.

The cost of prochlorperazine 3mg tablets, which are used to treat nausea and often prescribed to chemotherapy patients, rose from £6.49 for a packet of 50 to more than £51 between 2014 and 2018. This cost the NHS an extra £5 million in 2018 alone.

In 2013, Alliance Pharma sold the licence to market the drug exclusively to Focus Pharmaceuticals. It continued to manufacture the medicine and supply it to Focus at a fixed price.

The Competition and Markets Authority (CMA) said that two other companies, Lexon and Medreich, had been working on versions of the medicine. Medreich obtained a licence in January 2014 but did not begin selling its rival drug until late 2017. Instead, Focus agreed to pay Lexon a share of its profits from the medicine, which Lexon in turn shared with Medreich.

The CMA’s ruling is provisional and the companies can respond before a final decision. The anti-nausea medicine was among more than 70 drugs named in an investigation by The Times into a loophole in NHS pricing rules.

Alliance Pharma said it “has had no involvement in the pricing or distribution of prochlorperazine since 2013”. It said that it had not influenced or benefited from any price increases.

Advanz Pharma, formerly Concordia International, said some of the price rises dated from before it owned Focus. It said it did not believe that competition law had been infringed.

Cinven, which acquired Focus in October 2014 and sold it a year later, declined to comment.

Lexon and Medreich did not respond to requests for comment.

The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

There is more money spent on “lobbying” by Big Pharma than on Public Health consultants…

Trying to force the ethical and philosophical debate – Big Pharma and the Cancer Drugs Fund

Orkambi and Yescarta are merely illustrating an ethical problem that will get bigger into the future… Political dishonesty and denial stall a solution.

Japans bias is understandable, and to correct it they need graduate entry to Medical School. So do we…

It is natural for states to want value for money from their medics. The news that Japanese men are given preference to women was broadcast as if it were a scandal. I myself was an undergraduate entrant to Medical School in 1968. I would never have got a place today, with grades B & C at A level. Not the brightest student in my year, I just about coped, but as I matured I got to understand. The result was a full time GP who for 37 years gave good value to the UK Health Services in England and then in Wales.

Japans bias is understandable, and to correct it without excess women, they need to have graduate entry to Medical School. At 21 years old men have matured and do as well as women as has been proven in the UK. All medical students are graduates in USA, Canada, Mexico and many other countries, but Japan takes them straight from High School. (Quartz.com)

The Times reporter (see below) has failed to realise the significance of undergraduate v graduate entry.

 

Richard Lloyd Parry reports for the Times from Tokyo: Medical school that blocked women admits they outperform men

It was one of the most extreme cases of institutionalised sexism seen in modern Japan: a top medical school that deliberately made it harder for women to enter. After being exposed for its bias, the university has now allowed women to compete on an equal footing, and they are outperforming men.

Tokyo Medical University caused outrage last year when it admitted that its officials had doctored scores for entrance examinations to give women lower marks. The policy was justified on the basis that women were more likely than the male students to give up their careers at some point to have children, leading ultimately to a shortage of doctors.

After grovelling apologies, the university reports that it has held fair entrance examinations and the female candidates have been more successful than the male.

Last year, before news of the scandal broke, 9 per cent of men passed the highly competitive entrance examination for the prestigious university. The figure was lower still for women hoping to win a place: only 2.9 per cent of them were reported to have passed.

Male candidates, in other words, were more than three times as successful as their female counterparts.

 

The reason for this, however, became clear when the university admitted that it had been marking the scores of female applicants down by 20 per cent.

This year, 26.4 per cent of female applicants passed the exam, compared with 21.8 per cent of men, according to figures in the Asahi newspaper.

The higher overall proportion of successful applicants is explained by the fact that 60 per cent fewer candidates applied to Tokyo Medical University, whose reputation has been besmirched by the scandal.

Broadly similar but less dramatic results are seen in results from other Japanese medical schools. According to research by Asahi, male applicants were 10 per cent more likely to be accepted to study medicine nationally than women. This compares with a 20 per cent difference before the revelations.

