Monthly Archives: December 2019

An unhappy new year looms for the 4 UK Health Dispensations. A worsening disaster…. Hold onto your life..

Nobody discusses reality in health any more. So just a few thoughts for an “unhappy” new year for the 4 UK Health Dispensations. A worsening disaster…. Hold onto your life..

Hugh Pym reports 20th December for BBC news: Political heat eases but NHS chill sets in

Nick Triggle reports for the BBC 29th December 2019: Why 2020 will be a crucial year for the NHS

So 2020 looks set to be a crucial year as ministers seek to meet the challenges facing the health service in England head-on.

But what are the most pressing issues for the Westminster Parliament to address in the year ahead?

Reducing waiting times

Health is devolved, meaning the Department of Health and Social Care does not control health policy in the rest of the UK, although Scotland, Wales and Northern Ireland will be watching closely to see what it does.

Undoubtedly the most high-profile problem – and the one used by critics to beat the Tories – has been the deterioration in waiting times.

It is now more than three years since any of the three key targets covering A&E, hospital operations and cancer have been met.

Both A&E and routine operations are at their worst levels since the respective targets have been introduced.

A&E figures

The first tranche of the extra funding the NHS is receiving – 3.4% above-inflation rises until 2023 – kicked in at the start of April 2019.

But that still has not been enough to reverse the deterioration. Many predict it will take years before the NHS gets back to where it was a decade ago, when it was regularly meeting waiting time targets….

…In fact, Boris Johnson promised to “fix the social care crisis once and for all” in his first speech on the steps of Downing Street when he took office in the summer.

The election manifesto provided no detail on how the Conservatives would do this, beyond promising that people would not have to sell their own homes to pay for care – only the poorest get help from the state.


Ministers want to set up a cross-party commission, but with both Labour and Liberal Democrats plunged into leadership races after the election, there will be huge pressure on the government to start coming up with plans.

After all, a working group of experts has already spent 18 months drawing up options for the government to consider.

It was set up after the 2017 election – exactly 20 years after Tony Blair came to power promising reform.

After more than two decades of talking, surely the time has come for action.

Filling the gaps

Another thorny issue is the workforce challenge. One in 12 posts in the NHS is unfilled.

The government is already increasing the number of doctors and nurses in training, but it will be many years before the full impact of that is felt.

NHS vacancies by staff group – see graphic on BBC link

Instead, immediate attention is turning to retaining more nurses – every year more than 30,000 leave the NHS – and international recruitment.

The number of staff coming from the EU has fallen since the referendum.


Exit interviews, especially if done by outsiders, will tell health boards, politicians and the public the truth. There is no way to get sufficientt GP diagnosticians in time…

There are no exit interviews in most of the 4 health services. All 4 dispensations, health boards, politicians and the public are in denial. Witness the repeated postings since 2012 in NHSreality. here is no way to get sufficient GP diagnosticians in time… The rationing of medical school and GP training places has come home to roost.. 

A letter in the Times 29th December 2019 from Dr Douglas Salmon, a retired GP:

Concern at falling numbers of GPs has been expressed by the Department of Health, the Royal College of General Practitioners and other bodies (“Top doctor warns of £6.2bn black hole in NHS funding”, News, last week). However, at a recent reunion of GPs from my training group who had taken early retirement, none recalled being asked by any of these organisations why they were leaving. These are doctors who have retired five or 10 years early; the lack of interest in their reasons suggests retention is unlikely to improve any time soon.
Dr Douglas Salmon, Birmingham

2019 reports

Practice Business 12th November 2019:  Tories promise 50m more GP appointments a year and 6000 extra GPs (But by when?)

BBC News 2019: General election 2019: Tory pledge to boost GP numbers …

BMJ 2019: Tories promise 6000 extra GPs by 2024

The Guardian: NHS needs 5,000 trainee doctors a year, says GPs’ leader …

 2016 reports

2016 reports: Government to miss the extra 5000 GP target. Pulse March 2016. ,

Why Hunt’s pre-election promise of 5,000 new GPs is a long …way off. , for Pulse March 2016.

The Tories’ NHS Lies (Tribune Magazine)



Engineered and wealth related co-payments are fairer than the random musings of the 4 health kingdoms. No free lunch.

The health services are anorectic. They are burning up what little food energy they have, in the form of medical staff, whilst the body is shrivelling. None of it’s constituent parts have faith that it has the internal will to survive. The external will is there, in the shape of uninformed politicians, patients and media, who pretend that they believe we can still have Everything for everyone for ever.

