BMA ARM: Doctors spurn NHS long term plan

The BMJ publishes “Doctors spurn NHS long term plan”, ( BMJ 2019;365:l4392 ) at the Annual Representatives Meeting, which reflects reality. The profession has not bought in to it. It is not founded on a financial or philosophical rock. Without the honest discussion that Mr Stevens called for we can get nowhere. So it’s going to get worse..

Doctors at the BMA’s annual representative meeting have expressed strong doubts about NHS England’s strategy for the next decade, published in January.1

Representatives voted overwhelmingly against a part of a motion proposed by the Wigan division that the meeting, being held in Belfast this week, “welcomes and supports the aims and initiatives of the plan.”

Tom Dolphin, a consultant anaesthetist and member of the BMA Council, proposing the motion, compared the NHS Long Term Plan to a “sketchy unfunded wish list for the NHS.”

He said, “The plan has two major problems: workforce and finances.” He described as “vague” and as lacking identified funding its proposals to shift care from hospitals to the community, to focus more on prevention, and to rely more on digital technology.

“It could have been good, but there’s no detail, too many big reforms, and nowhere near enough money,” he added. “It’s doomed to failure. The government needs to think again.”

A majority of representatives voted in favour of parts of the motion that the plan’s ambitions were largely unachievable because of underfunding and that “the reforms and structural changes proposed are not in the interest of the NHS.”

Without an adequate workforce strategy, the plan would precipitate a greater crisis in this regard, they agreed.

Delegates voted for parts of a different motion that opposed funding cuts imposed through efficiency savings, shifting care from hospitals to the community without a concomitant increase in resources, and the long term plan being a route to a market driven healthcare system.

The motion had been proposed by the retired surgeon Anna Athow, of Enfield and Haringey division, who described the plan as a “business prospectus in code.”

She said, “It is an anti-NHS plan, which is not care according to clinical need but the road to American market driven healthcare.”

But delegates did not agree with part of Athow’s proposal that GP surgeries joining primary care networks could lead to competitive tendering of contracts for integrated care providers. Integrated care systems, she had claimed, would be incentivised to cut care. “These are the principles of the American accountable care system,” she said, which could be run for profit. “The big productivity savings are to come from NHS staff as local ICS workforce boards develop strategies threatening national terms and conditions . . . Skill mix reduction is mandatory, with trained staff replaced with untrained staff.”

George Rae, a GP, was more positive, saying, “In general practice at present we can’t survive without a shift of certain care to other healthcare professionals.” He said that the long term plan did away with aspects of competition and that integrated care organisations needed to be NHS not private bodies. “Let us not throw out the NHS plan with the bathwater,” he said.

Long Term Plan for the NHS | Five Things You Need to Know‎ – The Kingsfund

NHS Long Term Plan Summary | Analysis from Nuffield Trust‎

The NHS 10-Year Plan | Find Out More Information | health.org.uk‎ Health UK

Which party will be brave enough to open the discussion, on a new financial form of health service provision, and be honest about what cannot be provided?

 

 

Endgame for the NHS? Warrington and Horton Trust are bust – same as Wales. Two waiting lists, one for Wales, and one for England.

Just as Wales cannot afford (without central intervention from Westminster treatment for North Wales patients in CHester.  ( Solved by Loan or grant we wonder?) the services their patients need, Warrington and Horton are trying alternative methods to ration by encouraging purchase schemes. They forget that the average DGH has more complications than a private hospital, and if you are paying you might as well ensure safety, quality and a consultant of your choice. (The default operation consent allows any of the team to do your operation). Quite rightly, Helen Salisbury questions whether there us anything that can be done to stop the financial decline. If the 4 health services are to remain free at the point of need, (as opposed to want) we need to ensure that need is not defined by the patients themselves! Now it would be interesting if Chester patients were to demand care in Wrexham, but with longer waits and lower standards this wont happen. Wrexham would be delighted as the money moves with the patient. Chester and Oswestry will have two waiting lists, one for Wales, and one for England.

Helen Salisbury opines: Endgame for the NHS? (BMJ 2019;365:l4375 )

Since its foundation, the NHS has been committed to providing treatment according to clinical need. The distinction between want and need is important—there may be treatments that patients want but don’t need, such as cosmetic surgery. In these cases, they have to go to the private sector and pay up front or through insurance. This is set out in the first two points of the NHS constitution,1 which state that the NHS provides a comprehensive service, available to all, and that access is based on clinical need, not a patient’s ability to pay.

This week Warrington and Halton Hospitals NHS Trust was in the news for its published list of charges for 71 procedures.2 This is not entirely new: starting with an initial offer of varicose vein surgery in 2013,3 the scheme was relaunched in September 2018 with a hugely expanded list of procedures and has only now hit the headlines. This list appeared under the banner “My Choice—by the NHS, for the NHS,” next to the NHS logo. This is very confusing and would leave many people asking, “Is this an NHS service or not?” The list included prices for cataract surgery (from £2251 (€2523; $2872)), knee replacement (from £7179), and hip replacement (from £7060), all of which are beyond the means of most people served by these hospitals, given Warrington’s high deprivation.4

The justification given by the trust is that these procedures have been limited by NHS commissioners.5 Operations on this nationally generated list were initially referred to as “procedures of limited clinical value” and are now “criteria based clinical treatments.” If patients don’t meet the criteria but still want the surgery, they will have to pay.

This makes a mockery of the NHS constitution: either patients have a clinical need, in which case they should receive timely NHS care, or they don’t need the surgery, in which case it’s not in their interests to have it, and it shouldn’t be done by the NHS.

