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.

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….

Aneurin Bevan wanted the miners of Tredegar to have the same chances as the Bankers of London.

I am not a Royalist but a supporter of a Republic. Because Price Philip’s Dr “put his patient at the centre of his concern”, and because he could pay privately, he avoided the English Health Service. Should not the people of Wales have the same access to care as the Royalty of England? 

There are few anecdotal examples in NHSreality. Now and again one gets into the media and needs to be debated. One of these patient’s daughter is a medical student. She trusted the system not to let her mother down. But it failed.

There was no ambulance for another patient, again in N Wales, and there is usually “No room at the Inn”. You will be lucky to get a trolley, let alone a bed. Trusting the system to “do the right thing” just wont work. You will need an advocate….

Quite an ironic situation when you compare it to the claims about the NHS at its beginning… (Cartoon show)

On 20th November Northwaleslive reported: GP told patient “you will live” three days before she died of Sepsis. Dr Geeta Balakrishnan thought Samantha Brousas was suffering from gastric flu rather than the deadly condition, an inquest heard

On 25th November BBC News reported: Sepsis death: A&E ‘should have been warned’ of patient

On 20th December BBC News reported: Wrexham sepsis death: ‘Gross failure’ in woman’s care

Nathan Bevan and Lyddia Morris report 18th December for NorthWalesLive: Patient waits 6 hours on the pavement for an ambulance.

Plan your hospital advocate…. NHSreality warned you that it was happening near you. The problems of Mid Staffs and Sussex Mental Health services are endemic, and Christmas is not a time to be ill..

Family advocates needed? Hospital patients at risk of falls as ‘thousands cannot reach walking sticks’..

Mail on line: the birth of the NHS in Cartoons..

A review of a decade… Population health matters. Education is the answer, and not just about health, but also about health systems and the choices that have to be made….

The recent John Pilger film / documentary produced by ITV “The dirty war on the NHS” was released on terrestrial TV Tuesday evening. It has been available in cinema before this, but possibly suppressed before the election. The film begins with anecdotes, and derides the privatisation. It fails to compare UK with any other system than the USA, which we in the professions all know is inferior. It fails to give comparative population numbers, and it does not mention really cheap and effective systems such as Cuba. In EU there are at least 4 other systems that have consistently scored better on survival and life expectancy, but the producer seems fixated on the USA (Is there a worse system?). He says that the politicians are equally fixated! God save us all. From the political footballs that are the 4 health services….

In the final analysis the duty of a government is to populations ahead of individuals. That’s why defence and internal security come above health in Maslow’s hierarchy of needs. That’s why immunisation programs are more important than surgery for cancer. In the UK health lottery, poorer people are missing out because the waiting lists mean richer people buy faster (private) care. There is a problem: fear. The original single health service, which devolution has replaced with 4 health services, was In Place of Fear.  A Free Health Service 1952 Chapter 5 In Place of Fear People fear cancer more than they fear infectious diseases (measles), demographic lifestyle diseases (Obesity, Diabetes) less than they fear cancer…. Education is the answer, and not just about health, but also about health systems and the rationing choices that have to be made.

Image result for maslows hierarchy

The Dirty War on the NHS showing at Queen’s Film Theatre …

Nigel Hawkes reports in the BMJ on “The 2010s: a decade of disappointment in UK healthcare”, BMJ 2019;367:l6895

Despite health system reforms, improvements in life expectancy and neonatal mortality have stalled. Nigel Hawkes reflects on the past 10 years

A decade that began with a Conservative health secretary promising to transform the NHS in England through market discipline, legally enforced, ended with an election manifesto from his party embracing the polar opposite. Competition is dead; long live cooperation.

This meant that, even before the general election votes were counted, a 30 year experiment in the English NHS was over. “Choice and competition,” a mantra pursued as energetically by the Labour governments of Tony Blair as by the Conservatives, was dead.