Image result for no free lunch cartoon

In their hearts and in front of a lawyer and a judge, and promising to tell the whole truth, they would not be able to deny it. Rationing has to happen in every health care system. All we need to decide is the fairest way to do this. By neglect we are creating a two tier system nationally: the 4 states – and private. The systems have introduced different disincentives to make a claim: eye charges, dental charges, prescription charges, and parking fees. The trouble with these disincentives is that they do not reduce demand. Co-payments for access would reduce demand, but would be a charge on the poorer members of society disproportionately: they would be regressive.

In the end we have to decide whether the growing differences in outcomes between rich and poor should be encouraged by a declining health care system, or engineered so that the differences are as minimum as we can make them. There is no alternative, and no free lunch. The health minister has no clothes … and no defence.

Image result for no free lunch cartoon

Oliver Wright in the Times 28th December points out that “Free parking means less money for care, hospital chiefs warn.”

Hospitals have warned ministers that money for frontline care may have to be diverted to pay for their promise to abolish parking fees for some patients.

Matt Hancock, the health secretary, said that free hospital parking would be extended to those with regular outpatient appointment, staff on night shifts, the parents of sick children and blue badge holders.

The plan was in the Conservatives’ election manifesto and Mr Hancock said hospitals would be expected to start making the changes from April.

NHS Providers, which represents hospital trusts, said yesterday that it was unclear who would pay for the new system, which will cost money to implement and reduce revenue for hospitals.

Saffron Cordery, its deputy chief executive, said: “Trusts want patients to be able to access care at minimum cost and maximum convenience, but providing parking carries a cost.

“The government says it will ensure compliance with these measures but it isn’t clear about how it will provide the necessary payments to compensate trusts. The danger is that it will be taken out of funding for patient care.”

A source at NHS Providers said there was “no such thing as free parking” because it cost money to maintain car parks and keep them secure and well lit. “What concerns us is that over time the revenue base will be eroded and hospitals will be forced to recoup the shortfall from other areas of their operations and distract them from what they should be concentrating on, which is patient care,” they said.

“We are worried that there is not a cast iron assurance that the loss of revenue implied by the changes will be covered by the government.”

A government source said that in the election campaign Boris Johnson had promised up to £78 million to make up for any revenue shortfall to trusts. They said the figure had not been included in Thursday’s announcement because the precise amount still had to be finalised with the Treasury, but that there would be a £200 million capital investment programme in hospital car parking.

They insisted that no hospital trust would be left worse off as a result of changes.

It was also reported yesterday that private parking companies had been threatening vulnerable patients with bailiffs over minor offences in hospital car parks. The Daily Mail said that one company, Parking Eye, had spent 17 months pursuing a man who owed 50p.

David Sampson, 69, told the paper he had paid £2.50 for a parking ticket when he went for a blood test at Coventry and Warwickshire NHS Trust in August last year. Saying that a faulty ticket machine run by Parking Eye had registered the wrong amount of money, he said he had accidentally overstayed by 27 minutes.

Since then Mr Sampson, a retired engineer, has received “six or seven” letters demanding payment of a £140 fine. “The sort of letters they are issuing makes it sound as if every moment they are going to come along and seize goods,” he said. “It is demanding money with menace.”

Rachel Power, chief executive of the Patients Association, told the newspaper: “It is outrageous for any hospital to threaten patients . . . One can only imagine the horror and stress this must cause people, on top of having to cope with their illness.”

Commenting on Mr Sampson’s case, a Parking Eye spokesman told the Daily Mail that an independent appeals body reviewed the matter and ruled in their favour.

One hospital in three raised its fees for parking last year, charging up to £4 an hour. In 2018-19 NHS hospitals made £254 million from car parks, up 10 per cent on the previous year.

Rationing over Christmas. Just part of the routine now… in a toxic culture of denial.

Over Christmas we hate to hear about the hard truths of peoples lives. Dying alone is not something I look forward to, and I suspect I will not know the medical person who comes to see me in the last days. Continuity of care has disappeared, and in its place is part time working of both nurses and doctors. These professionals have not necessarily been trained to deal with the variety of conditions which the ageing community and General Practice demands of them, Many miss out on Paediatrics or Gynaecology or Dermatology as well. Most miss out on orthopaedics… The “hard truths” which Mr Stevens wishes to discuss (since 2014!), facing politicians and their electorate about health, are present all the year round. And its too toxic a subject for all politicians..