What this programme reveals is that access to procedures with a proven track record of safety and efficacy, which patients need in order to see clearly or move comfortably, is being denied. The “criteria” for many patients are increasingly stringent: the Royal College of Surgeons raised the alarm in 2017 about restricting hip and knee surgery on the basis of arbitrary pain and disability thresholds rather than clinical assessment.6 And cataract guidelines from the National Institute for Health and Care Excellence explicitly state that commissioners should not restrict access to surgery on the basis of visual acuity,7 yet that’s what happens to patients covered by over a third of clinical commissioning groups.8 These decisions are not about optimising outcomes for patients but are a reaction to inadequate funding, requiring patients to be significantly visually impaired or disabled before they’re treated.

Even more worrying is that an NHS trust is explicitly offering a two tier service, with earlier treatment if you can pay. We should resist this transformation from a single, comprehensive system, where all are treated equally, to one where rich patients have rapid access and poor patients struggle to be referred and then languish on waiting lists. Bevan must be turning in his grave.

Methods of rationing in 1966. Warrington shows that we have since invented many more….

Wrexham.com suggests the problem of Welsh patients being seen in Chester is resolved. What nonsense. The financial solution is opaque indeed… and will be so for the foreseeable future.

Manchester, Liverpool, Hartlepool: Death rates in your local DGH are too high..

 

Methods of rationing in 1966. Warrington shows that we have since invented many more….

A new look at Medicine and Politics: chapter 4 –  J Enoch Powell 1966. We have invented many more since Enoch Powell’s day, and the latest from Warrington is how rich or poor you are…

The answer for this post-code lottery is for GPs to send all their patients elsewhere. Since the money moves with the patient, Warrington and Horton will get none.

https://www.sochealth.co.uk/national-health-service/healthcare-generally/history-of-healthcare/a-new-look-at-medicine-and-politics/a-new-look-at-medicine-and-politics-4/

METHODS OF RATIONING

The preceding pages have been devoted to examining how the medical profession is affected by the system that has been adopted for the purchase by the state of a certain quantity of medical care outside the hospitals. That quantity, as already explained, is indirectly fixed by the remuneration the state offers, which determines in the longer run the number and quality of those contracting to provide that care.

Thus, outside as well as inside the hospitals the figure on the supply side of the equation is fixed at any particular time by those complex forces that determine the state’s decisions on expenditure. With this figure demand has to be brought into balance. Virtually unlimited as it is by nature, and unrationed by price, it has nevertheless to be squeezed down somehow so as to equal the supply. In brutal simplicity, it has to be rationed; and to understand the methods of rationing is also essential for understanding Medicine and Politics. The task is not made easier by the political convention that the existence of any rationing at all must be strenuously denied. The public are encouraged to believe that rationing in medical care was banished by the National Health Service, and that the very idea of rationing being applied to medical care is immoral and repugnant. Consequently when they, and the medical profession too, come face to face in practice with the various forms of rationing to which the National Health Service must resort, the usual result is bewilderment, frustration and irritation.

The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. This is not possible where its very existence has to be repudiated.

In the hospital service probably the most pervasive, certainly the most palpable, form of rationing is the waiting list. The waiting list is a complex phenomenon in itself. One component can be likened to a reserve of working materials: if the hospital resources are to be continuously used, there must be a waiting list. The simplest case is that of a consultant available (let us suppose) during a two-hour session. If there were no queue in the out­patient waiting-room, there might be gaps between one consultation and another when the consultant would not be productive— not, at least, in that sense. So it is always arranged that there shall be plenty of people waiting when the great man arrives, so that there is no danger of the expensive mill even momentarily lacking grist. Similarly, if the capital and resources represented by operating theatres and their staffs are to be intensively used, there must be, so to speak, a cistern from which a steady flow of cases can be maintained.

This element of the waiting list is only incidentally a rationing device, though even here time is serving as a commutation for money: a consultant in private practice can accept the dis­continuity of work implicit in a good appointments system, because his patients are in effect buying his waiting time as well as his consultation time or, putting it another way, the patient finds his own time worth more to him than the consultant’s.

Waiting lists, however, normally exceed the minimum related to full employment of the medical resources. They are then directly rationing in their effect. For example, they ration demand for the more able, experienced or celebrated advice and treatment compared with the less: the waiting lists of consultants in the same department of a hospital can differ greatly in length. It is sometimes said that consultants regard a long waiting list as a status symbol and preserve it with the same care and pride as an Indian would a string of scalps. Certainly, consultants are very possessive about their waiting lists. But the taunt is as uncomprehending as it is uncharitable. There has to be some differential rationing for different qualities of an article, and if not price, then, for example, time: better surgeon, longer wait, and vice versa. No wonder consultants, family doctors and patients too resist equalisation of waiting lists, which would mean that rationing by time would have to be replaced by some even less rational or intelligible form of rationing, such as rotation or the initial/letter of the surname.

Generally, the waiting list can be viewed as a kind of iceberg: the significant part is that below the surface— the patients who are not on the list at all, either because they are not accepted on the grounds that the list is too long already or because they take a look at the queue and go away. Naturally, no one knows how many these are. Indeed, the very question is rather absurd, as it implies some natural, inherent limitation of demand. But the part of the iceberg above the water is doing its work, directly as well as indirectly, by attrition as well as by deterrence.

It might be thought macabre to observe that if people are on a waiting list long enough, they will die— usually from some cause other than that for which they joined the queue. Short of dying, however, they frequently get bored or better, and vanish. Here again, time on the ‘waiting list is a commutation not only for money— measurable by the cost of private treatment with less or no delay— but also for the other good things of life. It is an interesting phenomenon of the waiting lists for in-patient treatment that at the holiday season and around Christmas time it may be necessary to go quite far down a lengthy waiting list to get patients willing to accept the long-awaited treatment in sufficient numbers to keep even the temporarily reduced hospital resources fully employed.

