We all need to be examined to make a proper diagnosis without wasting resources. Private Practice returning soon?

In a facetious post last week on Facebook I wrote: With some 75% of GP consultations now remote is there an opportunity for private practice, with the strap line:” I will see you face to face and I will examine you”? The MDU says over 50% of it’s total ever claims have come in the last 5 years.. which caused some mirth and concern in equal parts. Now as Paris Hospitals are about to be overrun, the position of GPs and Consultants using the phone to diagnose is worrying. Mr Parker-Bowles girlfriend may have had a delayed diagnosis because of the covid outbreak, and died very young. Whilst most people wont go privately, many a truth is spoken in jest, and if you need an examination and cant get it you may have to be assertive. Remember that telephone calls are not well recorded, if at all in some practices. Letters on the other hand are scanned and saved into the notes, and are part of the medico-legal record. If you ask for an examination in writing you will rarely be denied. Unfortunately, during covid, the type of patients who badly needed an an advocate before, and need one even more now, (All of us nowadays!) cannot have one at their bedside. In addition there is increased demand for “reassuring” tests and scans which result from not examining… so waiting lists get longer.
Kat Lay in the Times 29th March 2021 reports: Face-to-face diagnosis is better than phone, say GPs
GPs want to see their patients in person and fear phone appointments could mean they miss clues as to what is wrong.
Professor Martin Marshall, head of the Royal College of GPs, made the comments after a survey of trainees found most wanted to do as few remote consultations as possible once qualified.
In an attempt to control the spread of coronavirus the majority of GP interactions with patients became telephone or video appointments.
Marshall told The Guardian that this had proved “frustrating for some GPs”, who felt as if they were “delivering care via a call centre, which isn’t the job they signed up for”.
He added: “Remote consultations have advantages, particularly in terms of convenience, but we know patients prefer to see their GP face to face.”The challenge was particularly acute when dealing with patients who had complex health needs, Marshall said, adding: “It can also make it harder to pick up on soft cues, which can be helpful for making diagnoses.”

The King’s Fund, a think tank, asked 810 trainee family doctors how many four-hour sessions per week they wanted to work from home, a year after they qualified. A full-time GP works ten sessions each week. About 74 per cent said they would work either none, one, or two, and 21 per cent said they would do three or four.

One trainee said: “I think the team-working environment is essential. I need to feel part of a team and would struggle if I had to work from home. I also want to see patients. I would seriously consider changing career if consultations were only remote.”

Another added: “Working from home is undermining the speciality. We already lack respect from other medical colleagues. If by the time I am ST3 [final year of GP training before qualification] general practice is all remote — I will switch careers and do medicine or obstetrics and gynaecology. I do not want a career on the telephone.”

Dr Aamena Bharmal, a trainee who ran the survey while on secondment at the King’s Fund, said: “Working from home is not why I want to be a GP.

“Primary care is about giving the right care for their local population and offering remote consultation for some patients is the right thing — but that is not the case for all.”

Dr Nikki Kanani, NHS England’s primary care medical director, said: “More than half of primary care consultations in February in England were face-to-face, and a mixed model of care is both important for patients and offers a flexible way of working to support staff too.

“The balance is a decision for general practice, with a mix of different types of appointment important as it keeps both staff and patients safe. GP teams in England carried out over 250 million appointments during the last year.”

•Thousands of young people with drug or alcohol problems are unable to get specialist help and could face a lifetime of addiction, specialists have warned. The Royal College of Psychiatrists said funding for young people’s addiction services had fallen 37 per cent in real terms since 2013-14, with the number of patients also down substantially. New analysis published today by the college found £26 million in real terms had been cut from youth addiction services in England between 2013-14 and 2019-20.

Assertiveness pays: NHS (England) urges GPs to see patients in person….

Waiting lists and times matter. Should Katie Mayum have been more assertive?

“Social Determinants of Health” should be included in the medical history and in the medical record. The health divide is worsening, but as usual “deny, delay, defer and defend the status quo, deflect the truth” is the order of the day.

Deny, Delay, Defer and Defend.. The Perverse Incentives within the law related to Health..

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….

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’..

How to make a GP appointment: Write a letter.

Update 9th April: Helen Salisbury: Triage is for disasters, not everyday general practice  BMJ 2021;372:n845

Brexit will impact the 4 health services this coming year

The Nuffield Trust reports on “Understanding the impact of Brexit on health in the UK”

With the prospect of a deal still very much hanging in the balance, the UK’s transition period for leaving the European Union ends in a matter of days on 31 December 2020. This major new report maps out the health areas that will be affected by this decisive exit from the Union and discusses the dilemmas faced by the health sector in the face of such huge legislative changes. 

