Monthly Archives: March 2020

Will the epidemic/pandemic lead to a rethink of hospital closures?

The first antibiotics were developed during the first world war (Sulfonamides) and Penicillin was discovered and then isolated and purified between the wars. Anti viral drugs are not successful, and stocks of Tamiflu have proved useless for this coronavirus 19. We have been complacent for years, even though BillGates was warning us of the viral potential in 2015.

The move towards larger and more efficient hospitals, encouraged by all advanced thinking in the last decades, may change.  If we are to think about infectious diseases and the way we approach them in the future, we may wish for separate “fevers” hospitals as there used to be in the 1960s and 1970s. We may wish to retain more local but less sophisticated hospitals, so that the caring and the organisation of volunteers is easier. Fevers hospitals seemed to have had their day… until now,

When women gave birth in the past, it was often in a separate maternity home, and they were transferred to the nearby hospital if they needed surgery. This happened in my home town of Haverfordwest, and in many other Welsh towns.

When I am ill, and perhaps even terminally ill, i want to be near to my family. The closure of hospitals will make this aspect of care and modern medicine distant and unpopular. Unless we persuade and induce families to look after elderly parents in their own home, the hospitals will not cope. Why is terminal care in hospices only partially funded in any one of the 4 cradle to grave Health Services?

With an ageing population we need both local and specialist hospitals. With pandemics in mind we need fever hospitals again. Maternity care, given the amount of cross infection and the risk in this pandemic, might once again be better isolated from the general hospital.

While we are re-thinking health, why not appoint every Medical Student who aspired to do the subject this year? Those who cant make it can be weeded out at the 2nd MB stage. We need every one, and if there were 11 applicants for each place, as in the past, why not appoint all 11?

 

The NHS.. can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”).

How refreshing to read a correspondent who does not comply with the collusion of denial that most writers in the newspapers have with politicians. Perhaps Dominic Lawson can start the honest debate which Mr Stevens wants, and perhaps then we can debate if it should be covert or overt. I have a medical friend who genuinely believes rationing should be covert, and that citizens will only worry about what is rationed out. My answer is that rationing does not have to be of the same design for everyone. It can be means based, or income based, or a combination of both, but rationing by waiting list and post code is much worse. If this is agreed and is overt, we will have some sort of plan structure on which to base the new health service that emerges after Covid19. 

Dominic Lawson opines in the Times 29th March 2020:  All lives aren’t equal, but we still want them saved – Although the NHS favours youth, society will not abandon the old to Covid-19

The pathogenic micro-organism known as Sars-CoV-2 presents as an invisible but global Dick Turpin. Your money or your life. Here, opinion (in the media if not the nation as a whole) is fast dividing between those who think more of the loss of income and those who worry more about sparing lives.

This debate is intensifying as soaring unemployment (in America last week alone there were 3.3 million new benefit claimants) reveals the price of closing down all businesses dependent upon the interactions made impossible by anti-infection “social distancing”. In Britain, the astonishing measures of income support launched by the chancellor of the exchequer amount to a vast claim on future taxpayers (every pound of it is an addition to a national debt that must eventually be repaid).

But what amazes me is how few people seem to recognise that this dilemma — your money or your life — is a constant feature of the National Health Service. The coronavirus policy dilemma merely sheds a particularly harsh light on it.

As directed by the National Institute for Health and Care Excellence (Nice), the NHS will agree to fund non-palliative treatment for the seriously ill only if the drugs provided (for example) do not cost more than £30,000 in providing a further year of good-quality life. This is known as a Qaly (quality-adjusted life year). Since those with potentially terminal illnesses don’t have a good quality of life, that £30,000 limit would typically be cut to £15,000 per annum in their case — two of their years being regarded as of the same monetary value (in health accounting terms) as one year for an otherwise fit person.

As Sir David Spiegelhalter (who for decades ran the Medical Research Council’s Biostatistics Unit) put it to me: “It’s a myth that all lives are considered equally valuable in the NHS. The system already values years of remaining life given by treatment. So triage would be normal.” What Spiegelhalter means is that if the coronavirus crisis leads to a situation in which an older person is essentially left to die, in order to provide a scarce ventilator to someone with a greater life expectancy, that would be a graphic demonstration of the working model of the NHS.