Image result for toxic culture health cartoon

So it is no surprise that diagnoses are late, especially for conditions with rather unspecific symptoms such as early leukaemia ( Susan Oneill in the Times 27th December: A quarter of cancer patients go to GP three times before a diagnosis ). Doctors are taught to use time as a diagnostic tool, and if all patients had all possible tests on presentation the service would surely implode. Sepsis on the other hand is severe and should be recognised by every doctor.. It is still “causing more deaths than expected” in Wigan.

Dennis Campbell reports 10th December in the Guardian: Thousands die waiting for Hospital Beds – study.

Shaun Lantern in the Independent 27th December reports that the nursing profession don’t think Boris Johnson’s NHS plan is deliverable.

Laura Donnelly in the Telegraph: Hip Rationing

The Daily Mail reports that the Scots are to get three rounds of IVF compared to the one offered by most English Trusts.

Andrew Proctor for the Dermatologists reports on the rationing of emollients (which are almost all very cheap)

It features National Eczema Society’s Chief Executive Andrew Proctor discussing the important issue of emollient rationing for people with eczema.

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

The politics of health.. The Lemmings of the left leave a vacuum where Mr Stevens’ debate will not happen… Are we all lemmings as far as our health system is concerned?

The Election Horror Show, and denial… The political spin doctors are leading us into a health-less “black hole”. The Health services are too toxic for honesty…

NHS Rationing & Finances | A King’s Fund Report‎ March 2017. Understand the NHS financial pressures. How are they affecting patient care?

toxic work environment cartoon


The Tories’ NHS pledges only scratch the surface of a deep crisis – But who listens to experts these days?

John Appleby of the Nuffield Trust opines in the Guardian 19th December: The Tories’ NHS pledges only scrath the surface of a deep crisis. The plans to be outlined in the Queen’s speech won’t solve problems such as low staffing and long waiting times

But who listens to experts these days?

The NHS was a dominant theme in the 2019 general election campaign, from harrowing pictures of a child being treated on an A&E floor to fears over the impact of a trade deal with the United States.

Performance statistics released during the campaign showed the number of people waiting too long in A&E departments was at its highest level on record – in October, far from the depths of winter. Reflecting this and the poor state of staffing and buildings, public concern about the service rivals even Brexit.

While their campaign focus was Brexit, the Conservatives also pledged more money and more staff for the NHS as a response to these issues. But with major problems facing the service, they will now need to go beyond these promises if they are to turn the situation around before they face voters again.

Today we are expecting an NHS bill in the Queen’s speech, which will pledge to increase the annual day-to-day health service budget by £34bn by 2023-24. This is largely the same as the figure of £20.5bn pledged by Theresa May in 2018, without adjusting for inflation. But either way, it represents a sharp break from the years of austerity, bringing spending back to what has been the historic norm, and giving the service room to breathe again.

So far, we have seen no concrete plans beyond next year for the so-called “capital” budget, which the NHS needs to invest in buildings and equipment. The Conservatives have pledged 40 new hospitals alongside 20 upgrades in the coming years. This will require substantial investment over and above current levels of capital spending. The cost for the backlog of repairs alone has now reached more than £6bn, resulting in dilapidated wards and broken infrastructure. In addition, the UK has the lowest level of CT and MRI scanners of any comparable country.

We should look for at least a five-year plan for this capital investment – and if the new government wants to rule for the long term, it could consider giving even more stability by planning a full decade in advance for both day-to-day running costs and capital investment.

The NHS also faces a dire staffing crisis, with a nursing shortage of 40,000 in England and a decline in the number of GPs per person for the first time in 50 years. The government’s promises of 50,000 extra nurses, 6,000 extra GPs and other staff will be difficult to deliver.

We have argued that the NHS needs those extra 50,000 nurses in the coming five years. But when we crunched the numbers with the King’s Fund and Health Foundation, we found that training and retention could not reach that figure fast enough – not even with nursing bursaries brought back to attract students. That kind of increase would require immigration, on a larger scale than the Conservative figures assume. In social care, again, migration will be an indispensable support to a system that already has massive staffing shortages and yet is likely to need even more.

Earlier migration crackdowns on people from outside the EU caused a sharp slowdown in the number of staff from overseas, and there is a real risk that any post-Brexit crackdown will have a similar effect. The Conservatives have promised to soften the impact with “NHS visas” for doctors and nurses. But they should rethink any policy that results in a drop in staff migration.

Social care, meanwhile, is a failing system. Repeated cuts have meant many people who need help go without, and the unlucky minority who need most care often end up facing ruinous private bills.