To many observers, this confirms an assumption that other institutions in Japan also had a prejudice against women and that, even though they have not been exposed, they are discreetly taking steps to rectify the imbalance.

The university said that it offered places to 44 applicants who were denied them because of the exam manipulation. A total of 24 accepted the places, 16 of them women.

Medical Student debt – time for government to change policy on doctor recruitment

Fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

Women perform better at 18, so change the age at entry to med school

BBC News reported: Japan medical schools ‘rigged women’s results’

The Guardian reported in December 2018: Two more Japanese medical schools admit discriminating against women

In Kyoto the education ministry reports: More men pass entrance exams than women at 80% of Japan’s medical schools: survey

 

Health Consumers NSW‏ @HCNSW Jan 15

The proudest day of Grace’s life was graduating as a doctor. Then she began treating patients. Beautifully-drawn cartoon story of a first-year doctor and a widower in hospital.

Declining standards around children and autism…. the evidence is damning and could be stopped with an honest debate and rationing.

We have all got a personality (of sorts) but if you think that “The term ‘autism’ is used to describe different conditions including Asperger syndrome and Pathological Demand Avoidance”, and that more and more are being diagnosed, should we ration care to this group somehow? If we don’t then the care for the rest of us has to suffer. When there are not enough staff, there are going to be “gross failings”. There are bound to be “too many children in Mental Health Hospitals” if the community support and the staffing levels are not high enough. The system is only broken because we will not discuss rationing overtly…. If people and families know in advance what is not covered, then they can plan for the deficit… Privatisation trickery (as in Bradford) is not going to hide the shortfalls… Children and families who are less able to communicate well will be those suffering from more risk from sepsis.

On 20th May BBC news reported: Too many children in mental health hospitals, says report

On 21st May BBC News reported: ‘Broken’ care system for most vulnerable

On 2nd April Eva Ontiveros for BBC World Service opined:  Is autism being missed among women and girls?

“Lots of autistic girls and women come across as very quiet, shy and introverted,” says Alis Rowe, a UK author and entrepreneur who was diagnosed with autism a few years ago.

“These quiet girls – and their problems – can be ‘invisible’ to other people.”

Alis says she herself was not diagnosed until she was 22.

Autism spectrum disorder or ASD is a condition that affects how people communicate and interact with the world. It is estimated that 1 in 160 children worldwide has an ASD, according to data from the World Health Organization, but there is a huge disparity in diagnoses by gender….

On 10th April BBC News reported: Southmead nurse cautioned over man with autism’s death

Rosie Taylor May 22nd in the Times: Thousands of children still die in NHS sepsis care ‘lottery’

Thousands of children may have died or become disabled in the past decade because of a failure to end the postcode lottery in sepsis care, nurses say.

There is still no national early warning system for identifying the potentially fatal condition that affects up to 27,000 children every year, despite repeated calls from campaigners. Scotland introduced a checklist to spot sepsis in children in 2017 but no such scheme exists in England and Wales.

Today the Royal College of Nursing (RCN) congress in Liverpool will demand that a national paediatric early warning sign score (Pews) scheme for sepsis be launched “as soon as possible”….

Rebecca Thomas on 13th May in the Health Services Journal reported: Leaked report shows ‘continuing’ problems with mortality reviews

NHS England has been told to support areas which are failing to deal with a backlog of reviews into the deaths of learning disability patients, according to a new report.

The annual learning disabilities mortality review, leaked to HSJ ahead of official publication this month, has also found “significant variation and inconsistency” across regions, with the Midlands and East, and South East the worst performing areas…….

In the UK, official figures indicate there are about 700,000 people on the autism spectrum. Males are currently diagnosed at a higher rate than girls – up to a 16:1 ratio in certain studies.

Remember 2017: Connor Sparrowhawk: Mother questions NHS trust’s ‘culture’

John Monahan for BBC News NI 21st February reports : Autism diagnoses in NI children up by more than 100%

Some health trusts have seen a three-fold increase and there are also 2,500 under-18s still waiting to be assessed. Healthcare professionals and autism charities have pointed to increased awareness as a reason for the jump…

27th February Louis Lee Ray reported for BBC News: Autism-anorexia link ‘must be acted on’.