I  cannot  but  reflect sardonically  on  the  effort  I  myself expended, as Minister of Health, in trying to ‘get the waiting lists down’. It is an activity about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to ‘strafe’ the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity— otherwise it would lengthen —but of a backlog which, once ‘cleared off’, ought not to be allowed to recur.

Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca, tamen usque recurret: though you drive Nature out with a pitch­fork, she will still find her way back.

In a medical service free at the point of consumption the waiting lists, like the poor in the Gospel, ‘are always with us’. If at any moment of time they do not exist, they have to be re-invented, or rather they reproduce themselves effortlessly and automatically. Ministers come and Ministers go: the hospital service spends a rising fraction, or it spends a falling fraction, of the national income; but the ‘waiting list at 31st December’ in the Ministry of Health’s annual reports still stays the same, a reliably stable feature in an otherwise changing scene. On New Year’s Eve 1959 it was 442,519; on New Year’s Eve 1960 it was 475,643; I962, 474,353; 1963, 470,297; 1964, 475,863; 1965, (oh dear!) 498,972. And what had it been, pray, on New Year’s Eve 1951, back in those early, primitive days of the National Health Service? Why, 496,131.

At the same time, Ministers of Health are broadly truthful when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. For one thing, ‘urgent’ and even ‘critical’ are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the ‘urgent’ cases, seen or treated at once, and the ‘non-urgent’ cases on the waiting list— or, as the case may be, not on the waiting list at all. The latter are squeezed down— or off— by the former. To point to the fact that no ‘urgent’ case goes untreated as evidence that supply and demand can be brought into balance without rationing is like arguing in a famine that because nobody dies of starvation, there need have been no rationing system.

A  DOUBLE  STANDARD

In the last resort the waiting list, or the queue in the general practitioner’s surgery, is one aspect of rationing by quality. In the days of the reform of the poor law and abolition of outdoor relief for the able-bodied, this used to be known as the principle of ‘lesser eligibility’. What are called the ‘deficiencies’ of the National Health Service— the large number of patients per general practitioner, the age and quality of many of the hospital buildings, and so on —are not deficiencies in the literal sense of the word, that the service falls short to a measurable extent of an objectively definable standard. They are those consequences of the quantity and quality of medical care being purchased by the state that help to equate the demand with the supply. The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service.

This is why it is absurd to declaim against a ‘double standard’ of medical care, inside and outside the National Health Service respectively. The standard inside is that which balances demand with the amount supplied by the state; the standard outside is that at which the supply and demand for medical care balance in the market, given the existence of the National Health Service. The standard in question is not necessarily one of purely medical treatment, if indeed the purely medical aspect of care can be divorced from the others. For example, it may well be that a patient acutely ill or gravely injured may be treated as skilfully, efficiently and safely in a National Health Service hospital as in an expensive private hospital or ‘nursing home— often, I would guess, more so. But the paradox is capable of rational explanation. The ancillary aspects of medical care— amenity, privacy, attention in convalescence, a degree of freedom, choice and individual self-assertion—may be valued no less than the essentials that affect life and limb. Indeed, they are sometimes valued more highly, surprising though that may seem. There can also be an element of pride, prejudice, snobbery— call it what you will— that values the identical article more highly when it is purchased than when it is received gratis.

The principle of lesser eligibility has always been applied, cannot help being applied in some form, wherever provision is gratis. It was applied before the National Health Service started in the voluntary and municipal (ex-poor law) hospitals and, indeed, from the beginning of time wherever medical care was rendered free at the point of consumption. Since eligibility is a form of rationing, we naturally find that it, like the waiting list, is also used to establish an order of priority. This is the reason why, for instance, the geriatric and long-stay mental hospital wards are, and have always been, the most ineligible in the service. The priority accorded to the demands of acute illness requires that rationing be applied more severely to the chronic.

Two instructive contrasts outside the National Health Service will illustrate the rationing function which lesser eligibility performs in it. One is the striking contrast between the two forms of old people’s accommodation: the workhouse and the new-style old people’s home. The former was designed to meet a legally unrestricted duty to admit; the latter corresponds to a discretionary and highly discriminating right to admit or not to admit. Consequently the poor law institution had to ration by ineligibility, and still in practice does if it continues to exist, while the new-style home explores ever-rising standards of amenity and care under the shelter of a rationing system of a different kind. Similarly, the paradox of the relatively high standard of the subsidised local authority house, although it is subsidised, is explained by the fact that the demand is tailored to the supply by the discretionary waiting-list itself, and consequently the supply can be rendered in a relatively eligible form.

Parkinson’s Law

The fact that the necessity for these covert forms of rationing springs from the very nature of the National Health Service and not from any particular level of supply attained in it is borne out by ‘Parkinson’s law of hospital beds’, which asserts that the number of patients always tends to equality with the number of beds available for them to lie in. Thus, the ratio of hospital confinements to total births ranged in 1965 from as low as 53.8 per cent in East Anglia to 78.4 per cent in Wales—the national average   was  69.8  per cent. Yet the pressure on maternity accommodation was at least as high in the latter part of the country as in the former. Again, the number of hospital beds for acute disease in the North-West of England is almost twice as great as in the South-East: in 1961 there were 3 per thousand population in East Anglia against 5.6 in the Liverpool region. Yet the pressure of demand, as evidenced, for example, by length of waiting lists, shows no comparable variation. There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting.

It is unfortunate that the nature and the value of rationing by waiting and by ineligibility in the National Health Service are not recognised, at least by the professions. For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidences of ‘inadequacy’ and as blemishes that it lies within the power of politicians to remove, given the insight and the will.

