Monthly Archives: August 2019

Despite increases in the number of training posts and a decline in unfilled places, the latest figures show that the rate of GPs leaving the profession continues to outpace the numbers being recruited. Caring cannot be done by machines.

Part of the reason is poor manpower planning, with a disproportionate female workforce, and not enough graduate places, and part is the demographics of old age, Part is due to technology advancing faster than any states ability to pay. Part is due to the short termism of the FTTP (First past the post) electoral system which rarely commits longer than  4 years money, part is due to managers moving on in their jobs usually 2 years) well before the perverse results of their changes is evident, partly due to lack of staff feedback on the system, part due to the public being uncomfortable with looking at death and old age. But the most important (rules of the game) is the lack of leadership and truthfulness from our politicians. This has led to a change in the “Shape of the Job“, early retirement, emigration stress and part time work choices We cannot have Everything for everyone for ever… but we have to have enough staff. Caring cannot be done by machines. The recruitment crisis has been coming for years and there is no quick fix.

Rosie Taylor on 30th August 2019 reports: Pensions and paperwork lead to 1,000 GP partners quitting

The pensions crisis and high workloads are partly to blame for 1,000 general practice partners leaving the NHS in the year since June last year.

The figures from NHS Digital are equivalent to about one in 20 partners — doctors based permanently at a practice that they run. The GPs blamed “overly burdensome admin”, pressured working conditions and the strict new pension rules that disproportionately penalise senior NHS staff.

Overall, the number of fully qualified GPs working in England, including locums, fell by 576 (2 per cent) in the year to June this year. The number of GP partners fell by 5.3 per cent (1,035) to 18,511.

The decline in GP partners is particularly likely to affect patients who want to see the same doctor, instead of a different one each time they visit their surgery. An NHS survey of 770,000 patients has revealed that in the first few months of this year less than half of patients were able to see their preferred doctor when they wanted to.

The doctors’ pensions crisis has been triggered by changes to tax rules that mean anybody earning about £110,000 faces a limit on how much they can pay into their pension each year.

The changes disproportionately affect GPs and hospital consultants because the complicated method by which income is calculated under the rules includes non-pensionable overtime shifts and estimated growth in the value of NHS pension pots.

Doctors say that this unfairly pushes many over the threshold and means that they are hit with large tax bills, with some doctors reporting that their bills are so high they are in effect having to pay to work.

About three quarters of GPs and consultants had cut or were planning to cut their hours to avoid being penalised under the pension rules, a survey of doctors by the British Medical Association (BMA) union found this month.

Krishna Kasaraneni, of the BMA GP committee, said: “These statistics are a stark illustration of the workforce crisis that continues to blight general practice. In the face of high workloads, punitive pension regulations and the overly burdensome admin that comes with running a practice, it is no surprise that the number of GPs, and in particular partners, is continuing to fall. This is despite repeated pledges from the government to boost numbers by thousands.”

In 2015 Jeremy Hunt, as the health secretary, promised to recruit 5,000 more GPs by 2020. But despite increases in the number of training posts and a decline in unfilled places, the latest figures show that the rate of GPs leaving the profession continues to outpace the numbers being recruited.

Martin Marshall, vice-chairman of the Royal College of GPs said: “The number of fully qualified GPs leaving the profession is concerning and reflects the harsh reality of what it’s like for family doctors working in NHS general practice, facing intense resource and workforce pressures on a daily basis.”

Professor Marshall added: “The number of full-time-equivalent, fully qualified GPs is falling and at a rising pace, so we desperately need to see more funding for the roll-out of retention schemes across the country, if we have any chance of turning this situation around.”

A Department of Health and Social Care official said: “GPs are the bedrock of the NHS and we’re backing them with an extra £4.5 billion a year by 2023-24. Last year a record 3,473 doctors were recruited into GP training and we’re funding 20,000 more staff in GP practices. We are also making it easier for GPs to better balance their pensions so they can spend more time with their patients, without facing significant tax bills.”

It’s the shape of the GP’s job that needs to change. The pharmacist will see you now: overstretched GPs get help…The fundamental ideology of the Health Services’ provision. Funding of this type admits 30 years’ manpower planning failure

There is no sustainable ideology – so leaders find their staff disengaged and that their job is impossible..

Martini GPs or Dead end jobs. The option is in the hands of politicians..

It was the best job in the world – for me 1979-2012 – but now there are not enough of us to cover the country

Just how paternal could the state become? Jobless New Zealanders reminded to brush their teeth

A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

If Nurses fill the gaps left by the shortage of GPs, this will be the start of private practice in many towns..