This sort of calculation also governs expenditure on road-safety measures by the Department for Transport (DfT), under the formula known as the Value of a Statistical Life (VSL). The government will fund a new junction if it estimates that it won’t cost more than £1.3m per future life saved. Obviously, if your child gets killed because the DfT had worked out that the junction you and your neighbours had campaigned for was unjustifiable as it would cost more than £1.3m per likely life saved — well, you would not be consoled by the knowledge that they had dutifully followed the VSL guidelines.

But these calculations are the inevitable consequence of any system in which resources are centrally allocated according to need (rather than a market system in which individuals can pay any amount for what they want — which is not the same as need). This is especially true of the NHS, a centralised, free-at-the-point-of-use system unique in the western world, which can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”). Queuing is one form of rationing: on average, citizens are waiting four-and-a-half months for a hip replacement operation on the NHS. There is no measurable risk to their life expectancy with such a delay, even if the chronic pain of those on the waiting list may feel unendurable.

These are, by and large, the same old people whose lives are now at greatest risk from the coronavirus. The average age of the thousands killed by it in Italy is 79.5 years. This is what is driving many to say to our Dick Turpin pathogen: I’ll keep the money, please, if it’s all the same to you. Of course, they don’t mean that they are happy to die from the coronavirus and keep their money: only that they don’t want to see the nation’s economy suffer a hugely expensive shutdown in order to save the lives of people they don’t know and with not that many years left anyway.

Or, as one American health economist put it to me: “If the shutdown costs the UK 4% of GDP, that is equivalent to $104bn. If you didn’t shut down, according to your government’s advisers at Imperial College, that would cost about 230,000 more deaths from the coronavirus. I estimate those people who were saved would need to live for another 15 years on average to meet the Qaly limit of no more than £30,000: and given that the life quality of the unwell over-seventies is considered half that of a healthy younger person, that means they would on average need to live for another 30 years to justify the $104bn hit to the economy. If you spent all that money on NHS treatment across the board, you would save millions more life-years.” Besides, he added, if the UK had not pursued an economically toxic policy of enforced social isolation, the majority of those most vulnerable to the virus would be among the 620,000 anyway projected to die this year, from all causes.

But, I pointed out to my economist friend, if social exclusion had not been enforced by the government, the economy would still have taken a colossal hit, not just because of what was happening in other countries but also because of the public’s autonomous response to the risks of infection. And the first opinion polls taken on the matter show a remarkable 93% backing Boris Johnson’s latest, draconian measures.

It is not hard to understand why. None of us are creatures of pure reason. Logically, we should not put a high value on the last years of seriously ill relatives (or our own). But as the authors of a 2013 BMJ paper on Nice’s end-of-life criteria wrote, in some perplexity: “In a choice experiment . . . a gain in life expectancy without a gain in quality of life was preferred to an increase in quality of life with no gain in life expectancy, suggesting that focusing on extensions of life, rather than improvements in the quality of life, may be consistent with societal preferences.”

The government, since it comprises politicians, gets that. What it also gets is the likely reaction of the British people if a less dictatorial policy — combined with a gross insufficiency of ventilators — led to a situation akin to Italy’s, where thousands of old people have been abandoned to a horrible end, in effect waterboarded to death by the coronavirus as their lungs filled with their own blood and fluids.

In short, Boris Johnson would not just be suffering with the virus himself. He’d no longer be prime minister. The voters will accept only so much health rationing.

Is it worth it? The short term loss of liberty, to save lives now, against a longer term depression?

The press led by Matthew Paris is beginning to bleat about loss of Liberty. The suggestion is that longer term there may be more deaths due to a prolonged depression, and that these deaths would be in younger people, than there would be if we simply let the virus run its course. Is it

Many of us are tuned in to the latest statistics from the BBC, but how valid are these? Read Dr Lee below.. An alternative plan would have been to incarcerate at home all those over 65 (Canada stay at home recommendation).