Martin Bagot in The Mirror updated 2yh June reports Warrington’s plans to charge 20K for a hip replacement. It would be cheaper and safer to go abroad.

 

 

We have to make charges, and overseas patients are just the beginning.. The BMA motion shows just how non-representative they are.

It may seem an insignificant sum, at £5 per annum each to cover overseas visitors to the UK who need (or engineer) health needs, but this is just the thin end of the wedge. We need co-payments according to means as well as treatment according to need. The nature of the BMA means that it is manned by retired members (like myself) especially at conferences. Those at the coal face are never heard (No exit interviews) so the real feelings of the profession are out of step with the BMA. This adds further to the disengagement of the profession in the political process..…  Some hospitals / trusts come clean (Leicester) and more need to do so. Of course professionals should feel uncomfortable with the administration of charging, so managers in both hospitals and GP must step up to the plate.

The Times “charging foriegn patients for NHS treatment: Fair Care” – Doctors say it’s ‘racist’. To stop charging foreign patients risks turning Britain into a magnet for health tourists

Bn’s health service is facing daunting challenges: an ageing population, closures of GP surgeries in remote areas and high rates of readmission, particularly for elderly patients who are insufficiently supported when they return home. Yet doctors at the annual British Medical Association (BMA) conference have voted to stop billing foreign patients for NHS care.

In a Britain of limitless bounty, no one could quibble with the idea of allowing visitors from abroad to use the health service without charge. Regrettably, ours is not a land of on-demand milk and honey. Costs have to be kept under control if the health service is to provide adequate care for those whose taxes pay for it.

Under the status quo, patients are entitled to free NHS treatment if they live permanently and legally in Britain. Two years ago Jeremy Hunt, then secretary of state for health, obliged hospitals to check visitors’ eligibility for free care and to charge patients who fail to qualify. Visitors from the European Economic Area are covered for unplanned treatment, provided that they have valid documentation, while those seeking care who live outside the EEA are billed upfront. Not all hospitals collect their debts with the assiduity they should, and some care is free regardless of who is seeking it, including emergency admissions and treatment for some sexually transmitted diseases.

Seen on a global scale, the system of healthcare is generous. If you break your leg skiing in America, one of the first things medical aides will demand as you’re winched away by helicopter, is whether you have health insurance. Yet the BMA, which represents 155,000 doctors, insists that charging tourists and migrants for care makes medical staff complicit in racism and talks irrationally about them becoming “border guards”. Critics argue that the set-up fails in practice, costs the NHS more in the long run and foreshortens lives. Doctors go into their line of work to heal, so the argument goes, not to enforce borders. They do not want to stay in the business of withholding treatment from sick and frightened people deemed unfit to receive it.

That approach ignores reality and common sense. The total budget for NHS England in 2018-19 was £126 billion. Figures on the scale of health tourism are vague and need updating, but they suggest that the problem costs the NHS as much as £300 million a year. In one case, a woman from Nigeria racked up an unpaid bill of up to £500,000 after giving birth to quintuplets in a London hospital. Hours before, she had been turned away from the US by border officials. The last thing the health service needs is to become a magnet for those unable to afford treatment at home but able to board a cheap flight to Britain.

Indeed, people eligible for free care in the UK but infuriated by low standards and long waiting lists are resorting to paying for private treatment abroad. According to the Office for National Statistics, flights out of the country for medical reasons rose from 48,190 in 2014 to 143,996 two years later. Women with endometriosis, for instance, who are awaiting NHS treatment, often in considerable pain, are increasingly seeking surgery abroad. Hospitals from Turkey to Thailand are offering “endometriosis packages”.

It is not unreasonable to expect the NHS to restrict its care to those who pay for it. Nor is it racist to expect hospital staff to enforce rules obliging international patients to contribute to their care. Medical treatment costs money. Far from scrapping upfront charges to foreign patients, hospitals should become more efficient at collecting payments when they are owed, while respecting the possible vulnerability of those the service has treated. Overseas visitors can use the NHS as long as they pay for the care they receive, just like the rest of us.

Letters 28th June:

Sir, Charging migrants for care will not help to fund the NHS, as by the government’s own estimate “health tourism” accounts for only 0.25 per cent of the NHS budget, a tiny amount when compared with other costs (report, Jun 26, and letters, Jun 27). The people who will be hit hardest by this policy are long-term migrants who have been unable to regularise their status, asylum seekers trapped waiting years for a decision from the Home Office, and those people in the UK who do not have a passport. These are people more likely to be in precarious or low-paid work: they do not have thousands of pounds to pay for the care they need.

In practice the exemptions for particularly vulnerable people, and for treatment considered urgent, do not work. Research from the Equality and Human Rights Commission found that people seeking asylum were deterred from seeking care despite being exempt. We must not let the NHS become a place of fear that stops the most marginalised people in our society receiving the help they need. Instead we must ensure that the NHS remains open and free for all.
Dr Omar Risk
Newly qualified junior doctor, Oxford

Sir, In claiming that charges for foreign patients are racist, the British Medical Association has lost sight of the fact that foreign patients take up valuable NHS time and facilities at the expense of taxpaying UK residents. Although I understand doctors’ concerns about charging, there is a solution: allow the funds received to be retained by hospitals and surgeries without any devious clawback into the NHS system. This would be an incentive to collect the charges payable by foreign patients, and would provide additional income over and above budgets.
Ian Bennett
Lymington, Hants

Sir, In New Zealand, everyone — citizen or visitor — who can pay to see a doctor does so, with appropriate provision for the indigent. Nobody here suggests that the medical profession is racist or connives at racism. The members of the BMA who castigate those who support payment by those who have made no contribution to the NHS might take note of a system that works well for all, whatever their status.
David Abell (ret’d GP)
Christchurch, New Zealand

Sir, I am a consultant medical practitioner with almost 40 years experience. The decision of the British Medical Association to offer up the NHS as the “casualty clearing station” for the entire planet underscores why I left the BMA 20 years ago. The organisation has been captured by political extremists and does not represent the average medic.