“Serious risk of collapse”. The BMA represents the majority of consultants and GPs thoughts, and not the Royal College of GPs (RCGP). We ALL need to worry. Its going to get worse, until we face up to reality.

Its more than a thin front line, as half timers take over from deserters…

A first city GP service implodes. Being a GP is too stressful to do full time, say trainees

2,000 foreign GPs needed to tackle growing shortage. How about an apology to 20 years of rejected applicants to medical school?

Who on earth should health workers vote for? “Infantilised as a democracy….”

As standards fall, so the politicians look for scapegoats: GPs make an easy target

Personal, continuing care….. is going the way of the dodo. Basingstoke represents the rest of the country.

GPs less popular: You cannot expect an under manned and underfunded service to maintain it’s all star rating, especially in our media led society.

Mandator NHS service plan for new doctors…..? Run, Doctors, Run! (While You Still Can)

There is no plan – only inactivity and statemate. Gradual decline in state standards seems inevitable, in contrast to private…

GP recruitment and confidence crisis

The train crash is coming – slowly. Despite Oliver Kamm

NHSreality would like the politicians in our liberal democracy to tell the truth. Debate is only happening where Hospital Staff, doctors and Dentists meet privately: their coffee rooms, and behind closed doors in Whitehall. Occasionally i have heard a retired chairman let it slip
: “all health care is rationed”, but there is no follow up in the implications. Thus the “honest debate” demanded by Mr Stevens 1in 2014 is refused us. In my local Liberal Party we plan a debate on these issues, and possible use of ID cards to help more fairness. Will the members turn out to discuss such an unpleasant subject? If they don’t the train crash gets closer.

We need to be prepared to upset some people – those who are knot open to logic. The result is knee jerk opportunistic locality based rationing which is unfair’.

Oliver Kamm in the Times 30th August 2019 does not seem to support this view in “Private healthcare is no match for our fair and efficient NHS”

His first paragraph ends: “There is no crisis of affordability in healthcare and the model of “socialised medicine” is actually a pretty efficient provider.” Disagree for the future. The cost of new technologies is advancing faster than any state’s ability to pay’.

T&he last reads: “The evidence is that mental disorders (40% of the spend) such as clinical depression have a big impact in reducing labour productivity, and that treatments for it — psychological therapies such as cognitive-behavioural therapy — are time-limited and cost-effective. These remedies should be offered more readily on the NHS; they would benefit public health and the economy, and they are affordable.” Agree. But they need to be offered instead rather than as additional therapies. The reasons he gives for relative efficiency are “in the NHS, there is no perverse incentive for doctors to over-prescribe. That’s not what their salary is based on. Second, because treatment is free at the point of use, this encourages early diagnosis. Third, the decision on treatment is taken by the doctor rather than the patient, which tends to contain costs.” NHSreality agrees with all this, but if we want a universal system where the rich get thie same as the poor (England v Wales, Bankers and Miners of Tredegar) we need the speed and quality of the state service to be so good that private care offers little advantage. The trend is in the opposite direction..

January 6th 2018: “The NHS is like a tumour on the public finances, expanding so aggressively that it threatens to kill other organs of state …. Better still would be a formal policy if provision is to be limited — but the politics is too sensitive”.

21st December 2018: IMF forecast is damning.. A two tier system emerges from denial… A collusion of politicians and leaders…?

Nov 5th 2018: It’s about to blow up. There is no Mr Fawkes to arrest, blame and punish (hang draw and quarter) for the coming NHS failures

March 12th 2018: No good news for those who think money is the answer….

July 1st 2018: What models of funding are best for a healthy and just society? No other country has chosen our system, even after 70 years and our Olympic boasting. The public need to be led into realising why not.

September 15tih 2018: The 3 myths of the NHS…..& …No learning from other countries – no co-payments, and more scandals..

1st June 2018: The real cost of the English taxpayer subsidising NHS Wales – is twice the official figure

May 15th 2015: Britain ranked last (out of 20 rich countries) by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.

May 1st 2015: NHS funding advice: GDP worth debating… Showers of money will not work..

Nov 22nd 2014: When and who will eventually speak out honestly? 10% now to 20% of GDP by 2061

October28th 2013: GDP and GVA differences across the UK – a threat from Scottish Independance

Ju;y 18th 2018: Brexit dividend for NHS is a fallacy, says OBR

July 21st 2019: The value of the UK’s health information – and only partial value at that.