Despite years of commissions and promises to unveil solutions in government, the winning manifesto avoided any solutions. But the options are straightforward and well understood. We can look to Germany or Japan for state-run insurance systems, to Scotland for at least partially tax-funded care, or to the cap system passed into law under David Cameron but still postponed. With the largest majority in 15 years, the time for action is now.

Topping the public’s list of concerns, meanwhile, is the issue of spiralling waiting times – fed by every one of these deeper problems. Addressing funding and staffing should soften the pressure but make no mistake, the issue will take years to solve.

The Conservative manifesto was relatively silent on particular commitments to address waiting times. Both Cameron and Tony Blair once hoped that greater competition and outsourcing to the private sector would increase efficiency and operations. But this government seems to have no similar plan: if anything, the legislative proposals on the table for the NHS would reduce the marketisation by taking away requirements to put contracts out to the market.

In the past, driving down waiting times has taken management focus, particular tactics and a willingness to make it a priority, even if it means not every shiny new thing is affordable. Will we see this again?

If the new government wants the state of the NHS to be a favourable reflection on it in the next general election, it must start taking serious action now.

John Appleby is director of research and chief economist at the Nuffield Trust

Five years of Boris Johnson…

… and Brexit on the way. With a new Conservative government taking office, the Guardian’s independent, measured, authoritative reporting has never been so vital. These are turbulent, decade-defining times. Whatever lies ahead for us all, the Guardian will be with you – investigating, disentangling and interrogating. So our readers can make up their minds based on fact, not fiction.

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Rationing by queueing, and limiting access to a diagnosis – getting worse for over 20 years. So it must be deliberate policy of multiple administrations… Will the new year see and difference?

Some 15 years ago we were warned that patients might have to wait in tents to be seen in A&E. Ronan McGreevy in the Times November 3rd 2003: Casualty patients face wait in tents so why has nothing been done in the 15 years? As a result of long waits private health care booms: Patients pay to jump NHS queues. (Sue Leonard Jan 19th 2003) In 2014 the extra Out of Hours was threatened: Give us more resources or forget out of hours surgeries, warn GPs. By 2015 nothing has changed: 1,000 ambulances a day are being forced to queue outside A&E (Kat Lay in the Times 1st Jan 2015 ) In 2016 ( April 8th ) Chris Smyth reported Indian doctors to plug gaps in overstretched surgeries but this did not happen. The profession even tried avoiding examining patients and the usual safety netting: Phone screening is no help to overstretched GPs

Only this summer, in Scotland, Helen Puttick on 12th December reports “High summer death toll being linked to waiting in overcrowded A&E units”. 

Before the election, November 9th, Andrew Gregory in the Sunday Times asked: Will Tory promises help to clear your GP’s waiting room?

Mark Porter comments: It’s patients who suffer when GPs are overworked

and the GPs response; GP leaders draw up plan to turn away excess patients

On 21st December Paul Morgan-Bentley, Head of Investigations & Anna Lombardi, Interactive Journalist in the Times report: The best and worst-hit GP surgeries: Patients queue in cold to see a doctor

The only conclusion has to be that this is a deliberate policy. It can be deliberate neglect, denial or rationing. NHSreality maintains that it has been a deliberate act and that incompetence is not to be blamed.

Implication: The safety net has gone.

Result : An increasing health divide and a restoration of fear.

For Doctors in GP practices: An increasing percentage of their partners off sick, and fewer applicants to join them. More “salaried” and “part time” doctors.

Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

To paraphrase Spike Milligan: “I told you the Health Services were all ill”.

Declining standards correlates with declining staff numbers… and is systemic across all 4 health services

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

Six in 10 family doctors considering early retirement#

Burnout forces almost 10% of GPs to take time off work as pressure on occupational health services grows

There is no prospect of any improvement. Overseas GPs and doctors without cultural and linguistic skills will not be adequate. The temptation to go privately, for those who can afford it, seeems set to increase.

Paul Morgan-Bentley and Anna Lombardi report 20th December : The best and worst-hit GP surgeries: Patients queue in cold to see a doctor

Prince Philip’s care… “No room at the Inn” for us. You will be lucky to get a trolley, let alone a bed. Trusting the system to “do the right thing” just wont work. You need an advocate….

The letters on access to GP care, diagnosis and recruitment are revealing, but the last one is particularly relevant. Vaccinations are very important, but only to survivors. Health care is the same. As a population we prefer to forget those the service has failed.