You cannot have a club (the NHS) with an expensive membership fee (my taxes) that then freely admits non-members.
Dr Michael Creagh, MRCP, FRCR
Peaslake, Surrey

Sir, The doctors who oppose charging foreign patients for care need to be reminded that the organisation which pays their wages is funded by British taxpayers and is the National Health Service, and not the International Health Service.
Alec Gallagher
Potton, Beds

Sir, Further to your leading article “Fair Care” (Jun 27), NHS doctors do not invoice patients. That is what managers are for.
Frank Lawton
Ret’d gynaecologist, London SE21

The Express: GPs vote to stop charging overseas NHS patients – and call it racist

Jeff Taylor in Economic World: Free NHS Healthcare for the World!

The Sun: Doctors push to stop billing foreign NHS patients — calling it ‘racist’

If health and social care funding is combined, the reality of a “quicksand” foundation will be faster..

Perhaps the public need to feel and see the unreality of the situation regarding social care. With so many of the population ignoring their possible future needs, and health care being free, whilst social care is means tested, there is a perverse incentive for those making the decisions (who also hold the purse strings) to class as much as possible as “social”, and as little as possible as “medical”. The actuary is founded in reality, but even their solution only applies to 33% of us!

No wonder the people “ignore their future costs” when they have been told they can have (in health) Everything for everyone for ever. 

I have had several families as patients who have deliberately given away property in plenty of time to avoid the state getting their hands on their cash, and to ensure it all passes on to the next generation. Since inheritance tax is a double tax I am in favour of abolishing it, but that does not mean lucky people who live into their late 90s should avoid payments. The system needs to be altered, and to face reality.

Despite the warnings, especially from “Community Care” the politicians will not grasp the nettle. Homes are going to close. There are many areas of the country where the privately funded are so few that there is only one payment schedule. In richer areas the wealthy often subsidise the state funded clients….. its one of the questions needing asking when being admitted to a home and in my view, in the interests of openness, needs to be publicised on their internal notices, literature and website.

‘Your insurance doesn’t cover acts of God, like age related illness and accidents.’

Nick Triggle for BBC News 26th June reports: Care cuts inevitable in ‘fragile and failing’ system

The Actuary 25th June 2019 (They really do know) reports: Social care reforms proposed for third of UK population – Around a third of the UK population could benefit from targeted government incentives that boost saving for social care, the Pension Policy Institute (PPI) has proposed.

The Mirror reports that the social care time bomb is set to explode as millions ignore future costs entirely. 

Luke Haynes in “Community Care” opines 26th |June 2019: Worsening social care funding position wreaking increased human cost, warn directors – Numbers affected by home care provider closures double as fragile care market and NHS cost shifts exacerbate financial woes for councils

Update 26th June 2019: Next PM should lift constraints on public spending to fund social care like the NHS – report finds

( A report equally in the clouds of unreality. If we cannot afford the one for free, we cannot afford both! ) The BMJ opinion from Anita Charlesworth is well intentioned but unrealistic.

Dominic Brady in Public Finance reports: “Social Care heads are unsure that they can provide minimum finance…”

Anita Charlesworth in the BMJ opines: We need a social care system that is as much a source of national pride as the NHS

Some groups of votes don’t seem to matter. Addiction deaths are soaring as support is slashed……

When Oregon asked it’s citizens about rationing care, the answers that people gave about what they wished to exclude were embarrassing and difficult for the politicians to come to terms with. Abandoning babies under 28 weeks gestation was one of the choices made..

If the population at large were asked about drug dependency and treatment the result might be embarrassing. This is exactly why we have a representative democracy rather than a peoples democracy – or rather we had this until the recent plebiscite on Brexit – and John Strang, who was at Medical School with me, highlights a real issue. If we don’t fund this problem properly, we will be punished by the breakdown of law and order, by children being corrupted, and by many unnecessary deaths. 

Is it a coincidence that many of these people don’t vote? If they were a majority (god forbid) then surely politicians would court their votes. Just as the very elderly in care don’t vote (much or for long) and their votes matter little, so with drug addicts?

John Strang opines in the Times comment June 26th 2019: Addiction deaths are soaring as support is slashed

he UK is experiencing a surge in fatalities from drug and alcohol misuse. Over the last five years overdose deaths from heroin and other opioids are up 50 per cent, though there has been no rise in heroin use. This is a public health crisis requiring a complete rethink of drug strategy to focus on reducing the harm to individuals and society.

Historically, Britain has led the way in drug policy that reduces harm, benefiting not only people with drug and alcohol problems but also their families and wider communities. Yet the debate about drug policy has become more polarised and party-political, with individual approaches now demonised or lionised.

Drug policy should be based on firm scientific evidence, not political ideology, to produce public good. Wrong decisions can produce harm, even beyond the harm from the drugs themselves. For example, if prohibiting access to needles fails to stop injecting and merely leads to increased sharing of used equipment, the result will be a marked increase in the transmission of diseases such as HIV and hepatitis C.

This realisation, in the late 1980s, led the Thatcher government to support the introduction of needle exchange schemes and promotion of messages to change injecting behaviour — a bold, science-informed policy decision that undoubtedly reduced the spread of HIV.

We now need to reorganise the way in which addiction services are provided and funded. A decade ago, we had networks of treatment and rehabilitation services working across health, social services and criminal justice. Today we have an eviscerated skeleton of services, divided by endless competitive tendering that sets one agency against another, with decisions made on the basis of unachievable promises of “cures” and “recovery”.