Sept 28th 2018: Taxes must rise to pay for NHS funding, Lagarde says. Tax changes need to be considered as a whole.

July 2nd 2018: NHS at 70: Five medical experts diagnose NHS problems – and prescribe cures. The BBC is a government organisation, and funds the Radio Times. It cannot be expected to give credence to rationing overtly.

27th May 2018: Some of the options, all unpleasant, for raising money for the UK Health Services. Tax reform – “fishing for funds” in the Economist

May 25th 2018: Tax rise for NHS can’t be put off much longer

24th May 2018: Addressing the “black hole” in the health budgets – wait for political denial.

25thi April 2018: The NHS at 70: Loved, valued, and too costly (print version) / affordable (on line version) – even the experts don’t know where to stand. The core principles need to be changed..

March 27th 2018: Ten year budgets, fiscal vaccinations: these are all the dying suggestions of a system designed to fail.

March 26th 2018: “An illusory technical excape from spending choice”, “a fourfold revolution is required”, “clumsy and unreliable”…

March 23th 2018: Is Hyporthecated tax a solution, or a distraction? NHSreality is clearly against, but it looks as if we are all going to “share” a lot more..

Feb 9th 2018: A bigger and bigger deficit in West Wales…… Now at £600 per head……

Jan 28th 2018: A cash injection alone won’t cure NHS ills. Lets be clear: there is no more money, and no Brexit dividend.

Jan 27th 2018: Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

September 24th 2017: A 150% increase in patients going private is an indictment of the UK Health Services… Successive health ministers have ensured a thriving pprivate system.

20th September 2017: Pragmatic decisions need to be taken to insist on rationing… Are we are gullible enough to believe their lies?

September 18th 2017: Surveys of the uninformed are less valuable than those of the staff: survey doctors and nurses please Kings Fund

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

Despite “adequate or average” funding, our waiting lists are much higher than average. Even communication is failing at a basic level…5

Why aren’t the UK Health Services centre stage in this election? All 4 are bust.

If the NHS really is the envy of the world, why don’t countries copy it?

…political “unsayables”. Behind closed doors nearly every politician admits that the current system for paying for health and social care is decades out of date.

4th June 2014: Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”

Ju9ne 5th 2018: We need tax and fiscal policies that upset some!..”The role of a leader is to persuade voters of the need for reform, rather than just to follow public opinion.” but we have no leadership, and no honest debate ..

Going bust when it’s not allowed – all English Regions bar one.. The knee jerk response has yet to happen, as has the “honest debate”.

The cost of curing just one congenital disease…. The pace of advance of technology is faster than any government can afford

The good news this week – is usually too expensive. But there is hope on depression, and exchanging drugs for therapy.

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



The NHS is at risk from a no-deal triple whammy. Winter is coming, along with a flu outbreak and a “no deal”……

The risks of Brexit to the 4 health services are in inflated costs (products are bought in US dollars), and staff (many are from overseas, mostly non-European). The triple whammy : Winter is coming, along with a flu outbreak and a “no deal”.  

Chris Hopson in the Times 26th August 2019: The NHS is at risk from a no-deal triple whammy

Whatever your views on Brexit, our key public services need to be fully prepared for no-deal, should that occur on October 31.

Foremost in our minds should be NHS hospital, ambulance, mental health and community service trusts that provide vital healthcare to a million patients every 36 hours.
How ready are they to manage a
no-deal Brexit?

The NHS has a proud tradition of performing well in a crisis. Trust leaders are used to preparing for emergencies, working closely with other public services. As you would expect, there is a huge amount of planning being done. But there are two features of a no-deal Brexit that frontline leaders believe are significant risks for the NHS.

The first, due to the timing, is an awkward potential triple whammy: a difficult winter, a flu outbreak and a no-deal. The NHS is at its busiest over winter. Emergency care performance figures, the worst in more than a decade, show how much pressure the service is under, with concern that we’re heading for a pressurised winter. Levels of flu in Australia, often a good predictor for UK winter flu, are at their highest for some years. Combine that with the prolonged negative impact of a
no-deal Brexit, should that occur, and you have an NHS chief executive’s nightmare scenario.

The second concern is how many risks are beyond the immediate control of NHS trusts and require close and effective working with other public services and, particularly, central government.