Philip Aldrick in the Times opines 21st March 2020: There are economic consequences in trying to save lives on a mass scale

…if households, companies and markets could see an end to this, the economic damage would be half as bad. I’m 44 years old and would volunteer to be infected if it would help the country. Science may save us before then. But if it doesn’t, we need a better plan than waiting and hoping.

Dr John Lee in the Spectator also opines 28th March 2020: How deadly is the corona virus? It’s still far from clear

In announcing the most far-reaching restrictions on personal freedom in the history of our nation, Boris Johnson resolutely followed the scientific advice that he had been given. …

In the next few days and weeks, we must continue to look critically and dispassionately at the Covid-19 evidence as it comes in. Above all else, we must keep an open mind — and look for what is, not for what we fear might be.
John Lee is a recently retired professor of pathology and a former NHS consultant pathologist.

In the Times leader (The Times view on the coronavirus lockdown: Exit Strategy)  March 27th the author maintains that: “There is no simple trade-off between saving lives and saving the economy, at least not at the moment. But there is a limit to how long lockdowns can be sustained”

Matthew Paris in the Times 21st March 2020: Crashing the economy will also cost lives. – Just like the virus, impoverishment kills, and locking down the elderly might have been a drastic but fairer solution.

The Times letters 22nd March : Coronavirus: we should have learnt from Sars, not swine flu – If H1N1 had been worse, the elderly might not be in such danger today

In the UK, policy was initially based on the notion that the country would be better off aiming for early herd immunity than trying to suppress the spread of the new disease — until epidemiologists such as my near namesake Neil Ferguson (whom we must all wish a swift recovery, as he developed Covid-19-like symptoms last week) pointed out the likely disastrous consequences.

 

Niall Ferguson: Milbank Family senior fellow at the Hoover Institution, Stanford

and 23rd March: Crashing the economy versus sacrificing lives

Sir, Matthew Parris (“Crashing the economy will also cost lives”, Mar 21) and Philip Aldrick (Business, Mar 21) emphasise that economic hardship inflicted upon the working age population by adopting lockdown strategies will itself cost lives. If the models used to inform government policy are correct, by summer the number of new cases of Covid-19 will have fallen and restrictions can be lifted. But the models also predict that the virus will return in the autumn. The government then has a crucial decision to make. Will it reintroduce closures and shutdowns, inflicting further economic damage, or will it let the epidemic run its course, building up “herd immunity” that will suppress future outbreaks? I would vote for the latter. People will die, but time bought by the current measures is allowing the NHS to build the resources it needs to cope with most predicted levels of infection. Experience shows that the vast majority of the dead will be 70-plus. As a 72-year-old, I would rather take my chances with Covid-19 than see further damage inflicted on my children’s future. We baby boomers are a privileged generation. Late in the day, Covid-19 gives us the opportunity to do our bit at a time of national crisis, as our parents did under rather different circumstances.
Bryan M Turner

Emeritus Professor of Experimental Genetics, University of Birmingham

Sir, Matthew Parris is right to ask difficult questions about our handling of the current crisis. As a serving head of a leading school, Friday was an incredibly emotional day. We said goodbye to children not knowing when we would see them again. Across the land, young people’s education is now thwarted, their future plans on hold and the wellbeing of many at risk. Our staff have worked incredibly hard to launch a virtual learning service and plan for children of key workers who will still be on site. We are doing our absolute best, but we all know it will not be the same.

I cannot help worrying that our reaction to this illness goes too far. I see the need to isolate and protect the elderly and other vulnerable adults. However, shutting down the economy for everyone else and threatening livelihoods on a massive scale troubles me when the human costs are likely to be far worse than anything coronavirus throws at us. Perhaps it would be better to accept that the virus will spread and to focus on simple things we can all do to slow it, like washing our hands properly. The pre-occupation with social distancing for all seems like an over-reaction and I feel sorry for our children who are paying the price.
Nicholas Bevington
Norwich

 

Unprepared for CV19. Lets see who we can scapegoat for our unreadiness…? The magnificently ( unlucky ) 13

Update 12th May: The Cygnus Report

David Pegg in the Guardian 7th May reports: What was Exercise Cygnus, and what did it find? The 2016 simulation of a pandemic found holes in the UK’s readiness for such a crisis.

