Trying to find someone else to blame wont work unless Mr Sunak tells the hard truths about the manpower planning being hobbled by politicians over decades

The idea that Mr Sunak can scapegoat the GPs, or the Health Trusts, or the Public is laughable. He may try, but confusion will remian in the public, and more anger and violence will be displayed towarss the profession, unless he is honest. Sunak needs to tell the hard truths about the manpower planning being hobbled by politicians over decades. Just as the chancellor has planned ahead for tax reductions before the next election, the Health Minister needs to get the bad news out of the way soonest. Only then can the debate start,
Paul Gallagher reports in the Inews 28th October 2021: NHS staff morale plummets as medics brace themselves for ‘worst winter ever’ – Frontline doctors are calling for a “comprehensive staffing plan” from the Government to solve a crisis which has led to around 100,000 vacancies across the NHS.

Isabel Hardman in the I reports: Does the government want to tackle the NHS crisis, or just dodge the blame for it?
If you’d only listened to the first half of Rishi Sunak’s Budget speech, you’d be forgiven for thinking he was continuing with Gordon Brown-esque levels of spending on the NHS. Healthcare spending up £44bn to over £177bn, the health capital budget “the largest since 2010” and a list of important new hospitals and operating theatres to help the health service deal with its towering treatment backlog. It all sounded very generous.

Only towards the end did we get a glimpse of the Chancellor’s real attitude towards the NHS. He moved into a passage setting out his economic philosophy, asking the Commons: “Now, we have a choice. Do we want to live in a country where the response to every question is: what is the government going to do about it?”

He added that while “we’ve taken some corrective action to fund the NHS and get our debt under control”, he wanted to reduce taxes. In short, this isn’t a government that is going to throw money at every problem. It’s time for everyone else to shape up, too.It’s as if Sunak has taken inspiration from one of his beloved Peloton spinning classes and is hoping that if he shouts enough motivational slogans at public services and businesses, everything will be OK.This is in keeping with the wider mood in government towards the health service. Ministers are agreed that yes, more money is necessary to help deal with the backlog. But they aren’t going to keep throwing cash at the service. The NHS has to modernise and become more efficient: this isn’t a problem the government can solve purely with funding.

It’s why there is a retired general, Sir Gordon Messenger, carrying out a review into the management of the service. It’s also why Health Secretary Sajid Javid has set up something called the “Health Delivery Unit” in his department which is designed not just to ensure that the backlog is broken, but that the health service doesn’t just subsume the extra money with little to show for it.

The creation of this unit has inevitably put backs up in the NHS, given its senior figuresthought the reason the body’s full name is NHS England and NHS Improvement was that the health service was supposed to be doing its own delivery work. There are mutterings that Javid’s team will be more focused on redrafting the waiting lists so that people who are not clinically ready for treatment – because they need to lose weight, for instance – aren’t included in the numbers.In return, Conservatives argue that the health service never likes being told it needs to become more efficient, just as individuals don’t like being told they are unfit. It is still the case that one in ten trusts are still largely paper-based, for instance. Messenger will find many other surprising anachronisms in a health service that British politicians feel bound to praise as “world-beating”. But Sunak’s Peloton politics won’t make the NHS the true envy of the world, either. His Budget was missing something as important to the health service as a swanky bike is to a fitness enthusiast.

There was nothing about the workforce of the NHS. Staff shortages have long been a problem, and as I’ve written in previous columns, will likely get worse as a result of burnout and trauma in the pandemic. The ‘Red Book’ containing the detail of the Budget gestures at it, saying “this will be supported by funding to continue building a bigger and better trained NHS workforce”.
But there is no plan setting out how the workforce will get bigger over the next few years. Worse, the body responsible for workforce, Health Education England, looks set to get a real-terms cut in its funding. I understand that there is still a row going on over whether the Department of Health and Social Care or the NHS will cough up extra cash to plug the gap. It is a serious omission that this hadn’t been resolved in time for the Budget.

Can the NHS really clear the treatment backlog and prevent health outcomes from plummeting if it doesn’t have the doctors and nurses to deliver the operations and medicines needed? Or is the talk of the importance of efficiency less about the need for the health service to work better and more about a blame game for when it fails, having been set up to do so?