The NHS must change the way it assesses eating disorders to take account of a link with autism, a research charity has said.

Autistica said findings suggested one in five women presenting to UK clinics with anorexia may also have autism and tailored therapy was vital…..

BBC News reported 20th May 2019: Strike vote over NHS ‘privatisation’ plan in Bradford

What is the cure for depressed doctors? Adam Kay

The BMA tries to look after the wellbeing of doctors. We all know however, that a union is far removed from an employee! Adam Kay, author of “This is going to hurt” explains his views on solutions. He asks the question, in the Sunday Times 19th May 2019, “What is the cure for depressed doctors? NHSreality agrees with his suggestions, but adds more. In addition to being treated properly, and cared for by our employers, we need meaningful exit interviews, and we need to feel that the edifice of our particular health service is founded on a financial rock, is fair and equitable, so that across the nation those paying the same taxes get access to the same quality of care for serious problems. This is NOT the case. Wales in particular, of all the UK Health Services misses out on choice, quality and waiting times. 

In the BMA website the wellbeing of doctors is addressed.

The support services are explained clearly.

The BMA purports to support the wellbeing of doctors and medical students. it includes:

1. Report: ‘Caring for the mental health of the medical workforce’
2. Principles to improving the health and wellbeing of doctors and medical students
3. Report: ‘Personal stories of doctors in training with experience of mental illness’ 

Nursing crisis extends all the time… Surgery, ICU, intensive care and now oncology and cancer care…

We have as a nation, rationed the training numbers of nurses for decades. Now that Brexit means more are leaving than joining the profession, and we are obviously reluctant to accept more overseas staff, the crisis is on us, and the dissonances of the politicians, who want both Brexit and more Health Service staff are apparent. Export our elderly for their cancer and other care?

Dennis Campbell in The Guardian 19th February 2019 reports: Record numbers of NHS staff quitting due to long hours  – Number of nurses leaving the service almost triples – at a time of more than 40,000 nursing vacancies

Today 19th May 2019 Andrew Gregory in the Sunday Times reports: SOS call for 1,500 cancer nurses – A shortage of specialist hospital staff is having a ‘devastating’ effect, including cancellation of life-saving chemotherapy

Cancer patients face “life-threatening” delays to treatment because of a shortage of specialist nurses.

Some are told on the morning of hospital appointments not to attend because there are not enough staff. Others have chemotherapy cancelled repeatedly.

The NHS has begun a global recruitment drive for tens of thousands of nurses, but the shortages are having a devastating impact, Britain’s most senior nurse and cancer charities say.

NHS providers needed 1,411 specialist cancer nurses in the six months to September 2018, an analysis by the Royal College of Nursing shows. That figure was up 16% on the 1,213 vacancies for the same six-month period the year before.

The statistics, from NHS Digital, count advertised posts. NHS Digital says they are likely to understate the shortage because one advert can be used to fill many vacancies and not all hospitals advertise on the NHS Jobs website.

Dame Donna Kinnair, chief executive and general secretary of the Royal College of Nursing, said: “Chemotherapy and radiotherapy are proven to save lives. Any delays in delivering them can be life-threatening, so the shortage of specialist cancer nurses across England we’ve uncovered means that patients’ lives are inevitably being put at risk.

“People with cancer are worried and distressed enough as it is. They know all too well the impact delays can have on their prognosis.”

Kinnair will tell the college’s annual conference in Liverpool tomorrow that the shortage of specialist nurses is having a devastating impact on patients.

“What’s even more worrying is that the situation is only going to get worse, as the budget for nurses’ specialist training has been cut by over £100m in the past five years,” she said.

A lead cancer nurse at one of Britain’s 12 regional cancer centres, speaking on condition of anonymity, said: “Chemotherapy treatments are being postponed, cancer patients are waiting longer for pain relief and there is little or no time for communication with patients.

“The astounding thing is patients are so forgiving. Patients looking after each other is becoming increasingly common.”