…The Cygnus report was frank about the state of the UK’s readiness. “The UK’s preparedness and response, in terms of its plans, policies and capability, is currently not sufficient to cope with the extreme demands of a severe pandemic that will have a nationwide impact across all sectors,” it found.

One problem was that while each government body participating in the exercise had its own bespoke plans, enabling a flexible and decentralised response, nobody in the centre had oversight over everyone else.

In the absence of any “overview of pandemic response plans and procedures”, participants found it much harder to shift resources between one another so as react to unexpected rises and falls in demand for services such social care beds….

 

All breakdowns of the nature of the CV19 outbreak need a scapegoat. The trouble with this is that there are so many, from successive administrations. There are 13 over the last 30 years. It takes 10 years to train a doctor, so that is 3 generations of under-capacity in provision. The manpower planning has gone so wrong, even though the profession has been demanding more, that only these 13, and the 6 Prime Ministers can possibly take the blame. If you wish to download pictures for dart boards in the doctors mess, please feel free.

Bill gates gave his warning in 2015 regarding virus plagues.

NHSreality started as I retired 8 years ago and began NHSreality in 2013, warning of “killing the goose that laid the golden eggs”.

The secretaries of state for health and social care ( England) are listed here.

The department website ( DHSS ) is here.

Its evident that the person least responsible is the current incumbent. There is no need to go as far back as Lord Carlisle in 1848.  I have taken 30 years, and that covers the following administrations: John Major, Tony Blair, Gordon Brown, David Cameron, Theresa May and Boris Johnston.

William Waldegrave: 2 November 1990 – 10 April 1992 ConservativeWilliam Waldegrave visiting University of Salford 1981 cropped.jpg

Virginia Bottomley10 April 1992 – 5 July 1995 ConservativeOfficial portrait of Baroness Bottomley of Nettlestone crop 2.jpg

Stephen Dorrell 5 July 1995 – 2 May 1997 ConservativeStephen dorrell mp -nhs confederation annual conferencepercent2c manchester-11july2011 - crop.jpg

Frank Dobson 3 May 1997 – 11 October 1999 LabourFrank Dobson MP, crop.jpg

Alan Milburn 11 October 1999 – 13 June 2003 LabourAlan Milburn 2014.jpg

John Reid  13 June 2003 – 6 May 2005 LabourReidTaormina crop.jpg

Patricia Hewitt 6 May 2005 – 27 June 2007 LabourPatricia Hewitt.jpg

Alan Johnson 28 June 2007 – 5 June 2009 LabourAlan Johnson MP.jpg

Gordon BrownAndy BurnhamAndy Burnham2.jpg5 June 200911 May 2010Labour

Andrew Lansley11 May 2010 – 4 September 2012 ConservativeAndrew Lansley Official.jpg
(Coalition) Jeremy Hunt 4 September 2012 – 8 January 2018 ConservativeOfficial portrait of Mr Jeremy Hunt crop 2.jpg

Jeremy Hunt 8 January 2018 – 9 July 2018 ConservativeOfficial portrait of Mr Jeremy Hunt crop 2.jpg

Matt Hancock 9 July 2018 – Incumbent ConservativeOfficial portrait of Rt Hon Matt Hancock MP crop 2.jpg

Cartoon: Blair's War - The English Blog

 

The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

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

The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

The desperate state of General Practice. Black swans will not be diagnosed as often, or as quickly.

Doctors to see groups of patients – is probably madness. The fox is waiting..

There are just not enough geese to lay enough golden eggs. The cupboard is bare. We cannot be cloned.

Pastor not prepared | Backpew | Cartoons | Entertainment

Update from the Times 24th April 2020:

Hunt error – he admits he was unprepared for CV19 and should have learned from SARS reports.

 

Illegal Immigrants will become evident in this crisis. They will use the 4 Health Services. They should not be rejected.. Neither should ID cards.