MAIN POINTS: Our research confirms the well-known issues Brexit raises in many areas, from
medicine supplies to data flows. Most, though not all, are relevant whether
or not an agreement on a future relationship is reached between the UK and
EU at this late stage. It has also uncovered the following less widely discussed
impacts, which deserve urgent attention:
• The short-term supply of medicines and medical devices to the UK after the
transition period is a serious concern, with levels of uncertainty very high.
The UK government is preparing for disruption, but it is not clear which
scenarios it is and is not ready for. Border closures in December due to
coronavirus have introduced an unpredictable new element. Flows of data
will also face blockages.
• Beyond this short-term picture, our interviewees and roundtable
participants believed the UK will face a lack of competitiveness in terms of
investment in health-related industries, a permanent increase in the cost of
supplies for health and social care, and difficulties in accessing them. Yet
there seems to be no detailed plan for how the UK will regulate medicines
and medical devices after we leave the single market and EU institutions.
• The end of the free movement of labour is likely to make it more difficult for
the NHS and social care to access the growing number of workers they
need. Our data analysis shows that the Covid-19 pandemic has also slowed
migration dramatically – from the EU and the rest of the world – even
before Brexit changes take effect, with a 70% drop in migrants entering the
labour market. The pandemic has therefore raised the bar still higher: the
UK now needs to dramatically accelerate migration from 2021 to meet
government commitments on nursing and on providing more social care.
• Industry representatives and government officials described uncertainty
around how medicines, supplies and staff will enter Northern Ireland after
the transition period, and what this would mean for access to health
services and medical products in the future. While the recent decision
of the joint committee has set out short-term allowances, longer-term

decisions have yet to be taken and there is an expectation of widespread
accidental failure to comply with the law.
• While food safety issues such as chlorinated chicken have received
significant media attention, the most important question for public health
will be how the UK government regulates causes of ill-health such as poor
air quality, tobacco and unhealthy food. There has been little discussion of
plans for this after Brexit.
• Slower economic growth and decreasing spending capacity following
Brexit may worsen wider determinants of health, such as unemployment
and access to health services. It will be possible to track indicators of
these changes – such as healthy life expectancy or child poverty – over
the long term. However, there will be a challenge in disentangling the
impact of Brexit from the effects of the recession brought about by the
Covid-19 pandemic.
• There was significant uncertainty regarding powers returned and
redistributed through the Internal Market Bill (IMB), with respect to the
UK’s four constituent nations. Officials in Scotland, Wales and Northern
Ireland are concerned the Act could curtail their ability to regulate in
the future to improve public health, tying them to unclear Westminster
plans, and depriving the UK the opportunity to learn from regulatory
experimentation, such as Scottish measures on smoking in public places
and alcohol pricing. The Internal Market Act, approved on 17 December,
partly addresses these fears, by including amendments that permit
regulatory divergence from UK-wide rules, where the four constituent
governments have agreed on a common approach. This mechanism has
been set out in principle, but remains to be monitored in practice.

Read / Download the full report here

No national agreement on pay.Could it be cynically political if staff are paid differently in different dispensations?

The media is having a field day as the deveolved regions try to embarass Parlaiment into being forced to match the pay rises offered by the Scottish and possibly the Welsh to staff. The politics of this stink. By using their devolved rights to reward the largest part of the workforce (Health Service Staff) the cynical calculation is probably purely about votes, as smaller increases with additional increments later would be far more appropriate..
If the future of health lies in encouraging people to be more autonomous, surely we need more long term money put into health education, prevention, and re-introduction of prescription charges. The long term effect on the English, who have patiently given proportionately more to the devolved may we that patienve runs out and they are asked to manage on the same per capita budget as the ENglish. Ironically it is much harded to fill consultant places in Wales so a form of adverse selection by pay might work.. if it was large enough.

BBC News reported 3rd March: Nurses’ union anger over ‘pitiful’ 1% NHS pay rise when they had voted for a 6.5% pay rise

BBC News 5th March 2021 reported: Welsh NHS: ‘No ceiling’ for possible pay rise, says minister

MailonLine reports 16th March 2021 that Matt Hancock will offer England’s staff 1%

Mark Smith for WalesOnLine reports 17th March 2021: All NHS and care staff in Wales to get £735 one-off bonus – It is estimated the payment will benefit 221,945 people in Wales

On 24th March the Guardian reported that NHS Scotland staff are to be offered “at least” a 4% pay rise. This will affect 157,000 staff.

28th Jan 2021: Public sector pay: Latest – gov.scot – The Scottish Government

WalsonOnLine reported 16th December 2020 that members of the Welsh Synod froze public staff pay whilst awarding themselves a 2.4% rise (Averaging £10,000) and in contrast the MSPs (Scotland) have agreed that it would be inappropriate for them to have a pay rise in 2021.

Kieran Andrews reports in the Times 26th April 2021: Nicola Sturgeon’s NHS pay boost piles pressure on Johnson

Boris Johnson is under pressure to increase the “miserly” pay offer for NHS staff in England after Nicola Sturgeon raised their wages in Scotland by at least 4 per cent.

On the eve of the Holyrood election period, the Scottish first minister announced the offer to the 154,000 health staff north of the border.