Trust leaders are very dependent on the work of others to secure 8,000 medicines and other medical devices from European supply routes. They are similarly reliant on others to ensure that the NHS can feed 120,000 patients a day and to guarantee the free flow of traffic in areas such as Kent so ambulances, patients and vital staff can reach their destination.

Trust leaders need greater support as an NHS free at the point of use for all EU citizens moves to being one where staff will, overnight, become responsible for eligibility checks. They need the government to remove obstacles and uncertainty for European staff on whom the health service is heavily dependent.

NHS leaders are working hard with other public services and Whitehall to manage these risks. But we need to recognise that this is a complex and resource-intensive task, especially when set alongside everything else an overstretched NHS is trying to do.

Chris Hopson is the chief executive of NHS Providers, which represents all English NHS hospital, ambulance, community and mental health trusts

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Hip and IVF rationing – the thin edge of a web of denial

The rationing around hip replacements not only causes pain and depression, and lack of mobility, but it accelerates ischaemic heart disease, obesity from inactivity, and diabetes. This means more hart attacks and strokes than we need to have as a nation. The profession knows all this and when we are in need we may be in a post code with well managed waiting, but we may be in a poorly managed or funded trust, perhaps with a shortage of long term staff. Manned by a succession of locums the result is more infections and complications. No wonder many people vote with their feet and go privately. They can choose their consultant, when they are operated on, and reduce risk greatly to avoid complications.

What is so silly is that the government does not admit to rationing at all. If it did we would rightly wish to know the how, why, where, when and what was not available to us all… it is only when this type of honest discussion is possible that things will change. 

In the last week I have heard first hand of different rules regarding wheelchairs for paraplegic and legless patients, hearing aids (In England they have WiFi compatibility but not in Wales) and expensive drugs for rare conditions. We have to ration overtly…

Meanwhile they will get worse, and the unofficial, unintended (presumably) two tier system will extend…Just wait until it affects YOU, or your nearest and dearest.

Max Pemburton in the Daily Mail 24th August 2019 waxes lyrical about his gran’s waiting for her Hip replacement.

On the same day in the Telegraph Dev Chakravarty asks: Why shouldn’t single women be able to have IVF on the NHS

Aside from the fact that there is no NHS, the rules in Wales and England, and from Trust to Trust and Post Code to Post Code are different.

Since it is funded by the taxpayer, there will always be a degree of rationing in the services the NHS offers patients for free at the point of use. The debate over which services it provides, based on which criteria, is therefore a constant in our public discourse. There are few areas more sensitive than the provision of IVF.

The NHS limits access to IVF in all sorts of ways in different parts of the country, but the reports that NHS South East London is to bar all single women from receiving funding for such treatment were startling. In justifying its decision, which is now under review, the authority controversially cited a document which declared: “A sole woman is unable to bring out the…

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GPs told to stop closing for half-days . Corporate bullying and breaking contracts unilaterally will not “gag” self employed GPs.

The contract between an independent GP as a self employed practitioner, and the state is a written one negotiated by the BMA. Some practices are large enough for there to be no half day closures, but some are not. This “instruction” is illegal, and should be ignored and challenged in court. (By the BMA). However, there is a problem with single handed practices, usually either in distant rural locations, or in city centres. GPs, mainly female appointments since 2000, are NOT an emergency service any longer, and their contract states this. Many GPs work part time to accommodate family commitments. The idea of the instruction is to free up appointments; I know of no GP who is not exceeding his contractual commitment, but it is very possible that corporate bullying of this nature will mean they start working to rule. It is not the professions fault that there are too few bodies at the coal face. Even today, when Medical Schools are trying to train more, there are 10 applicants for every place. Why not appoint on criteria rather than competitively…. Overcapacity might result in rather more appointments but it will take a decade. It is the perverse incentive to save money and plan for only the next four years, rather than empower good manpower planning, which has led to this situation. Government has been in denial of it’s own part in the mess that is General Practice today for at least 6 years… The corporate culture of Hospital bullying will not work in General Practice.

Exclusive: Doctors are ordered to stop halfday closing at surgeries …
Daily Mail19 Aug 2019

Anviksha Patel reports in Pulse 0n 19th August: GPs told to stop closing for half-days or risk losing £40k in funding

GP practices have been warned to stop closing for half-days or risk losing £40,000 in funding, according to new plans by NHS England.

The plans to withhold funding come as figures show over 700 practices in England regularly close for part of the working week, according to findings from the Daily Mail…..