This “survival of the cheapest” approach, necessitated by savage budget cuts, reduces the quality as well as the quantity of services. Before 2013, budgets for treating people with substance misuse problems were ringfenced under the NHS budget. In 2013-14, the government moved responsibility for substance misuse services from the NHS to councils. Since then, spending has fallen by £63 million and the latest government figures suggest that alcohol and drug-related deaths have almost doubled.

What folly that, at a time when Britain is improving mental health services for adolescents and young adults, those with substance misuse problems are being excluded.

Professor Sir John Strang is head of the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London

Rationing Medical Care – The Oregon Health Plan May 29 2001 in CMAJ JAMC

BMA Chairman tells it as it is. Even he still refers to an “N”HS… and he has ignored the need to ration.

Paul Gallagher in the BMJ reports: BMA chair warns: ‘Deal or no deal, Brexit will be bad for the NHS’  Dr Chaand Nagpaul tells i a no deal Brexit would be disastrous, leading to potentially thousands of EU doctors leaving the service.

Whoever wins the Tory leadership contest and takes the UK out of the European Union will be responsible for damaging the NHS, the head of the British Medical Association (BMA) has warned.

 

Dr Chaand Nagpaul told i that a no deal Brexit would be disastrous for the health service, leading to potentially thousands of EU doctors leaving the country. Even if either Boris Johnson or Jeremy Hunt secures a new deal with Brussels, which is supported by Parliament, European health staff will still consider walking away among other risks to the NHS, he said.

 

Asked whether it matters who becomes Prime Minister next month, Dr Nagpaul said: “I think the important thing is to focus on what this is going to mean in terms of the impact of the NHS and admittedly that will depend on whether we leave with a deal or not. Although there’s still the option of not leaving at all, but nevertheless.

 

“The most immediate issue for us, and what will affect the NHS, is that we have about 12,000 Europeans who work here. We know from our own figures that 1 in 3 intend to leave if we leave the EU without a deal – and that’s because they want to feel stable and secure and they already feel uncertain about their future.

 

“In an NHS where we have 10,000 doctoral vacancies and where the impact on services that is already being felt by the profession and patients, we can’t afford to lose a single doctor let alone several thousand.”

Dr Nagpaul said that a no deal Brexit would effectively end the mutual recognition of professional qualifications, which means that doctors from the EU can come here to work immediately.

“So not only might we lose the doctors who are here, but the doctors that would be coming here will dwindle in number because there would be new barriers – from examinations to other restrictions for them to enter the UK to work. That would be the worst situation.

Biggest impact

“On top of that, other effects on the NHS, such as the regulations of medicines, the movement of specialist drugs like radioisotopes, there will be impact to us in a lot of those areas too. Reciprocal healthcare which we take for granted, that will also cost us considerably if UK residents living in the EU are no longer covered and in terms of those travelling to the EU.

“Even in a Brexit deal, if there is one, we run some of those risks because the deal is only going to be applicable in a couple of years and the uncertainty for EU doctors is there. We’re still very worried [in that scenario] EU doctors will leave the UK and there will be less incentive for anyone to come and work here.”

Speaking to i on the eve of the BMA’s annual conference, which begins in Belfast on Monday, Dr Nagpaul said the UK remains far behind the rest of Europe when it comes to the number of doctors per head: 1 doctor per 366 people here compared to an EU average of 1 in 288.

“So we are trying to provide a service similar to other nations but tens of thousands of doctors short. It just isn’t possible to square that circle.”

 

 

The future of the NHS has been linked to both candidates for Number 10. Mr Hunt said in recent leadership debates he – as Health Secretary – was responsible for securing the extra £20bn funding settlement for the NHS, while Mr Johnson infamously claimed during the referndum that leaving the EU will enable the UK government to spend an extra £350m a week on the health service instead.

 

Dr Nagpaul would not be drawn on either claim, but in what will be seen as a thinly-veiled attack on the pair he said that the public has had enough of political rhetoric that fails to match reality.

 

“We’ve got a very good system, and a system we can be proud of, but what we need is the resourcing that matches that which a comparative developed nation takes for granted.

 

“What I hope and believe is that the public have become much wiser to the fallacy of some of the political pronouncements we’ve had over the last decade. The public expect a more honest government. They’re experiencing the realities of a pressurised health service. The public understand that.

 

“They recognise it’s the government’s duty to enable and staff the NHS to provide good quality care. A lot of it is about stripping out the political motives that have plagued the NHS for too long.”

Workplace bullying

The future of the NHS in a post-Brexit world is expected to be among the main talking point among members at this week’s conference. Several motions will be also be debated on the widespread problem of workplace bullying – some 4 in 10 doctors reported experience of bullying and harassment in a recent major survey by the BMA.

 

It is an area the BMA has focused on under Dr Nagpaul’s leadership since he became council chair in July 2017, hosting a one-day summit on the problem last November where several recommendations emerged on how each trust can clamp it down.

 

Another motion calls to remove the postcode lottery that restricts NHS funding for IVF and other NICE evidence based recommended procedures in some areas, something Dr Nagpaul supports.

 

“I think it’s really important to remember that we call ourselves a National Health Service. That word ‘national’ is really important, because it defines the origins and principles of our health service which is one of fairness, one of insuring patients receive care according to need not who they are and because it’s national it’s delivered wherever you live in the UK, that you have access to comprehensive services.

“The current reality where different parts of the country takes different approaches, which means a patient may get a treatment like IVF in one part but not in another is not acceptable. It’s not in keeping with the principles of the NHS, it’s not fair and not therefore a national health service. That’s not keeping in what we stand for and not what the BMA would support.”