Only 1 per cent has been proposed for NHS workers in England but The Times reported this month that ministers were considering increasing this to between 2 per cent and 3 per cent.

The pay offer from the Scottish government, which is to be backdated to December last year, also guarantees a rise of more than £1,000 for staff now on salaries of less than £25,000.

“The Tories’ miserly 1 per cent pay offer south of the border shows that they have the wrong priorities,” Sturgeon said.

“People will no doubt wonder how they can find the money to massively increase their stockpile of nuclear weapons, or build a bridge to Northern Ireland, but refuse to find the money to properly reward those who were at the front line of the pandemic.”

Scotland receives more money from the UK Treasury than it raises through taxes at present and Rishi Sunak, the chancellor, pointed out that Holyrood’s funding had been boosted by £1.2 billion by his budget. The Scottish government does not have to imitate UK spending, leaving it free to invest elsewhere. It has to balance its budget, however, and has increased taxes for higher and middle-income earners to increase the funding available to central government.

Douglas Ross, leader of the Scottish Conservatives, said the higher pay offer to NHS staff in Scotland was possible only “because the UK government have invested that £13.3 billion of additional support in Scotland”.

“My message to Boris Johnson is, it’s a decision for him and his government,” Ross added. “We will look at what’s happening in other parts of the country, and it is an independent body which sets the deal for NHS staff.”

The prime minister faced a backlash from Tory MPs yesterday, and trade unions used the Scottish offer to increase pressure on his government over the offer in England. The 1 per cent offer has been submitted to the NHS Pay Review Body, which is expected to respond in May. The pay rise should have been paid on April 1.

The 14 NHS unions, representing 1.3 million workers, have written to Johnson asking to meet him and his officials to find a way forward. They highlighted that the new financial year began next week, when a new pay deal should have been in place, and accused the government of “deliberately delaying” until the summer.

The letter, signed by the lead negotiators from Unison, the Royal College of Nursing and the Royal College of Midwives on behalf of all 14 unions, said: “When NHS staff in England contrast the Scottish offer with what you have proposed for them, they will feel increasingly bewildered by how you are choosing to treat them.”

Sara Gorton, head of health for Unison, said Sturgeon’s offer showed that “where there’s a political will there’s most definitely a way”.

She added: “The Westminster government should . . . be shamed into following the Scottish example.”

#

Watch this space – will our rulers make sustainable changes to Social Care (and by implication health care) this year? There’s no way without bottom up discussion and community consent..

NHSreality suspects that the changes announced will be just the start of a long debate. The demographics of the UK mean an increasing elderly population needing dementia care (excluded from health) , and with fewer births and lower fertility there will not be enough people to look after these elderly people. I may be one of them. Whilst Social Care is means tested, Health Care is (Meant to be) free. NHSreality will judge suggestions on whether the perverse incentives to designate dementia as “social” that exist today are removed. We can either means test health, or make social care free, and any suggested middle path seems unworkable. Since everything free is unsustainable, there is only one real alternative.
When I first started life as a GP there were local authority care homes, bit gradually they were all closed or privatised. History will tell us the cost then, and the ageing process goes on much longer now, despite the unofficial scandal of the DNRs!

Simon Murphy, Oliver Wrigh report in the Times 25th March 2021: Social care reform to be announced in Queen’s speech, hints Boris Johnson
Ministers hope to bring forward plans to reform social care as early as May, Boris Johnson suggested yesterday.

The prime minister pledged on his first day in Downing Street in July 2019 to “fix” the social care crisis and has come under sustained pressure to reveal the government’s solution.

Giving evidence to the Commons liaison committee, Johnson offered the closest indication yet of when reforms might be announced, saying it was “highly likely” social care would be featured in the Queen’s speech on May 11.

He told the committee: “One of the problems that we have . . . is the gulf between the NHS and social care into which so many people fall, and that’s a problem we need to fix. And if you’re going to ask me, ‘Do we need a plan to do it, a long-term plan, a ten-year plan?’ Then the answer is yes.”

The prime minister’s comments come as a new critical report from government auditors warned that the sector was facing a fresh cash squeeze. The National Audit Office (NAO) found most local authorities were paying care providers below a “sustainable rate” for the residents in their care, while occupancy rates had also fallen significantly.

NHSreality posts on Social Care

NHSreality posts on Means Testing

The reform of Social Care means an honest debate: something far beyond every political party today.

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

Spin doctors? Richard Smith isn’t buying it. “The NHS doesn’t need more money, it needs a radical rethink”.

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

Asya Likhtman in The Week August 2020: NHS care homes told to put ‘Do Not Resuscitate’ orders on all residents at Covid peak – Survey suggests one in ten managers and nurses were told to change DNRs without discussion with patients, relatives or fellow staff

The increase in complaints reflects system failure. Unfortunately the complaints are aimed at the staff because they are easier targets than the managers or politicians who created the systems.