How the NHS is organised generally makes less difference than its planners hope, though competition and choice seemed to have some successes, including shorter waiting times. But this was before the 2008 financial crisis cast its long shadow over the succeeding decade.

Faltering progress

Since then, progress has faltered, not only in the UK but across Europe. Decades of improvement in life expectancy have plateaued, even gone into reverse.1 Neonatal health has paused in its steady improvement.2 Doctors are demoralised, GP surgeries and hospitals are under siege, and public satisfaction with the NHS, which rose sharply between 2000 and 2010, has fallen back as quickly as it rose.3 The 2010s have proved to be a decade of disappointment.

Many blame austerity. In England, health department spending rose by an average 1.5% a year over the decade, much slower than the long term average growth of 3.7% a year.4 Productivity improvements failed to fill the gap. The pips began to squeak.

Austerity had an effect, certainly, but not only in the UK. Eurostat data on life expectancy, for example, do not show the UK as a conspicuous outlier,1 with an increase in life expectancy at birth (sexes combined) between 2010 and 2017 of 0.7 years, greater than in France, Germany, and Italy but less than in Spain, Switzerland, and Sweden. For life expectancy at 65, the UK fared worse than all these countries except Germany over the same period. Not a good performance, but other countries also struggled.

The decline in UK infant mortality tailed off after 2010, a trend also seen in other countries.2 In 2010 the UK had 4.3 infant deaths per 1000 live births, while France had 3.6. By 2016 the gap had narrowed: the UK down to 3.9, France up to 3.7. Similar countries saw little progress or, in some cases, declines.

The common challenge, at home and abroad, is affordability. How can any healthcare system continue to pay for care whose costs rise inexorably year by year, unaffected by the state of the rest of the economy? This question has dominated domestic politics in the US during the Obama and Trump administrations, with no sign of consensus emerging. In France, often seen as an exemplar of good medical provision, the state has recently been forced to take over €10bn in public hospital debt after months of protests and strikes by healthcare workers.

Can digital health cut costs and improve outcomes? Certainly many think so, even though experience during the 2010s was mixed. Websites and phone services such as NHS 111 (launched in 2013) have not reduced demand. Health apps appeal to the young and fit, not the old and multimorbid people who fill the wards. The same applies to “digital first” online services such as GP at Hand, 94% of whose patients are under 45. Electronic health records have made slow progress, and the promise of a paperless NHS by 2020 is already in the wastepaper basket.

Sluggish drug pipelines

The 2010s were not a great decade for new drugs, either. Pharma pipelines were sluggish, though they picked up later in the decade. About half of newly licensed drugs were biologicals, which are around 20 times as expensive as traditional drugs and account for almost all the increase in the drugs bill. A splendid exception to this gloomy picture was new treatments for hepatitis C, which NHS England, swallowing hard, finally agreed to pay for.

Credit, too, should go to Public Health England for championing electronic cigarettes, which has given tobacco cessation a boost at no cost to the public purse.56 Critics of vaping, vociferous at the start of the decade, have largely fallen silent, in the UK at least.

If somebody could come up with a similar technological fix for obesity they would be the hero of the 2020s, as exhortation has failed. The decade began with 26% of men and women classified as obese in the Health Survey for England. In 2018 (the latest data available) the figure for men remained the same, while that for women had risen to 29%.7

To end on a brighter note, sometimes things can change for reasons that aren’t immediately obvious. The teenage conception rate in England and Wales, long the cause of hand wringing, halved in the 2010s from 34.3 per 1000 women in 2010 to 17.9 in 2017.8 All credit to those who brought this about: mostly young people making sensible decisions.

Rapid Response:

Re: The 2010s: a decade of disappointment in UK healthcare

Dear Editor,

Market discipline not adequately implemented with the difficult arithmetic of personnel and costs, faltering steps are not confined to UK healthcare but easily extend to the continent. A huge influx of refugees creates changed equations of healthcare costs. Westwards, insurance has risen in costs and coverage affected. In developing countries, the percentage expenditure on health has the scope of being enhanced for better output.