The nurse added: “Most people are so gracious, but the fact is that if delayed by more than one or two days the treatment may not be effective.”

Rising numbers of cancer nurses who quit because of stress, burnout, a change of career or early retirement were worsening the shortage, experts said.

Lynda Thomas, chief executive of Macmillan Cancer Support, said the vacancy figures demonstrated “the significant crisis that now faces our cancer workforce”.

“We urgently need a government plan,” Thomas added. “This crisis needs a solution, and it needs one now.”

The Department of Health and Social Care said plans were in place to hire an extra 1,500 cancer staff but conceded this was across all medical professions — not just nurses — and in any case will not be achieved until 2021. It insisted: “Improving cancer care and reducing waits continues to be a priority for the NHS.”

The cost of care means we may end up exporting our elderly.

 

Scottish Highlands: Bullying continues as endemic

 “Last year, a group of senior clinicians claimed there had been a culture of “fear and intimidation” at the board for at least a decade.” What is needed is exit interviews on all staff, in all four dispensations. Hundreds of staff may have been harmed by bullying and harassment in NHS Highland BMJ 2019;365:l2166

BBC News reported 9th May: ‘Hundreds’ faced bullying at NHS Highland

The review led by John Sturrock QC said staff had described suffering “fear, intimidation and inappropriate behaviour at work”.

Concerns raised by a group of clinicians prompted the review.

Health Secretary Jeane Freeman apologised and said other health boards should learn lessons.

• ‘Culture of bullying’ at NHS board

At Holyrood, Ms Freeman said the culture at the health board had been unacceptable, and she supported the review’s recommendations.

These include educating all staff on the effects of bullying and providing a “properly functioning, clear, safe and respected wholly independent and confidential whistleblowing” mechanism.

NHS Highland runs services in Argyll and Bute, and another recommendation was that a separate review be done of the “functioning of management” in this area, partly because of its geography……..

Peter Gregson in an email to me asks “if only the BBC could take it up” and it has but it wont be sustained:

The Minister has not changed position on anything relating to whistleblowing apart from in one regard. In future she will choose the whistleblowing champions in each board herself. Therefore if any particular champion is getting nowhere with any particular board they just go to her for help. Simples!

She rejects the idea of a whistleblowing hotline again, but gives no indication as to how any whistleblower might be assured that somebody somewhere will register their concerns. “We believe that it is right that Boards, as employers, have the responsibility to initially respond to a concern and that this is key in improving local culture. Where a whistleblower remains concerned about a Board’s approach they will have the ability to raise the issue with the INWO”. [Independent National Whistleblowing Officer].

So we continue to be lumbered with the useless PCAW helpline, the use of which continues to fall. (I calculated in my last email to MacDonald that our helpline sees one-twentieth of what we should be seeing, if conditions in hospitals here can be compared to England [if you missed that, see www.kidsnotsuits.com/nhs-staff-whistleblower-hotline-parliamentary-petition])

How will she know when whistles are blown? Through annual “Duty of Candour” reports from each Board. Which at the moment are not standardised, so for at least the next year, Boards can say as little as they like.

It feels to me that she and her Dept have learnt little from the recent Tayside and Highland shenanigans.

If only we could get the BBC to take up this matter.. Any other ideas?

 

Extreme inequality leads to extreme health outcome differences…

Inequality in wealth is not the only inequality. Opportunity, education, political involvement and awareness, health and life expectancy are all changing. The economist also argues for sticks as well as carrots in Welfare Programme – Spilling over, 9th May 2019:

Talking about penalties (school exclusion and removal of benefits) for a child not being vaccinated “The papers find that such penalties have wide-ranging effects. They encourage compliance not only by the family that is directly affected, but also by their neighbours, and by the families of classmates and siblings’ classmates.”……

 

Delphine Strauss in the FT reports: Britain risks extreme inequality, says Nobel Prize winner

Angus Deaton-led review urges UK to ‘change the rules’ to avoid excessive disparities