Working in fear. Everyone in the 4 health services is terrified of being sued. When my senior partner retired the MDU wrote to him something like “In view of the fact that there has never been a complaint since you first insured with us, we are pleased to give you cover for the rest of your life”. Meaningless from a financial point of view, as he was no longer working, but what a compliment after nearly 45 years of General Practice. Today nearly all doctors have a complaint to handle, and most every five years. Complaints are stressful and debilitating. They can lead to suicidal tendencies in very proud people, who are often meticulous and/or perfectionist. The fact that 50% of all complaints have been in the last 5 years is signoficant. It can be interpreted in many ways however. Increasing expectations, diminishing standards, non-learning organisations (without exit interviews) and communication related (as most complaints relate to doctors not qualified in the UK). Organisations are meant to learn from their complaints, and critical incidents should be reported always, as although there may not be a complaint, there might be one in the future if repeated. Unfortunately, for some years now, juniors could be reporting critical incidents all day, at the expense of their clinical work. It would be interesting to compare the complaints rate with other G7 countries, in different systems. General undercapacity leads to overwork and more complaints. Rarely are complaints made against management or the trusts or their sytems. Rarely are Trust Boards complained about for making a weak appointment, or for appointing when they should have re-advertised. The minister needs to veto some consultnt appointments as well as managers..

Zosia Kmietowicz reports in the BMJ reports on figures from the MDU: Nearly all doctors have faced a complaint in their career, survey finds (BMJ 2021;372:n707)
Nearly all GPs (97%) who responded to a survey from the Medical Defence Union (MDU) said they had received a complaint against them during the course of their career, with slightly lower figures for consultants (88%) and trainees (71%).

The survey, conducted in December 2020 was sent to 32 000 MDU members and received 741 responses (a 2.32% response rate), 296 from GPs, 274 from consultants, and 59 from trainees. The main findings were:

• ● About half of complaints were made within the past five years
• ● The most common complaints (46%) about GPs were related to an alleged delayed or missed diagnosis
• ● The most common complaints (30%) about consultants were related to alleged treatment complications, while most complaints against trainees (43%) related to an alleged breakdown in communication
• ● Of the complaints against GPs, 40% were resolved locally within the individual’s own clinical team. Among consultants 55% of complaints were resolved at senior management level while 45% were resolved within the individual’s own clinical team. Most complaints (66%) against trainees were resolved within the clinical team
• ● GPs were most likely to say that the complaint had an impact on their professional (70%) and personal lives (65%), although about half of all doctors said their lives were affected in some way.

NHS reality posts on Litigation

NHSreality posts on Complaints

NHSreality posts on No Fault Compensation

Shaun Lintern for The Independent reports 8d ago: Ministers seek powers to veto local NHS trust appointments – Health secretary says integrating care will mean better outcomes for patients and promises NHS budgets will be signed off ‘very shortly’

The damage was done well before covid, and there was no “reserve” or capacity to withstand the assault. The British Academy is being at best kind and at worst disingenious: health and social care decay began well before covid.

Decades of denial have led us to this crisis, and it cannot be corrected quickly. If you don’t build a castle your control centre can be overtaken easily. It all boils down to causing increasing inequality by neglect and short termism. We are reversing all the progress towards equality in medical outcomes. This began at devolution when the original NHS “mutual” was broken up. With not even a suggestion of how to solve the social care problem, and the perverse incentives of current care, the prospect for those entering old age is not attrative. Patrick Butler, for the Guardian reports 23rd March 2021: UK faces ‘Covid decade’ due to damage done by pandemic, says report – British Academy review calls for wide-ranging new policies to reverse rise in deprivation and ill health

Britain faces a “Covid decade” of social and cultural upheaval marked by growing inequality and deepening economic deprivation, a landmark review has concluded

Major changes to the way society is run in the wake of the pandemic are needed to mitigate the impact of the “long shadow” cast by the virus, including declining public trust and an explosion in mental illness, the British Academy report found.

Published on the anniversary of the UK’s first lockdown, the report brings together more than 200 academic social science and humanities experts and hundreds of research projects. It was set up last year at the behest of the government’s chief scientific adviser, Sir Patrick Vallance.

The British Academy warned that failure to understand the scale of the challenge ahead and deliver changes would result in a rapid slide towards poorer societal health, more extreme patterns of inequality and fragmenting national unity.

Government-led intervention including major investment in public services is required to repair the “profound social damage” caused or exacerbated by coronavirus across areas including the economy, mental health, public trust and education, it said.

“With the advent of vaccines and the imminent ending of lockdowns, we might think that the impact of Covid-19 is coming to an end. This would be wrong. We are in a Covid decade: the social, economic and cultural effects of the pandemic will cast a long shadow into the future – perhaps longer than a decade,” it said.

The report’s publication came as Boris Johnson delivered an upbeat reflection on what he called one of the most difficult years in the UK’s history, offering condolences to those who lost family and friends to the virus but paying tribute to the “great spirit” shown by the nation.