This sounds like the sort of conspiracy theory espoused by someone who is convinced the Tories are on the brink of some kind of darkly evil US-style privatisation of the service. They’re not: any thinking Conservative recognises that the debate about the principles of the NHS is pointless. Besides, a conspiracy theory credits the Tories with some kind of elaborate long-term plan for the health service. What is going on is precisely the opposite.

Isabel Hardman is assistant editor of ‘The Spectator’ magazine. She writes a monthly column on health policy for i

Scapegoating the GP workforce…..

Even the Times now agrees that Health Care needs to be rationed overtly. No way without debate, and the politicians are too scared.

More value for money from Medical Students please..

In some countries a state funded medical student will usually be posted into a rural deprived area. They can either buy their way out of the posting, or serve their time. Most wish to return to the cities after their “countryside service” but some remain. It is in the European Convention of Human Rights that a citizen has the right to change where he works, or if he/she works at all and medical recruitment policies need to address the issues raised by Prof While below, as well as graduate entry replaing undergraduate entry. A complication of private training, expensive as below, is that many countries only train a small percentage of their doctors with state funds, the rest being private. This, perversely, creates a tribe or a caste of well educated doctors from (usually) mdical families. Many of them come to the UK because of our deliberate undercapacity. We pinch them from poorer countries without blushing.…

MEDICAL STUDENTS
Sir, The health service should of course have sufficient doctors to provide skilled care (letters, Oct 23 & 26) but it seems that a significant proportion of those funded by the government (it costs about £250,000 to train each medical student) to become doctors do not enter the workforce. Perhaps medical and other healthcare professional education that is funded at the taxpayers’ expense should require some obligation upon the recipients to work in the NHS for a period of time: staff planning will never succeed if efforts to recruit students are not associated with entry into the workforce. The GP workforce shortage is also partly a result of the reduction of full-time working GPs, who again have had additional taxpayer-funded training after their initial training. Now would seem a good time to address this inefficient use of taxpayers’ money.
Professor Alison While
King’s College London

Sir, Christopher Wilson’s timely assessment of the qualities required to be a good doctor is perhaps best summed up by Logan Pearsall Smith’s observation that the test of a vocation is the love of the drudgery it involves.
Jonathan Frappell, FRCS, FRCOG
Ret’d consultant gynaecologist and obstetrician, Yelverton, Devon

THE NHS cannot afford to rely on overseas health workers and must do more to recruit more nurses locally, a report urged today.

An unethical government persists in denuding the developing world of much needed skills…

We are creating a “caste” of doctors – by neglect. Neglecting to change our electoral system is equally crass..

Update 2nd November 2021: Times Letters DOCTOR SHORTAGE
Sir, Professor Alison While (letters Oct 28 & 30) omits a key fact: it takes three part-time doctors to replace one retiring full-time doctor. Any postgraduate employment has to be focused on full-time equivalents to justify the colossal expense in training such a privileged professional. The pendulum has swung too far towards part-time working.
Richard Wells
Ret’d full-time GP, Stapleford, Wilts

and PRIME HEALTH
Sir, Further to Carol Midgley’s Notebook (Oct 30) on the “Amazon Prime mentality” to healthcare, years ago a medical colleague lamented the duties of the “tuppence doctor”. All that was required to summon a doctor, day or night, was to go to a red phone box, put 2d in the slot, dial and press button “A” to request a visit by the family doctor, who would duly appear. Amazon Prime could not have matched it. Dr DW James Market Rasen, Lincs

Scapegoating the GP workforce…..

NHSreality has warned about scapegoating GPs for the long term failures of government(s) of all colours over thrity years. Yes, GPs should return to consulting normally as much as they can, but waiting rooms are a naturally spreading ground for covid -19 and protecting the most vulnerable may mean more remote consultations. The real culprits are the successive ministers of health who have rationed places in Med School.. There are big weaknesses in recruitment policy, as the drop out rate demonstrates, and the ratio of graduate to undergraduate entrants needs to increase (no medical undergraduates?)….but manpower planning has failed because of the short termism of our politicians

Constanza Pearce reports in Pulse 25th October: BMA urges GPs to move to 15-minute consultations and close patient list and Major hospital trust could make ‘advice and guidance’ mandatory following trial – “Barts Health NHS Trust announced last week that ‘from this month, GPs wishing to refer a patient into some Barts Health services will first need to consult with hospital specialists’ via A&G. It said: ‘The change is being trialled across 13 specialities and could become the default for all of our services.’