….Figures show in 2018/19, 722 practices were shut for part of the week, 197 of which initially did not declare they were closed for a half-day. Additionally, 38 practices reported their total opening hours amounted to fewer than 45 hours per week, lower than the contracted 52.5 hours per week.

The BMA has said instead for ‘threatening’ GPs by reducing their funding, NHS England must address the GP recruitment and retention crisis as a solution to ‘lasting improvement to patient care.’

BMA GP committee chair Dr Richard Vautrey said: ‘It is disingenuous for NHS England to be so categorical in claiming they know exactly how many more appointments would be available if practices changed their opening arrangements….

Richard Ault in Stoke on Trent live 23rd August reports “North \Staffordshire GPs ordered to end half-day closing.

Orders issued to GPs to end the practice of half-day closing have been slammed as ‘political nit-picking’ by a leading North Staffordshire doctor.

NHS England says more than a quarter of a million GP appointments will be available when surgeries end the practice of shutting midway through the day…

In future, as part of the NHS Long Term plan, practices will have to seek permission from local health authorities to shut during working hours or risk losing funding worth more than £40,000 per business……

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Pulse 29th September 2017: Extended GP opening has ‘no immediate correlation’ to A&E … –

Sofia Lind in Pulse 27th October 2013: Longer opening hours needed



NHS s compared to 10 days for public sectors workers generally (10 days) and private sector (5 days) NHS staff take average of 14 sick days a year

You are twice as likely to take sick leave as a public sector than the private sector worker. Those who take least sickness are the self employed. If you are self employed you cannot get Statutory Sick Pay as you are working for yourself and therefore do not have an employer. GPs are self employed, but more and are becoming “salaried”, and of the new entrants a large majority are women. If GPs do become self employed, rest assured their sickness rates will go up. I suspect rates for hospital doctors are rising right now..  without their hearts and minds believing it is sensibly founded this will continue and worsen..

In the public sector, 9.8 days were lost to sickness per employee last year (compared to 5.0 days in the private sector), while employees at businesses with 1,000 or more staff took 7.6 days off sick. Mean is the sum, or average, of a group of numbers in a set. Median is the middle value of a list of numbers.4 Jul 2018.

In 2017, women had, on average, 72% higher physician-certified sickness absence than men, compared with 33% higher self-certified sickness absence than men [42,43]. The present study therefore concentrates on the evaluation of longer sickness absences that may qualify for physician-certification.

Doctors in training had an average annual sickness rate of 1.1%, and the average rate among consultants was 1.2%. This compares with an average annual sickness absence rate of 4.2% for all NHS hospital staff, 4.5% for nurses, and 5.5% for ambulance workers.

Andrew Gregory in the Times 25th August reports: NHS staff take average of 14 sick days a year

Ashleigh Webber in “Personnel” on 4th July 2018 reports: Employees taking less time off sick, yet costing employers more.

NCBI resources Aug 1st 2018: Gender equality in sickness absence tolerance: Attitudes and norms of sickness absence are not different for men and women

Andrew Goddard 26th May 2018 in the BMJ: Doctors sickness rate is a third of other NHS staff. (And its even less in self employed GPs)

Physiotherapy and counselling for NHS staff in drive to cut sickness rates

Hospital job vacancies top 100,000 due to bad planning. NHSreality adds political short termism, & high sickness and absenteeism..

The NHS culture is sick – and so are its staff – But is there any “quick fix”?

Waste in the Health Services. It;s mainly due to staff absenses…

Cleaning up the UK Health Services, changing the culture and importing honesty..

A recent article in the BMJ pondered “Why Doctors Don’t take Sick leave”

Independant GPs: RCGP chair Clare Gerada calls for all GPs to become salaried

Update 31st Au9gst 2019:

Health Service Journal 30th Augu9st 2019 Managers most likely to say mental ill-health caused sick leave

Merto 25th August 2019: NHS workers’ most common reason for sick days is mental health issues and Sheffield Telegraph: Mental health problems main cause of sick days for NHS workers across England

Hospital chief says family time would give patients a better end to life

The end of most of our lives will not be planned or expected for long. The “handover” from oncology and chemical treatment to attempt cure, and palliative and then terminal care, is not good enough. Those in charge of the former are reluctant to give up and hand over to the latter. The result is a lot of unnecessary discomfort and stress, and often in rural areas, of travelling long distances to achieve very little. The interface between these specialities would be best facilitated by a GP, preferably one with a palliative care interest. 

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Advanced directives would also be helpful, and other countries are showing us the way.