“We have all played our part, whether it’s working on the frontline as a nurse or carer, working on vaccine development and supply, helping to get that jab into arms, home-schooling your children, or just by staying at home to prevent the spread of the virus,” the prime minister said. “It’s because of every person in this country that lives have been saved, our NHS was protected, and we have started on our cautious road to easing restrictions once and for all.”

The British Academy cautions against overoptimism as the UK thinks about recovery from Covid, however, warning that it is “no ordinary crisis” that can be fixed by a return to normal, but one that thrived amid pre-existing social deprivations and inequalities and which has exposed deep-seated flaws in public policy.

Too many people experienced the pandemic in poor housing, were badly equipped for home schooling and home working and vulnerable to poor mental health, and found themselves at high risk of economic insecurity, the report said, pointing out that “many people are ‘newly poor’ and only one month’s wages away from poverty”.

Areas for action highlighted by the report include:

• Declining public trust: after an initial surge in the first months of the pandemic, trust in UK government and feelings of national unity collapsed, with little sign that progress on vaccinations has halted the trend. Unless addressed, this will erode social cohesion and undermine future public health campaigns.
• Widening inequalities: geographic, health, racial, gender, digital and economic inequalities have been exacerbated by Covid. If not tackled, they risk becoming permanently locked in, scarring the prospects of groups disproportionately affected by the social impact of the virus, such as young people.
• Worsening mental health: soaring mental illness, especially among children, low-income households and black, Asian and minority ethnic communities, risks embedding long-term problems if the underlying causes are not tackled.

The report calls for renewed spending on community services, local government, social care and local charities, especially in deprived areas, noting that some of the most effective responses to Covid have been at a local level, where public trust has remained strong. Investment was need to erase the digital divide and establish internet access as a “critical, life-changing public service”.

With unemployment expected to rise, the report questions whether the existing social security system, which is geared more towards helping low-paid workers than people without jobs, could cope with a pandemic-induced recession, saying: “This may prompt reflection on what kind of system the country wants and needs.”

The lead author of the report, Dominic Abrams, professor of social psychology at the University of Kent, said the investment package needed would be expensive, but that much could be achieved by reframing existing policies. “I don’t think this is necessarily about extra money, it’s [about shining] a laser light over existing policies.”Asked whether he was optimistic that the government was open to making changes on the scale the academy called for, Abrams said this was an opportunity to address a range of serious social issues that were not going away. Without a post-pandemic strategy, he said, “these things will get worse”.

Hetan Shah, the chief executive of the British Academy, said: “A year from the start of the first lockdown, we all want this to be over. However, in truth, we are at the beginning of a Covid decade. Policymakers must look beyond the immediate health crisis to repair the profound social damage wrought by the pandemic.”

A government spokesperson said: “Coronavirus is the biggest public health challenge the UK has faced in decades and as we recover from this pandemic this government is committed to building back better and levelling up outcomes for every individual across the country.

“That’s why we’ve implemented robust support to those who need it most – raising the living wage, spending billions to safeguard jobs, investing £2.4bn each year for disadvantaged pupils, and boosting welfare support and local authority funding. On top of that, we are providing an additional £500m for mental health services and £79m to expand mental health support teams in schools and colleges.”

The 4 Health services biggest asset – staff – and there just are not enough. How do we rebuild to withstand another crisis? It will take a decade at least..

Decades of denial have led to this crisis. With “inexperienced inadequates” running the country we are in for a long winter.

Capacity management be re-thought – For both plant and people..

A letter in the BMJ from DMr Charles Diaper, consultant ophthalmologist reminds us of the benefits of overcpacity in order to maintain the plant. The same is true for the staff. NHS needs more capacity to tackle surgery backlog BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n696 (Published 15 March 2021)  BMJ 2021;372:n696. As long ago as 2010 the BMJ warned that quality and efficiency might be better under central control than market forces. We need to stop rationing staff and beds, and if that means restructuring the method of funding for the 4 health services, then thats what should be done.

NHS needs more capacity to tackle surgery backlog Carr and colleagues discuss the growing backlog of planned surgery caused by covid-19.1 Cataract surgery is by far the most common operation done in the NHS, usually provided by one of the smallest units, consultant-wise, in hospitals. It is also the operation with the highest average increase in quality adjusted life years.
The authors call for a leaner , more cost effective and more flexible NHS….Compared to the NHS which runs at full capacity (around 95%) for long periods, the German Health Care system is designed to consistently run at a capacity of around 80%. This allows for maintenance and development in good times, and capacity for emergencies during bad.
What efficiency do we want for the NHS, which Covid-19 has shown us was dangerously lean to begin with?