 

Dr Nagpaul is yet to receive a reply from Theresa May to the letter he sent her two weeks ago on “punitive” pension reforms which the BMA believe will exacerbate the NHS workforce crisis by forcing staff into early retirement, although he believes actions will be more important than words. He remains upbeat about the future, despite the mounting challenges facing the health service.

 

“The NHS is as a system remarkably cost effective and an organisation that is rooted in making best use of the public resource. The values and principles on which it was founded are as relevant today as they were then.”

And it’s getting worse still…..as predicted

Rajeev Syal in the Guardian 24th June reports: Areas with most homeless deaths disproportionately hit by cuts.

This applies to medical care as well as social care. As the system implodes further, those areas where the population has more income and wealth are able to pay for disproportionately more services privately. Going abroad can help the NHS – Chris Smallwood in the Guardian 2016.

Anecdotal evidence of declining care is all over the place.  Here is an example in the Mirror. 111 service calling is pretty useless. The  is another sign of the problem, and this is endemic miscounting and configuring (Temporary escalation) of beds. Dennis Campbell in the guardian 22nd June reports that we need 10,000 more beds, but however many we create will never be enough. Point surveys in Hospitals have repeatedly shown that 80% don’t need to be there at any one time, given a celestial discharge option.

More and more people should be demanding to go abroad for medical treatment. The barriers for this are custom, fear, and the risk of complications that then have to be dealt with locally. Other countries are in equal financial difficulty, but have far less manpower planning failure. There are many more staff in France, Netherlands and Germany than there are here.

A new “Gambleing clinic for children” reveals how desperate things have become. The decline of sport in school, the impression that sport is only worth doing if one is in the top team, and then has a professional outlet is morally wrong. Teachers and teaching have been downgraded, and mistreated to the point where team sport experience becomes rare rather than the rule. The suggested mandatory levy in gambling firms is a good idea, but will it reach statute, and will it be practical in an e-world?

And the 4 dispensations will have even worse finances and outcomes after brexit according to Dr Chaand Nagpaul, Chairman in the BMJ.

 

 

 

Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding? If we don’t keep the gatekeeper role for GPs the system will get constipated.

A recent report in the Times (Not on line) opines “Gatekeeping by GPs called into question. This is not new, as you can see from the debate following Matthew Paris’ article in 2015. The problem is not referrals, but the 90% who do not need a referral. Allowing others, less trained in dealing with uncertainty, will lead to more referrals, longer waits and a constipated system. The useless 111 service where there has seen no reduction in GP workload is another attempt to wriggle off the hook of under capacity and poor manpower planning. In his Imperial College funded report, Geva Greenfield and others report: “Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding?”.

One solution is to make patients pay for their GPs and let them have appointments free with the nurses and paramedics. A two tier system by design. Lets see the comparisons in referral rates, expense and survival!! The result would be anarchy.. (sic) Geva Greenfield says “There is a trade-off that needs to be found between GPs serving as hgatekeepers to secondary care, and at the same time allowing patients to see a consultant when they wish”. We are trying to treat patients, and the governement are treating populations. Money matters, and the services are all rationed. (covertly)

This is the sort of thinking “outside the box” of current opinion that we have to get to talking about openly.

On November 26th 2018 Chris Smyth reported in the Times: Bypassing GPs could help to diagnose cancer sooner

In Pulse 2015: GPs should give up their Gatekeeping Roles

Matthew Paris on June 16th 2012 reported in the Times: GPs – little more than glorified receptionists

In this age of medical specialisation, if family doctors didn’t exist we wouldn’t feel the need to invent them

Next Thursday, family doctors plan to strike. Striking doesn’t suit the profession’s humanitarian image. Interviewed, doctors’ leaders struggle to insist (on the one hand) that nobody needing medical attention will be denied it, without implying (on the other) that few will suffer if doctors aren’t there.

How much, though, would we suffer? If family doctors had not existed, would we today have found it necessary to invent them?

We pay general practitioners more than we pay airline pilots, but they are becoming glorified gatekeepers: a portal to the more specialist medical care that our health service offers in growing measure. As GPs have receptionists, so the NHS itself uses GPs as its receptionists. Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?……..

……..Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The response June 18th 2012:

Sir, Matthew Parris (Opinion, June 16) is not quite correct in describing GPs as “becoming glorified gatekeepers”. We have already had that role (among others) for decades.

It is true that part of this role is to refer to secondary care, but he seems to miss the corollary of this; that we also judge when not to refer, thus saving patients, and the country, the burden of over-investigation and over-treating. The internet has expanded everyone’s access to specialist knowledge, but has not, perhaps, increased our ability to apply that knowledge appropriately. We know more, but understand less.

Mr Parris also fails to acknowledge that GPs have a vital role in the other direction of travel; from specialist care to the community. In this past week I have picked up the care of patients after their discharge from heart by-pass surgery, psychiatric in-patient treatment, dermatology, gynaecology, child autism and palliative care clinics.

In addition, we need to manage patients whose symptoms and conditions cover several specialties, as well as those who have exhausted all secondary care investigation without any diagnosis being reached.

“A decent grasp of the whole thing” is exactly what GPs need.

Dr Jonathan Knight
GP, Ipswich

Sir, Matthew Parris assumes that his interaction with his GP is typical of the work that GPs do. I have been working in general practice since 1987 and my experience is very different. We spend most of our time managing long-term illness such as high blood pressure, diabetes, kidney disease and asthma. When I was in training in the 1980s these conditions were managed in hospital but are now managed mainly in primary care. Of course I do not profess to be an expert in everything so I may refer to colleagues for opinions about aspects of a patient’s care, but they are then usually discharged to my care.

Allowing less-qualified health professionals to manage patients has never been shown to be more cost effective than using GPs.