In short, in the last decade, almost at a global level, disenchantment with health services has grown. Outbreaks continue to threaten and lifestyle disorders dominate. Influence of AI may take over, but at what pace may be a guess difficult to make.

Dr Murar E Yeolekar, Mumbai.

US Hospital to advise London on safety….. and what a terrible record their country has when treating populations

Meningitis B – Can Wales afford it? Government’s treat populations and not individuals.

Prudent healthcare reforms and a suggestion for GP recruitment

The numbers of GPs have increased, but the number of Full Time GPs, (Which means 9 sessions a week) has reduced because more and more are taking options to mix and match their portfolio careers.

The first letter below is correct: GPs need portfolio careers to survive themselves, and for the local service to survive. Changing the shape of the job…. In the festive season (see below ) doctors cannot be expected to behave like turkeys in their voting… Ask around and I expect you will find demoralised people who did not know who to vote for, but in a PR system would have voted Liberal.

The Times letters 18th December 2019:

Sir, Libby Purves makes some very good points about the crisis in A&E departments in many NHS hospitals (“Don’t just throw money at the NHS, be smart”, Dec 16). She suggests a return to convalescent homes or cottage hospitals, with both staffed by nursing auxiliaries and overseen by local GPs. Patients who did not require the “high tech” care provided by the acute hospital but required good nursing and general care before returning to their home or other long-term care could be transferred to one of these units. I was a GP and we had a 100-bed unit that did just this. The patients were well cared for and many were able to return home. Like many other units, however, it was closed; all we have now is a 600-bed acute hospital some miles away.

I met another retired GP this morning. He had been away: his wife, who is disabled, had suffered a serious injury to her face and he had taken her to the acute hospital A&E. They were there for about ten hours; the place was chaotic, being full of people suffering from minor ailments whom in the past we as GPs would have dealt with. When she was treated by the medical staff the care was first-class. We both agreed that it was time that the problem of GP out-of-hours care was sorted out; the pressure on A&E departments would then reduce.
GBR Fisher

Cononley, W Yorks

Sir, Libby Purves makes an important case for new convalescent homes but creating them will take time. A quick interim fix would be for the government to seek bids for building basic accommodation modelled on budget hotels over hospital car parks. Hotel operators and some house builders would respond quickly, a standard brief could be produced and a new permitted development right or development order could avoid planning delays.
Brian Waters

Chairman, London Planning & Development Forum

Sir, In her article Libby Purves makes many good points about the medium-term future of the NHS. A further core problem is unscheduled care. Until there is more integration between GPs and emergency departments problems are likely to continue. It is a pity that the so-called internal market of 1990 widened this chasm and that budgets within the system still drive change. The royal colleges of both the physicians and GPs advocate generalists, and some emergency departments have innovative ideas. There is, however, a need to devise a qualification for interested GPs to integrate seamlessly within emergency departments, thus allowing patients to see the most appropriate person on arrival.

Who knows, perhaps by offering a dual base this could help to solve the problem of GP recruitment.
Dr Michael Houghton, FRCGP, FRCP

Preston, Lancs

Sir, I went to my local surgery last week. The person before me was a “no show”; the nurse told me that there had been four “no shows” the day before. Last year I had knee replacement surgery. I was given an ice machine to take home after the operation. I didn’t want it and didn’t use it, preferring the flexibility of using frozen peas. I tried to return it but it was refused on the grounds of cross-contamination. I was also unable to return the crutches for the same reason. Throwing money at the NHS is not the answer to all its problems.
Ann Hadingham

Alton, Hants

Times letters: Prudent reform of the NHS and social care

Don’t throw money at the 4 health services. Put the plug in first, and then concentrate on recovery in 10-15 years time…