The UK needs to “change the rules” to avoid the damaging extremes of inequality seen in the US, according to Angus Deaton, the Nobel prize-winning economist. Britain has not yet experienced anything like the wage stagnation and rising mortality seen among less educated Americans, but on recent evidence, it risks following the US example, Sir Angus will say at Tuesday’s launch of a review that aims to identify the forces driving UK inequality and propose solutions. The five year exercise, led by Sir Angus and initiated by the Institute for Fiscal Studies, a think-tank, is one of the most ambitious attempts yet to understand and address the economic disparities that are often blamed for the surge in populism and decline of mainstream political parties across the developed world. It comes amid a ferment of intellectual activity in both the UK and US, with new think tanks on the left advocating radical remedies to capitalism’s perceived shortcomings, ranging from a universal basic income to a four day working week. Politicians across the political spectrum have been searching for a response to the sense that the UK’s economic and social structures do not give all of its citizens a fair chance. The IFS review, funded by the Nuffield Foundation, a charitable trust, will harness academic heavyweights from several disciplines, with a panel including experts in sociology, demography and philosophy, as well as the World Bank’s chief economist Pinelopi Goldberg and the Nobel-winning economist Jean Tirole. Paul Johnson, IFS director, said the first goal was to understand the interaction between different forms of inequality — of income, work, health or family structures; and between generations, genders or regions — and identify those that matter most.

A report by the IFS, to be published on Tuesday at the review’s launch, noted that while UK income inequality had been stable, this was largely because tax credits had offset worsening earnings inequality. “Benefit income received from the government may feel quite different, in terms of the dignity and security it brings, from income earning in the labour market,” said the report. But inequality “is not just about money”, added the report. Among other examples, it called attention to a rise in the UK of middle aged “deaths of despair”, from suicide, drug overdose or alcohol-related disease.

The IFS report also noted diverging family structures: high earners have become more likely to live with a partner, while those on low wages have become more likely to live alone. As well as mapping out changing patterns of inequality, the IFS review will draw on international experience to examine the underlying causes. It will look at frequent scapegoats, such as technological change and globalisation, but also at the decline of trade union membership and the widening gap between the most successful companies and the rest, which could point to failures in competition policy. The aim is to design an overarching response — ranging from changes in taxes and benefits to reforms of labour markets, education, competition policy and ownership structures — so that measures complement each other.

“If working people are losing out because corporate governance is set up to favour shareholders over workers, or because the decline in unions has favoured capital over labour . . . we need to change the rules,” Sir Angus will say.

 

Mental Health post code differences, and thats without Wales, Scotland and N Ireland. Nothing National about mental health..

Tom Whipple reports in the Times 14th May 2019: Mental health patients ‘are put at risk by NHS postcode lottery’

A postcode lottery for mental health services leaves vulnerable people in some regions struggling with little more than half the NHS funding of those in the best-resourced areas, according to research from the mental health charity Mind.

In Surrey Heartlands, one of the 44 NHS groupings that cover England, the average annual spend on mental health services per head of population is £124.48. In South Yorkshire and Bassetlaw, which allocates more than any other region, it is £220.63.

Paul Farmer, chief executive of Mind, said that at a time when the NHS was recognising that it needed to increase its funding for mental health, it was crucial to understand that different regions were starting from very different bases. “While we expect differences, we are very surprised by how low the baseline is in some areas,” he said.

Funding would be expected to vary according to the needs of different populations, Mr Farmer said, but it was unlikely that this could explain such large disparities as were found: £70 or more per head separated the least-funded regions such as Somerset and Gloucestershire from those near the top of the list, such as Cornwall and North Central London.

“What this means is, if you’re turning up wanting to be treated for mental health in those regions, there will be fewer resources available,” he said. “It will mean the eligibility threshold will be higher and the level of service lower. You might wait longer and have fewer people available to offer you support.”

Improving the treatment of people with psychiatric problems has been recognised as a priority for the NHS. In its recent long-term plan there was a pledge to put mental health provision on a level footing with physical health, with another £2.3 billion a year in spending to be allocated by 2023. A separate goal was for any investment elsewhere in the service to be matched in mental health, something that the NHS reports has been achieved in all areas.