Letters to the editor on GP recruitment The Times Dec 2019

See the source image








Is the Times aware that there is no NHS? GP and appointment shortages have been predicted for decades… In a Darwinian dystopia its survival of the fittest. “Exactly the opposite of what the NHS was set up to do.”

NHSreality is trying to get an honest debate about health, which has to be about what we cannot have. Realistic expectations are part of this debate… There are some interesting facts which the Times has omitted. The consultation rate has risen from 4 per annum to nearly 7 appointments per annum. The patients are getting older and more complicated, but its continuity of care as well as availability that upsets patients. The medical student intake is female by a large majority, and they mostly have normal female instincts. Having children is normal but the manpower planners never factored this, and the need to go part time, into their calculations.

The Times publishes a map or two, but fails to mention that this verifies NHSreality contention that there is no NHS. Where are the figures for Wales, Scotland and Northern Ireland?

NHS Queue.

Pulse reported 1st September 2019: No-deal Brexit to irreparably ravage healthcare services … and yet we are now post that decision. The strategy of the Liberals and Labour to allow an election when they had the Conservatives on the rack and locked on it by the 5 year obligatory term was stupid and reckless.

The RCGP in the Editor’s Briefing opines under the title “Poor NHS”. Like the Times the RCGP has yet to acknowledge that there is nothing National left as far as the patients are concerned.

“Our new government now has to focus urgently on the health and social care provisions in the UK. It must work out how the crisis in primary and community care can be turned around, and how the UK’s rapidly deteriorating indicators for investment, which has fallen substantially in real terms, treatment facilities and health outcomes, many of which compare unfavourably with other less prosperous OECD countries, can be improved. The NHS is looking distinctly threadbare……

The Leigh Journal reported the BMA response to the Queen’s Speech this week: It called for “realistic expectations. 

Health experts have welcomed funding commitments to help the NHS as a “relief”, but cautioned that money will not immediately solve the mounting pressures facing the health service.

The Government’s pledges to commit an extra £33.9 billion per year provided by 2023/24 will be enshrined in law, the Queen’s Speech set out.

But the British Medical Association said the money “falls short of what’s needed to make up for years of underinvestment and to meet the rising health needs of Britain in the future”.

Paul Morgan-Bentley and Anna Lombardi report on the GP shortage in the Times 21sr December 2019: The best and worst-hit GP surgeries: Patients queue in cold to see a doctor

GP Shortages in the Times 21122019

and GP crisis: NHS shortages mean one doctor has to care for 11,000 patients – Nine-week wait for appointment at some surgeries

If they wanted to upset the GP workforce it would be harder to see how. The Times leader implies that GPs are not working hard enough, don’t choose to work full time, and are overpaid. They hark back to the origins of the first NHS (before it was devolved and broken up) and resent the structure of self employed GPs (and presumably Dentists and Opticians).

GP Shortages – Leader

GP recruitment crisis means it’s becoming survival of the fittest – Dr Mark Porter

My practice in a pretty market town in the Cotswolds is happy, small, currently fully staffed, accessible (we see all urgent requests the same day) and relatively well funded. Yet even we are noticing a worrying change.

We are trying to recruit at least four GPs to work in a neighbouring surgery we are merging with — a practice with 5,000 patients that is staffed entirely by locums — and the lack of interest among colleagues is giving me sleepless nights.

When I first started as a GP in the Cotswolds there were at least ten good applicants for every job. Today there are often none. Young doctors (and older ones) are put off by factors including burgeoning workload, increased bureaucracy and inadequate funding. The knock-on effect on recruitment makes the job even harder for those in post. Morale plummets and so starts a vicious downward spiral with fewer staff put under even more pressure, and patients paying the price.

As of next month my contract is just over half time (three fifths) but I still put in 33 hours a week. And each day is flat out. No breaks. Lunch at my desk. My (younger) partner does this all week, but at 57 I simply couldn’t. And nor, it seems, will the generation behind us, who are eschewing partnerships in favour of flexible salaried or locum posts.

Patient satisfaction is unusually high at our practice, but for how long? No one wants to have to wait days or weeks to see a stressed, tired and rushed GP. It’s a recipe for disaster and one we are doing our utmost to avoid. Many practices — and their patients — are not so lucky.

What we really need are more doctors (and nurses, paramedics, midwives, pharmacists etc) and the conditions to attract and retain them. It is not in my power to influence that nationally, but I intend to do what I can locally. However, in the current crisis, where there are simply not enough professionals to fill the vacancies, that means other practices and their patients are going to lose out. It’s becoming survival of the fittest — the very antithesis of what the NHS was set up to do.