Sarah Kate Templeton on June 25th in the Times reported: Professor Marcel Levi: Dying should shun treatment and take final holiday – Hospital chief says family time would give patients a better end to life

Patients who are dying should be allowed to go on a final holiday rather than be subjected to gruelling treatment, according to the boss of one of Britain’s largest NHS trusts.

Professor Marcel Levi, a practising doctor and chief executive of University College London Hospitals, said the NHS is wasting time and money treating dying patients at the end of their lives.

He said: “I often think, ‘You would be better going on holiday with your family and you may have a little shorter but a lot better end of your life.’”

Levi, who is Dutch and was previously chairman of a leading hospital in Holland, said: “I do not find the discussion, ‘Which patients should we not treat any more at the end of their lives?’ very well developed in the UK.

“The patients do get anti-cancer treatment when the oncologist, probably the patient and his or her family know it is not going to contribute a lot and it may cause a lot of safety problems and harm.

In Holland, Levi said it is common for patients to state they have had enough treatment and do not want to go back into intensive care.

In the UK, however, he said patients are automatically continuing with treatment in the absence of an honest discussion about what is going to be achieved.

“Patients who are 85 years old do not have to expect a lot of gain from haemodialysis [kidney dialysis], but they still go there three times a week. They feel terrible on the day of dialysis, they feel terrible the day after dialysis. That is six out of seven days of the week,” he said.

“Somebody should at least discuss with them, ‘Is this useful for you? Are you really having any gain of quality of life by doing this?’

“They have a very short life expectancy and we are actually spoiling the last weeks of their lives instead of making them comfortable and them spending quality time with family and friends.”

About 43% of NHS spending goes on the over-65s, according to the Nuffield Trust healthcare charity. This age group also occupies about two-thirds of hospital beds, National Audit Office figures show. Between 10% and 20% of the NHS budget is spent on people in the last year of life, a government-commissioned palliative care funding review found.

Dr Gordon Caldwell, a consultant physician at Worthing Hospital, West Sussex, agrees that British doctors — himself included — often avoid frank discussions about letting patients die.

He said: “Often, as doctors, we hold on to hopes of marginal benefits — ‘You could live 30 days longer, perhaps to three months’ — but omit, ‘This will involve 60 days attending hospital, so you could not go to see Snowdon and Anglesey with your grandchildren.’

“We have relatives demanding, ‘Do everything, doctor.’ Those same relatives, when the patient dies, ask, ‘He didn’t suffer, did he?’ Well, if we were honest [we would say], ‘Yes, he did because you asked us to do everything.’

“I strongly suspect many patients would want less medical interference, such as tests, treatments, last-ditch attempts at chemotherapy.

“Doctors must learn to be honest about the true likely effects of their tests and treatment — a marginal benefit in a few patients at a lot of opportunity loss. A day spent having chemotherapy is a day not with the family.”

Levi said it is up to physicians to broach the subject and it is often welcomed by patients and their families.

“It is the doctors who start the discussion. It was a bit tricky when we did this [in Holland] but it actually turned out that many, many patients and their families were extremely supportive,” he said.

“There were many families of patients who died of cancer who said, ‘If I knew before this was going to happen, we would not have done this operation or this chemotherapy.’”

Professor Karol Sikora, former chief of the World Health Organisation’s cancer programme and chief medical officer of Proton Partners International, a private cancer and healthcare specialist, said there are now more than 25 cancer drugs available that cost more than £50,000 for one year’s treatment and in most cases these would prolong life for only an extra three months.

He added: “There is so much pressure to be active, driven by the pharmaceutical industry and the breakthrough mentality. Giving patients permission to let go has got a lot harder over the last decade.”

However, Baroness Finlay, a crossbench peer and palliative care consultant, believes patients must be given the options of treatments that could help them live longer.

“Sweeping judgments about a person’s quality of life are dangerous,” she said. “Anyone can refuse or cease treatment and that wish must be respected but it becomes dangerous when people are not given the options that might help them live longer and live well.”

Judith Kerr, 94, the children’s author and illustrator who wrote The Tiger Who Came to Tea, has already made her preparations. Last year she told The Sunday Times she keeps “a little piece of pink paper signed by the doctor, saying ‘Do not resuscitate’.”

She added: “Having had a good life, to go through this misery, and at great expense to everybody else — expense not only in money but in emotion.”

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

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

Selecting doctors, and portfolio careers crossing from primary care to Hospital.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

The Canadians shame us with their plans for end of life care

Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

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