Mr Farmer said that after years of underfunding, mental health provision was still in some ways a Cinderella service. “For lots of people, their experiences are still not parallel to those in physical health. There’s a big job still to be done. Even the ones spending the most are still not spending at the overall levels needed.”

He said the findings showed that for those spending the least, the extra funds would not be enough to cover the gap and clinical commissioners needed to look at reconfiguring their budgets.

A spokesman for NHS England said: “The fact is overall spending on mental health across the country has gone up year on year, and every local area is on track to meet the mental health investment standard: seeing an increasing number of people in good time.

“As Mind also acknowledge, funding for mental health services will grow faster than the overall NHS budget over the next five years, with a new ringfenced local investment fund worth at least £2.3 billion a year by 2023-24 helping an extra 345,000 young people and 370,000 more adults as part of the long-term p[lan.”

Geoff Heyes, head of health policy and influencing at Mind, said: “The treatment you get shouldn’t depend on where you live. We are nearly at the end of the five-year plan the NHS set out for itself in which it promised to make serious financial investment to improve mental health services.

“We are seeing some positive change on the ground, across the country, but a long-term historic postcode lottery still exists.”

Case study
Last year Alice Mitchell, 22, admitted herself to Kent and Canterbury hospital (Tom Whipple writes). She had attempted suicide twice and this time, she told the staff, she thought she might succeed. “I said to them, ‘I cannot be alone tonight. I will end my life.’ ”

Far from being seen as an emergency, she was almost ignored, she said. “I was shoved into a waiting room for nine hours, with almost no contact.” In that time she was seen by a nurse for five minutes. Finally, the hospital said she could not be dealt with there, and had to be transferred to Ashford hospital. But when she arrived there, there was no bed for her. “Nobody knew I was there, let alone why.”

Eventually she was told that no one could see her until the morning. “It is crisis care, but they don’t work at night. You can’t be in crisis at night.” After another 13 hours she at last saw a staff member, and was discharged. “They said, ‘Go back to your GP and get medication’. In other words, ‘You’re on your own’. ” She had no money and her phone battery had expired.

She said that her 22-hour wait to be seen was only the worst example of the care she has received for mental health problems, which has often seemed to her to be an afterthought compared with the resources available for physical health.

“I’ve had ongoing treatment, which was awful, and crisis treatment which was also awful,” she said. “Bear in mind I went in feeling suicidal, saying I needed to be around someone. I thought what happened was despicable.”

Successive ministers of health are responsible for the nursing shortage. And they are not accountable!!

Of course someone is responsible.

The minister(S) of health are those responsible, over the last 30 years. However, with a short time in office they are not accountable. The result of our first past the post system is short term planning for manpower in all the medical professions.

A disengaged and cynical workforce often cites conspiracy, but it is nothing other than neglect, denial, and lack of any form of guilt.

Perhaps we need an Asperger’s child to ensure we listen. We cannot have Everything for everyone for ever, and we have to ration health care. Better to ration it overtly rather than by randomised post code choices.

Exit interviews would inform Trust boards but they don’t happen, but even if they did, would the feedback get to the minister?

NURSING SHORTAGES The Times letters 13th May 2019
Sir, We are seven years on from the 2012 Health and Social Care Act. The act left nobody accountable for a workforce strategy for health and social care. The nursing vacancy rate has reached new heights — 40,000 vacancies across the NHS in England alone, with thousands more in social care.

The answer to the workforce crisis gripping our health and care system does not lie in a sustained over-reliance on the recruitment of nurses from overseas due to our failure to grow enough of our own. Overseas nurses are a short-term solution for a long-term problem. It’s not fair on other countries, when there is global shortage of qualified nurses. On May 8, the prime minister said “for too long, governments have failed to produce the proper workforce planning to give our staff in the NHS the care that they deserve”. But she will not get a result unless there is clarity about who is responsible.

The secretary of state for health and social care should be explicitly accountable to parliament for provision of workforce.