Growing backlog of planned surgery due to covid-19 | The BMJ

Millions of people are now waiting and worried.
Covid-19 continues to have a severe effect on planned surgery in the UK, and dealing with the resulting backlog is a critical concern for the NHS. Data from NHS England show that the number of patients awaiting treatment hit a record high of 4.46 million in November 2020,1 with the number of referrals well below 2019 levels. The same data suggest that roughly 2.3 million people are currently waiting for surgical care.
Though the number of surgical patients treated within the 18 week NHS standard is improving from its worst point in the first wave of the pandemic, the number who have already waited more than a year for treatment has reached 138 401, a 153-fold increase from 904 in November 2019, and growth shows no sign of slowing. Trauma and orthopaedics, oral surgery, and plastic surgery seem particularly affected, but even cancer surgery has been delayed: the percentage of patients having cancer surgery within one month of the decision to treat dropped from 92% to 88% over the same period.
Why have waiting times increased so much? Solid evidence is not yet available, but several contributors are likely. Operating theatres and outpatient clinics were closed as they became needed to treat patients with covid-19 during the first wave in 2020. Surgical staff, particularly junior surgical and nursing staff, were redeployed to provide cover for extra beds occupied by patients with covid-19 and for staff unable to work because they had covid-19 or were isolating. Despite better availability of protective equipment, hospitals remain high risk areas for acquiring the infection. The procedures put in place to protect patients and staff mean that seeing and treating patients in hospital takes much longer than it did before the pandemic. Delays or failures in patient testing have also been problems at times, wasting much needed space on operating lists. Workforce shortages may be amplified by increased viral transmissibility in the current wave.
The NHS has enjoyed substantial public, political, and media support during the pandemic. However, the historical lack of spare capacity in the NHS has arguably resulted in poor resilience and weakened its ability to cope with a stressor such as covid-19. The full effects of limited capacity will become clearer only as the long term consequences of delayed care are better characterised. Although many patients have been understanding and are waiting patiently for the situation to improve, they have concerns about delays and the lack of information about expected new timelines.
Patients also want reassurance that they will be safe from covid-19 when they are admitted. Governments must develop communication strategies that identify patients’ concerns and misconceptions about risk of infection and provide information that patients can trust. Individual differences in perception of risk are key to effective communication, as is open acknowledgment of uncertainty. Patients want information that is easy to find, transparent, consistent, timely, and understandable so that they can make more informed decisions about their treatment and contingency plans. While many patients embrace digital technologies, care must be taken to address the growing digital divide affecting hard to reach groups as well as other emerging health inequalities.
Predictive modelling suggests that around 28 million operations were cancelled or postponed globally during the peak 12 weeks of the first wave3; this number will surely increase as the pandemic progresses. The ability to clear the resulting backlog will depend on the resources available in different countries, and will be a serious challenge for many. In the US, one study estimated that a backlog of at least one million orthopaedic surgical cases would remain two years after elective surgery stopped being deferred because of covid-19
As the huge task of clearing the backlogs begins, surgical teams must be provided with appropriate resources, facilities, and both professional and mental health support.56 One promising route to increasing the volume of surgical care in the UK is so called “green pathways”—covid-free areas of hospitals where planned surgery can continue with substantially reduced risk to patients and staff. New ways of working with remote consultations, community diagnostic hubs, increased use of the independent sector, and regional treatment hubs with ring fenced resources for planned care are already emerging in many areas.7 One concern, however, is that extra capacity in the independent sector is concentrated in the south east and not where it is most needed.
Some regions are increasing activity by pooling waiting lists, prioritising cases, and removing patients from waiting lists who no longer need surgery. Many patients have had to accept compromises, including reduced choice about where and by whom they are treated. Clear and regular communication with patients regarding local plans and the likely timescale for their surgery remains critical.
Additional resources and greater capacity will not be enough. Profound changes to the way we work will be also be required, along with reform to create a leaner, more cost effective, and more flexible NHS able to make nimble decisions in response to crises such as covid-19.

Collateral damage, DNRs, cancer…. its important to be honest about rationing, and the inevitable collateral damage

Perhaps some lay people will begin to ask “why are there so many health charities in the UK?” when we have a system that denies rationing. The Brain Tumour Charity has been calling for the extra costs of going abroad to be waived and said that “many people with rare and incurabe forms of cancer find that they have to travel to countries such as Germany to gain access to new and experimental treatments unavailable in the UK” (Kat Lay in the Times 22nd March 2021). It sid these patients sometimes had to raise £100,000 to fund treatment and travel, then covid 19 tests before and after travelling. In the letter below Sarah Lindsell, CEO, says “Many have no option but to take the chance on a difficult journey abroad in the persuit of hope …… we believe the governement could make a big difference by providing those travelling abroad for treatment for incurable cancer with covid 19 tests fro free. Welcome to the reality of collateral damage, and rationing Sarah. Just because it’s more obvious now does not mean its not happenning all the time.
Then there is the question of funding for the Brain Tumour Charity and how much of it comes from companies sponsoring PET/MRI scanner, or Proton Beam therapies or unproven medications. Does this matter? NHS reality believes its important to be honest about rationing, and that collateral damage is worse during “pandemic wartime”.