There are between 800,000 and 1.2m illegal immigrants in the UK. ( BBC news and the Telegraph respectively ).  Most of them are now going to be unemployed. They will be ineligible for government assistance. This crisis will “bring them out of the woodwork”, and make the scale public and clear.

So if illegal Immigrants will become evident in this crisis, will they use the 4 Health Services? Of course they will, and they should not be rejected.

See the source image

So now is an opportunity for us to be pragmatic. We need to set aside fears of “illiberal” changes, such as ID cards, and embrace the opportunities they offer.

2016: Liberal beliefs need to be modified pragmatically to create a sustainable health service – especially in Wales

Identity Cards could help, addressing inequality in health, and helping younger families.. Bring back the guillotine for Mr Hunt

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

Hardship…? Lets seize the opportunity for more much needed change..

Patients in same street get different NHS car

Neighbouring surgeries provide sick with different levels of care.

2017: The UK Health services are facing a “dead end” – both literally and figuratively if we don’t accept rationing.

Charges are acceptable – at last the ideology of 1948 is challenged

Patients should pay to see their GP…?

A curse on all their houses. Banal debates omit the really important questions. Entertainment has come before long term politics and unity..

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

See the source image

 

See the source image

 

Reverse the devolution of health.. Now is the time to combine the 4 health services to give us efficiency, equality and unity.

The 3 smaller health services should be closed down, and decisions made by England should apply to all. Its clear to NHSreality that Now is the time to combine the 4 health services to give us equality and unity. Why have Public Health Wales when the English administration is fit for purpose? NHS Health Scotland is fine and dandy, and it sometimes comes out with advice earlier than England, but the duplication of expensive resources cannot be justified. How many more incubators, respirators, and hospital beds could we fund with this money? So not only equality and unity, but also efficiency would result from unification of health services.                                                                                                                  BBC Wales news emphasises the difference and independence of its health service 25th March 2020

The democratic and opportunity deficit in health will become apparent, especially in the retrospectoscope, after this pandemic. Watch for different death rates, infection rates, and survival rates. The fact is that devolution has failed greatest in N Ireland, whose parties and public remain in a repressed civil war, and secondly in Wales, where the population is only a little larger, and non violently, but multiply tribal, and more successfully in Scotland because they have a separate budget. Certainly reversing health devolution should be considered carefully.

Unfortunately politics and media conspire to forbid pragmatic and unemotional discussion of any change to devolution. Indeed, the mood amongst these two conspirators is for independent taxation and then what: fiscal independence as well?

The pandemic has shown us that unity helps. Big mutuals do better. In defence and armaments bigger stronger countries can defend themselves better, and weaker ones least. The same is true for a pandemic. Reverse the devolution of health. Thee shock of this virus will either bring us together more, or tear us apart. Europe is at risk of the latter.

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Poor state of Welsh health. The experiment with devolution has failed….

Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

The democratic deficit. Applies to health as well as devolution, and to leaving the EU. The first honest party should get public support.

See the source image

The shock of coronavirus could split Europe – unless nations share the burden

See the source image

See the source image

 

On the cusp of collapse – the continued story of heroic survival

The 4 Health Services survive due to the heroics of their staff, but for how long? This was only 4 months ago! I want to remind readers of NHSreality that in November, well before the CV19 epidemic, Peter Blackburn for the the BMJ reported:

NHS on the cusp of collapse, on 14th November 2019

Overcrowding and underfunding have left patients and doctors at risk and, as a demanding summer turns into a winter of alarming challenges, how will the NHS cope? Peter Blackburn talks to doctors across the UK struggling on the front line

‘When I left my shift at 2am there were 56 patients in the majors department – in a space with just 16 bays. Each bay was split in half for two patients and we had to leave one bay free to be used for toileting and another as a drinks station owing to the sheer amount of people in the corridor.

‘It is a terrifying situation.’…..