It must then be clear who is responsible for a credible and continuing assessment of the needs of our population, and the staff we need to deliver care, and then for funding this in the long term. Asking NHS Improvement to come up with a plan does not go far enough in resolving these questions.
Stephen Dorrell; Sir Bernard Jenkin, MP; Eleanor Smith, MP; Dr Paul Williams, MP; Dr Philippa Whitford, MP and Baroness Jolly

 

Long term dysfuctional health systems – all of the UK’s 4. There is learned helplessness, and any exit interview would tell you this.

NHSreality is concerned that it may be too late. Just like the “tipping point” in climate change, the situation in some parts of the country has reached tipping point. You will not know it until you or your nearest need it, but it has “gone over the edge” in places like Pembrokeshire and Hywel Dda Health board in Wales. Ian Kennedy is right (last letter) and Carrie MacEwan is wrong. There is learned helplessness, and any exit interview would tell you this. There is no way the already overworked GP can find time for another 1m appointments. You will be seen by nurses and paramedics first…… unless you exercise a liberty to pay.

The Times reported that 1/3 of doctors use drink or drugs, and the Telegraph 1:7. Has it always been so?

LETTERS TO THE EDITOR February 18 2019, 12:01am, The Times  Times Letters: Treating the root causes of a ‘dysfunctional’ NHS

Sir, While we do not disagree with much of the diagnosis of the NHS’s troubles expressed by Lord Prior of Brampton, the chairman of NHS England (“Health service is chaotic and dysfunctional, says NHS chief”, Feb 15), it is important to look forward, not back.

The NHS long term plan gives us an ideal opportunity to do this, as it allows us finally to unpick the disastrous reforms of the 2012 Health and Social Care Act. It promises an end to fragmentation of the service, pointless competition and excessive or inappropriate targets, which have conspired to make integrated care focused solely on clinical need far harder to deliver. For this reason, the medical royal colleges are working closely with NHS England and NHS Improvement to make the plan’s aspirations a reality.

However, we do not recognise Lord Prior’s implication that staff no longer go the extra mile for their patients. Every hour of every day, doctors, nurses and other NHS staff strive to do everything they can for patients and lead innovative service developments wherever that care is being delivered. They do this in spite of the dysfunctional environment he identifies and entirely because of their vocational approach to a job that is under-resourced and overstretched.

Yes, the NHS must change. But this time around, let the people who work in the system design and lead it.
Professor Carrie MacEwen
Academy of Medical Royal Colleges

Sir, I was horrified to read Lord Prior’s suggestion that NHS staff suffer from “learned helplessness”.

Attributing the difficulties staff and patients face to a dysfunctional system does little to address wider concerns about resource allocation away from frontline services and the recruitment and retention of staff.

His comments come as the NHS publishes its worst A&E four-hour target figures since records began in 2010. Utilising this stance to justify the scrapping of these targets doesn’t address the underlying reasons why targets are being missed but simply shifts focus away from the problems.

Lord Prior briefly addresses issues of morale in the NHS, mentioning junior doctors who previously helped in A&E after their shifts. He fails to appreciate that doctors often work beyond their shifts, covering the jobs of multiple colleagues because of longstanding rota gaps and a shortage of 10,000 doctors. GPs retiring after several years of NHS service do so for many reasons, including worsening working conditions. To imply that NHS staff have lost their sense of vocation adds insult to injury.
Dr Rinesh Parmar
The Doctors’ Association UK

Sir, Lord Prior is to be congratulated for his remarks. History will not look kindly on the flaws in NHS strategy and policy over the past 20 years or so. Three examples would be: first,

the obsessive preoccupation with the wrong business model, stressing healthcare over health; second, the disastrous triumph of form over content represented by the structural changes under Andrew Lansley; third, the extraordinary coexistence of a policy of creating foundation trusts as islands of competition offshore from the rest of the NHS, alongside a recognition of the need to integrate services within the NHS and between the NHS and other services.

The first step is to identify the problem. Lord Prior has his work cut out in taking the next step: solving it.
Professor Sir Ian Kennedy
London EC4