Update 22nd March 2021 BBC News: Covid vaccine: Doses ‘down 250,000’ in Wales in coming weeks

Huw Pym for BBC News 3 days ago 18th March 2021: Covid-19 nearly disabled NHS says hospital boss

18th March 2021 BBC News: Fears over future of ‘essential’ Swanage paramedic car

James Hacker on 5th March for NHS England: Blanket DNR orders for people with learning disabilities and autism ‘never acceptable’, warns NHS England and ITV opines: Covid: Watchdog finds more than 500 cases of ‘do not resuscitate’ orders made without discussion and The Financial Times reports that NHS doctors “criticised” over DNR reports during pandemic and even the MPS have been affected according to the BBC: Covid: Ex-MP’s husband ‘had do not resuscitate order’

Kat Kay monday 22nd Feb in the Times reports: Thousands with cancer struggle to pay the bills because of Covid pandemic

Mailonline cricisises the limited use and supply of the Pfizer vaccines: Coronavirus UK: Britain starts to ration Pfizer’s Covid vaccine ahead of supply dip – in reality Astra Zeneca is equally effective and cheaper.

Edinburgh Nes reports March 20th: Slower vaccine rollout in NHS Lothian ‘due to supply from Scottish Government’

Cancer patients are being left to die – The Times Letters 22nd March 2021:

I have been treating cancer patients for nearly 50 years and I can honestly say I have never been as worried about cancer care in this country as I am now.

You report that thousands of lives may be lost to cancer because the pandemic has “derailed” treatment services (News, last week). This is not hypothetical: people will die because they did not receive prompt cancer treatment. The whole country and its healthcare came to a halt to fight Covid-19 — but where is the outrage for cancer patients?

Cancer will continue to kill relentlessly unless we get our diagnostic processes back into full swing. I am not one for apocalyptic predictions, but this will get a lot worse before it gets better.

Cancer patients deserve better than this. Restoring full services has been recognised as an urgent priority at the top of the NHS — but I am concerned that the implementation of an effective solution will come too late for our patients this year.
Professor Karol Sikora, medical director, Rutherford Cancer Centres
Rapid response
Covid-19 has had a devastating impact on cancer services. Bowel cancer patients now face five-year survival rates last seen a decade ago. This is a living nightmare for those whose treatments continue to be disrupted.

Bowel cancer, which is curable if diagnosed early, was already the UK’s second-biggest cancer killer as we went into the pandemic. It is now even more deadly. The NHS must move quickly and restore cancer services to avoid a wave of untimely deaths.
Genevieve Edwards, chief executive, Bowel Cancer UK

Please come and see us
The Institute for Public Policy Research is right to highlight the impact of the Covid-19 pandemic on cancer referrals and treatment. Its warnings echo the concerns doctors have been raising for months.

In the latest survey for the British Medical Association (BMA), more than half of GPs said they had seen more patients presenting later with conditions than they would normally expect, with cancer symptoms causing them most concern.

Yes, the government and NHS must urgently address the huge backlog in non-Covid care. Equally, patients should not be put off seeking help when they need it.
Dr Richard Vautrey, chairman, BMA GP committee England

Why are so many charities supporting an “unrationed” Health Service?

Prostate cancer waiting could kill many citizens. They are covid collateral.

Why is there variation in treatment and outcomes in different trusts? Could some be rationing more effectively (and covertly) than others? It may be the best are those spending least!

Big Pharma has taken over some charities and Single Interest Pressure Groups….

Is money spent by NHS charities together spent rationally? How do they decide? Dont say you weren’t warned about the health services collapse.

Crisis has exposed the weaknesses of too many charities

Charities should not be needed in a comprehensive, cradle to grave health service

Prostate cancer waiting could kill many citizens. They are covid collateral.

More money just to catch up, and it won’t solve the ongoing problem of denial and collusion to avoid the debate needed.

Remember the NHS bus in the Brexit debate? We now need 120 times as much. 350m is 0.35 billion, and we need 120 times that per annum. Suddenly the real cost of good health care and of not being prepared is hitting home. Its the staff that matter, and need to feel they matter and there are not enough of them.

Now you will be pleased to hear that the amount of money needed is 120 times this, per annum, in order to catch up.

Kat Lay (print copy) / Cameron Charters (on line copy) report in the Times 17th March 2021: NHS ‘needs extra £12bn a year’ to repair Covid damage, says IPPR report

The NHS faces a “decade of disruption” unless major funding can be found to cut waiting lists following the coronavirus pandemic.

A report by the Institute for Public Policy Research (IPPR) says hospitals need £12 billion a year to repair the damage done to their infrastructure by the virus.

In its report, State of Health and Care, the think tank said there had been 31 million fewer GP appointments since lockdown began and an extra 4,500 avoidable cancer deaths are forecast next year.

The report also found checks on people with severe mental illnesses had fallen below a third of their target levels, resulting in 235,000 fewer people having been referred for psychological therapies.