….‘We are completely under the cosh and I don’t think there’s an emergency department in England or Wales that thinks that patient care isn’t going to suffer over winter. The truth is that it’s already suffering – and it’s not through lack of effort on the part of trusts. Trusts are doing all that they can do, they are engaged in the process of trying to free up beds but it feels a bit like the bottom has fallen out of the system – particularly social care.’

winter pressures graphs

A Sussex nurse adds: ‘We don’t really have a time when we aren’t full to bursting point and are normally on black alert – where the need for beds is just overwhelming.’

But why was the summer so bad – and what might it tell us about the winter ahead?

During the three summer months the NHS averaged 17,536 emergency admissions per day – a 3.6 per cent increase from 2018. Emergency admissions place a huge strain on resources as trusts can’t plan for them and a small increase can cause significant blockages in hospitals. On top of that attendances at emergency departments across England increased by 5.7 per cent and the NHS seems to have suffered a winter hangover, with four consecutive winters of at least 150,000 trolley waits leaving trusts on the back foot heading into spring, summer and autumn.

Consultants’ despair

The problems have been exacerbated by the pensions crisis – with consultants being prevented from picking up shifts for fear of dramatically increasing their tax bills. A recent Royal College of Emergency Medicine survey reveals that nearly 90 per cent of consultants who responded said the rules would affect rota gaps at senior levels….

…Best-case and worst-case scenarios would represent the most pressurised winter on record. The worst-case scenarios see performance drop markedly: trolley waits rocketing by tens of thousands, attendances and admissions increasing dramatically and four-hour targets likely to drop significantly.

winter pressures graphs

One Midlands emergency department consultant says: ‘It is absolutely daunting looking ahead to winter. I’m not a naturally negative person, I tend to believe we can manage but we didn’t a couple of years ago and we are in a worse place than we were then. There is genuine concern among colleagues about what this particular winter holds and if we have the flu or a lack of medications through Brexit or a lack of people in care homes to look after patients then we are in serious trouble….

…While trusts and NHS leaders might like to talk about resilience of staff during conferences and high-level meetings, the truth is that such consistent pressures take a toll on very many of them.

As the south-west specialty trainee says: ‘When people ask me what training programme I am on and I tell them, they suck through their teeth and they don’t envy me at all. Anyone who comes into any emergency department would wonder why on earth you would go into it because you are asking to be burned out in that environment.’

He adds: ‘It is just not feasible for someone to work that hard for that long in a system at breaking point. The buzzword of resilience is great, but you don’t get through medical school and training without being a resilient individual. It is down to the system.’

winter pressures graphs

The pensions crisis also represents a serious concern ahead of winter. Last month, NHS Providers, which represents hospital, mental health, community and ambulance services, said patients would be at risk of unsafe care unless an ‘urgent solution’ to the problem – which is seeing consultants avoid working extra shifts due to being hit with massive tax bills – is found.

With doctors already on the brink of burnout and the most pressurised winter in history on the horizon can anything be done to avert disaster?

The first answer is yes – with genuine political will and proper investment. The BMA has long campaigned for the NHS to increase its bed stock, and it is crucial this is done before winter begins.

Beds needed

BMA emergency medicine lead Simon Walsh says: ‘Last year the BMA called for a minimum of 10,000 additional hospital beds to be opened across the UK after an analysis of recent years’ performance and hospital occupancy left no doubt that there are insufficient beds to cope with the number of emergency admissions that are required over the winter months.

‘It is notable that even the chief executive of NHS England, Simon Stevens, has recently acknowledged that we need to go into winter with more hospital beds than last year. The problem of course is that trusts don’t have the funding or staff to do that so what is required is for the Government to acknowledge the scale of the problem and to fund these additional beds and staff before it’s too late.’

And steps also must be taken to ensure doctors are not prevented from working by the pensions debacle.

Dr Walsh says there needs to be an immediate increase in funding to health and social care, and also a plan which can better meet the needs of an ageing population.

‘It is going to be too late to wait – the Government needs to take urgent action now before the worst of this winter fully arrives and we face a perfect storm undoubtedly resulting in the worst ever winter on record. I’m afraid the staff cannot bend any more to absorb the pressure of this broken system – I fear for the consequences this winter if action is not taken immediately.’