21 October 2021 BMA to ballot GPs on industrial action against Government’s access plan

October 2021 Health secretary ‘beating’ general practice with ‘a big stick’, says BMA GP chair

20 October 2021 GP media bashing ‘may put off’ 5,000 extra medical students needed

27th October: The plan that shook general practice

NHS England’s strategy to increase face-to-face appointments…

Nobody likes to , and wants to see that we come to this situation . But,
(1) This is no longer just a matter of being ethical , but also about dignity and honour . I always believe that we are to treat rational beings as an ends rather than means with respect . But that is always a two-way traffic . If one wants to throw the respect out of the window , I am afraid that I am not prepared to uphold this principle of universal values.
If our next generation colleagues can still lift up their heads and be respected , this is the time to salvage what is about to be lost .
(2) Why do we come to this ? There can be many factors for history books and academics to judge eventually. But one thing is clear , there is no equal playing field as far as power is concerned. The government running the ‘system’ is always dictating the game . GPs are always overshadowed by our hospital consultant colleagues (to be fair , they have to be submissive as well ). The modifications of the Health and Social Care Bill by the last health secretary was simply consolidating even more power for the Secretary of State
(3) The despicable , duplicitous and disingenuous politics adopted by this government, was ironically complicated by feckless , incompetent and capricious policies everyday . Health services only represent one example. The pandemics ( which has not ended yet) has provided the opportunity to expose this egregious disparity .Ultimately in NHS , PCN is just a political expedient , well exploited by the government to cover themselves for this .
As I always say , I remain as an ‘engaging’ PCN-sceptic CD (schizophrenic, isn’t it?) . Nevertheless, ‘If this can be tolerated,then what can be called intolerable?’
(4) Any uncooperative movement comes with a price in history and inevitably involves a degree of scotched earth politics and even brinksmanship. Well , the latter should be well familiarised by our ‘patriotic’ prime minister .
If we decide to go down this route , it is not because we do not care for our patients. In fact , I would argue this is part of a mission to save the NHS to save our patients. Do you agree with the Health Secretary that the NHS is currently NOT unsustainable?
That is why it is still absolutely justified to carry on with the Covid booster and flu campaigns against the backdrop of another rapid upsurge of Covid-19 new cases deep into the months of winter . Anything else e.g. QOF and new PCN DES ‘targets’ are simply about ‘doing just enough’ , in my personal view .
(5) Can the government still do something sensible ? The answer is always a yes because it carries all the power and a political engine with several propaganda media ready for fuelling more populism .
For us , as I wrote yesterday, ‘ain’t matter if you were dovish or hawkish ; ain’t important how the history will judge us’ .This is the moment for our solidarity and unity

It is no longer about deserve, it is about what we believe. I believe this is the ‘right’ thing to do at the historic ‘right’ time …….
Vinci Ho
A PCN-sceptic PCN Clinical Director

Clive Morrison27 October, 2021 11:06 am

None of the actions proposed by the GPC will have any impact on the government or patients and just attract more adverse criticism.
The only options I see available for GMS GPs who are unable to RLE are –
1 – Die in service through stress and over work.
2 – A patients dies through your overwork and fatigue. The GMC will then help and support you to cease work.
3 – Resign the GMS contract and declare bankruptcy due to your financial liabilities (staff redundancy, unsaleable/fire sale of empty surgery building).
They all have their plus and minuses. With option three at least you will not have to pay as much tax on your pension.