It is suggested that most of the 30,000 care home deaths in the first wave were largely avoidable. An extra 12,000 avoidable heart attacks and strokes are expected in the next five years because of Covid-19 disruptions to routine health services.

The IPPR says the severe strain being endured by the NHS in England can be tackled with an extra £2.2 billion a year for the next five years to reduce the backlog and manage the surge of demand on mental health services.

Just restoring England’s NHS to its pre-pandemic level was not enough, said the IPPR, which calculates that a further £10.1 billion of annual investment would be needed on top of the £2.2 billion Covid-19 catch-up funding to help get it back on course to meet its own NHS Long Term Plan objectives.

The IPPR says this spending should be funded by borrowing but taxes will need to rise in the future to fund the higher spending permanently.

The latest NHS statistics show that the number of people waiting for all medical treatment in England has reached a record high, with urgent cancer referrals dropping significantly.

Figures from NHS England show that 4.59 million people were waiting to start treatment at the end of January, the highest number since records began in August 2007.

In January the number who had been waiting more than 52 weeks to start hospital treatment stood at 304,044, the highest number for any calendar month since January 2008. In January last year the number having to wait more than 52 weeks was 1,643.

The data shows the impact of lockdown, with a 54 per cent drop in the number of people admitted for routine treatment in January compared with a year earlier.

Nearly 380,000 patients had been waiting more than six weeks for a key diagnostic test, such as ultrasound or MRI, in January compared with 46,157 a year earlier.

Dr Parth Patel, IPPR research fellow and author of the report, said the report offered costed solutions to the shrinking workforce, the crisis in care and fragmented health services.

He said: “The NHS has been there for us, from outbreak to vaccine. Our blueprint for reform is the booster shot it now dearly needs.

“A decade of austerity left our NHS running at the top of its capacity, rather than the top of its game. As a result, the consequences of the pandemic on people suffering with illnesses such as cancer and depression have been huge.

“There is a real risk now that this damage embeds and the NHS falls further down international rankings.”

The NHS faced a waiting list of 7.2 million people in May 2020 following several months of lockdown.

The IPPR is calling for at least £1.4 billion to enable an average pay rise of five per cent for NHS staff as an immediate priority along with the guarantee of a living wage for all care workers through government wage subsidy at a cost of £1 billion.

It also says that social care should be free at the point of need and internet costs should be reimbursed for those most in need.

Dame Donna Kinnair, chief executive and general secretary of the Royal College of Nursing, said: “The government must take urgent action to retain the thousands of exhausted and over-worked nursing staff. We are clear this means investing in a 12.5 per centpay rise because more nursing staff will equal better patient safety.

“When the pandemic ends, services cannot be rebuilt better without the health and care professionals to operate them. Nursing staff must be at the heart of any recovery plans.”

Longer-term plans should include reforming health education, training and progression to develop a workforce with the right skills mix to meet future health needs, the IPPR findings state.

A government spokesman said: “We are backing the NHS in every possible way in our fight against this virus, investing £63 billion this year and £22 billion next year.

“This investment comes on top of £9.4 billion capital funding to build and upgrade 40 new hospitals and £3 billion we have earmarked for supporting recovery and tackling the NHS waiting lists.

“It is already making a difference, with average waiting times for elective treatment falling by 40 per cent since July and we will continue to work with the NHS to ensure all patients receive the best quality care as quickly as possible.”

Should we increase diversity at risk of losing quality? A suggestion that apprentice training will be good enough needs debating..

NHSreality is all for more good diagnostician doctors. When a friend who has reached 60 revealed to me that over 90% of his year have already retired it came home to me exactly how short of doctors we are. NHSreality is all for more diverse medical education, and has argued for “virtual medical schools” whereby the standards are set in the centres, but as many as want to can be trained in the periphery. By having to take the same exams, both on knowledge and skills, we can ensure quality outcomes. Unfortunately this approach, possible 9 years ago when I began NHSreality, is now more difficult. Apprenticeship training as suggested by the Telegraph (Laura Donelly 13th March 2021 reports: Controversial plan could see doctors without a degree learning on the job) and the Times (Kat Lay: 13th March 2021: Apprentice doctors won’t need a degree ) , would definately be possible if there were enough doctors, but there aren’t any longer. To allow time for safe supervision the coalface output of the trainers will have to reduce. The idea is to increase diversity..
Another problem will be the increase in risk, as apprentices are given more responsibility, and inevitably miss more complications and diagnoses than the more experienced staff. With litigation already at an all time high the nation cannot afford to do without “No fault compensation”. But this is a long way off, and has not been suggested by any party.

The Telegraph account is below.

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We do know from the graduate entry medical schools that fewer students drop out completely, but we still have losses due to emigration. Should undergraduate entry to medical schools be tied for a 5 year period after graduating, like India? Trainers also knwo that graduates are more determined and driven to succeed. (as the penalties for failure are higher?)