It is this system of every patient having a GP, enshrined in Bevan’s original vision for the NHS, that other health systems around the world have strived to emulate. We should not discard it lightly.

Steve Charkin
London NW3

Sir, Matthew Parris says that he believes he could refer himself appropriately to a specialist, but he is not our typical patient. GPs’ time is predominantly taken up with the very young and the elderly, particularly those with chronic, complex and multifaceted medical conditions. For these folk, it is their GP who sees the “big picture”, the context and impact on the individual and their family, while each specialist focuses in on his own area of expertise. Approximately 90 per cent of healthcare needs are met in the community, by GPs and their practice nurses, with only 10 per cent of care being hospital-based, at far greater expense. It is true that a GP’s role includes “gate keeping” access to expensive specialist opinion, but I would suggest this is essential.

As Mr Parris concedes, most GP consultations do not lead to a referral to a specialist. His vision of a future without GPs to manage the majority of our health concerns would be financially unsustainable and bewildering to many. Would a woman with lower abdominal pain and back ache refer herself to a gynaecologist, urologist, gastroenterologist, oncologist or orthopaedic surgeon? Does she need a specialist at all if it is just a urine infection? How does she know?

While a single day of industrial action will cause no more inconvenience than the extra bank holiday for the Diamond Jubilee, Mr Parris belittles our role at his peril.

Dr Isabel Cook
Reading

Sir, Before getting rid of GPs Matthew Parris might be wise to wait until he is a bit older when he may have to see more than one specialist at the same time. He will find that the treatment for one condition often aggravates another and he will then be grateful for a generalist’s opinion. He will also find it more efficient to keep seeing the same GP so that he does not have to keep repeating his past history.

Dr Richard Stott
Epsom, Surrey

Sir, As a GP I know Matthew Parris is right. A lot of what GPs do is pointless or could be done by others. So there is a simple solution: stop giving us work.

John Booth
Middlesbrough

Sir, There is overwhelming evidence that GPs deliver highly effective, cost-effective care to our patients. Moreover, we do so with the trust of our patients, and with care and kindness.

I invite Mr Parris to sit through a surgery with me at any time, where he will see first hand how GPs care for the elderly, the frail, the disadvantaged and the ill. I’m sure that afterwards his perceptions of general practice will be different.

Professor Clare Gerada
Chair of Council, Royal College of General Practitio

 

We do have a choice, both as individuals (to pay or not to pay) and as a Nation. To ration overtly or to ration covertly.  This trust was wriggling on the hook of financial bankruptcy, and like Wales was unable to afford to pay Chester until the bailout, they are unable to fund comprehensive care.

The Mirror reports 20th June 2019 that Warrington and Halton Hospital Trust have tried to initiate payment schemes for operations that have formerly been free. £18K for a hip. By the end of today the Trust had changed it’s approach, and returned to the standard political speak “Everything for everyone for ever”, which of course is unsustainable. Better to ration high volume low cost treatments and services that patients can usually afford, than low volume high cost treatments that everyone assumes is included in the safety net.

By the end of the day the Mirror on line headlined: “Hospital stops plan to charge patients”.

NHS hospital stops plan to charge patients almost £20k for operations after outcry

EXCLUSIVE : Warrington and Halton Hospitals Trust has announced a ‘pause’ of of the My Choice service which the Daily Mirror exposed on it’s front page today

Update: 20th June 2019

The Trust are pausing the availability of this service and reviewing it to ensure it can in no way disadvantage NHS patients. To date, no NHS patients have been impacted as no one has been treated as part of the My Choice service. The Trust continues to meet all of its diagnostic, cancer and referral to treatment standards.

My Choice scheme and current media coverage

You may be aware of the current media coverage regarding the above scheme. I would like to reassure you about this. For the avoidance of doubt, I would wish to be very clear that Warrington and Halton Hospitals NHS Foundation Trust does not charge NHS patients for NHS treatments and we have no intention of doing otherwise. It is not the role of hospitals to determine which treatments are funded by the NHS and which are not; this is the role of NHS commissioners.

Present for many years, there is a growing list of procedures that our commissioners will no longer pay for if criteria are not met. The Trust does not make decisions with regards to eligibility for such procedures. There is a national list, locally implemented by commissioners. Initially this list was referred to as Procedures of Limited Clinical Value (PLCV); this then became Procedures of Lower Clinical Priority (PLCP) and these are now referred to as Criteria Based Clinical Treatments (CBCT). They emerge from evidence-based guidelines, reflecting the changing nature of clinical practice over the years and the focus on evidence-based medicine and clinical effectiveness. The list of procedures, set by commissioners, includes commonly undertaken operations such as hip and knee replacements and cataract removal.

These remain available on the NHS in the usual way if the criteria are met, as is usually the case. We are now also able to offer these procedures via our My Choice service to make them more accessible for patients who otherwise would not qualify for them under commissioner guidelines. If a patient does not meet the criteria laid out by commissioners, patients have two choices: they can either seek the procedure through the private sector or not have the procedure at all. What we are trying to do, like many others, is to improve the offer for patients with a third choice if they do not meet the criteria required by commissioners; that is to self-fund their procedure within their local NHS hospital at a cost that is potentially more affordable than the private sector, at a price based on the NHS national tariff.

Each case is of course an individual clinical consideration on its own merits with conversations about the risks and benefits of procedures occurring between patients and clinicians as is standard practice. The Trust relaunched the My Choice service in September 2018. To date no patients have been treated under this scheme. Once again, our Trust does not charge NHS patients for NHS treatments; it is the role of the commissioners to determine which patients are eligible (and funded) for which treatment and which are not. Our role, as ever, is to provide safe, high quality healthcare in a way that is sustainable for the future of our local population.