PAUL BALLINGER27 October, 2021 4:27 pm

Jenni Murray makes some excellent points .
Lets stop all this pointless hysteria and get back to doing the job face to face.
The irony of a privileged protected group in the top 5pc earning a 6 figure salary for working 3 days a week who never stop moaning threatening ‘action’ is not lost on the majority who rely on food banks, zero hour contracts and juggling jobs just to get by.
The public is rightly appalled . Most other groups are back in the workplace as we should all be.

https://www.dailymail.co.uk/debate/article-10133577/JENNI-MURRAY-face-face-appointment-dedicated-GP-prove-crucial.htmlReply
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Patrufini Duffy27 October, 2021 11:21 pm

I think Paul’s missed the point. This is about being targeted, monitored and shot at for manning the front door of a perverse NHS. The fuse has blown. Regardless of outcome. People feel hated, gutted and made to feel that they drive Maseratis and play golf with £200,000 salaries whilst making people die. That’s just a sick media narrative. Compare yourselves not to zero hour contractors, but your peers: bankers, dentists, solicitors, surgeons, pilots…and sadly politicians. Prepandemic your FF counted for zero, countless complaints, packed walk in centres and slagging off. Now, still GPs are doing face to face. But, with their skill set honed and brain turned on – an expert GP doesn’t need the theatre set up for an ugly toenail, runny nose, one missed period and a panic attack, within this sour pandemic. GPs are humans too, maybe they’ve lost a relative or colleague because of a stupid manoeuvre, or letting their guard down because of trivial demands and complaint culture. By all means bring the headache, tired and dizzy patient in. But the “I’ve split up with my boyfriend”, and “I read I could have gluten intolerance”, doesn’t need covid passing through your small corridors. You have a duty of care as an employer, by law, to your staff. That is law.

Listen to the anger – the scapegoats for the people could well become the government.

What we need is an old fashioned United Kingdom, and a truly National Health Service. Scapegoating is too soon, and wrong..

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

Looking for more scapegoats: “Banish bosses who cross moral line, NHS is told”

Lets ration back fear, inequality and lower standards… Lets create a two tier service, and scapegoat the GPs on the way… How could we have done this better?

Speaking up – Whistleblowing in the NHS – file on four. The profession needs a scapegoat – Mr Hunt.

Successive ministers of health are responsible for the nursing shortage. And they are not accountable!!

Even the Times now agrees that Health Care needs to be rationed overtly. No way without debate, and the politicians are too scared.

The Times leader 26th October 2021 omits to mention that there is really no “N”HS any longer, and since devolution we have been part of a big experiment to see if smaller mutuals could match the results of the largest one (England). The WHO does not report on an NHS but on 4 different health systems, with different choices outcomes and life expectancies. Since governments’ first duty is to the population, rather than the individual, we may see poorer parts of the UK moving towards a “Cuban” style health service, where apoliticians want to spend on education, diet and prevention. The feeling that the safety net no longer works if a patient is unlucky to need an expensive treatment for a rare condition has upset the Cuban doctors when they see what is available elsewhere in the world. But for their population, whose average age is longer than an Americans’ the resources have been directed appropriately. Will Wales and Scotland follow Cuba?
If social care is to continue to be means tested and combined with health care seamlessly, why not means test health care as well? Mr Enoch Powell MP was right in his analysis of health when he said:
 “The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted.” BMJ Letter 28th Feb 2021

The Times view on the NHS: Ailing Health Monday October 25 2021 – The pandemic has intensified pressures on the service’s budgets. There is no realistic alternative to charging for treatment and extending the role of private insurance

Health workers have shown skill, dedication and raw courage in protecting people in Britain during the pandemic. Yet admiration for their efforts should not mean the health system is immune from scrutiny. It has long been a shibboleth of British politics that any attempt to extract value for money from the National Health Service is a heartless attack on the poor and vulnerable. As Britain emerges from a historic crisis of public health and the economy, the government should strive to break this taboo.

The pandemic has intensified pressures on NHS funding. How to pay for healthcare will be a central concern of Rishi Sunak’s budget tomorrow. The government has already announced an additional £5.9 billion to expand operating capacity, on top of a new health and social care surcharge on national insurance of 1.25 percentage points for both employers and employees. Yet there is scant realistic prospect that this will be sufficient to meet demand. Health spending was already rising steadily in real terms and as a proportion of public spending before the pandemic. At the turn of the century, it amounted to about 27 per cent of day-to-day government public service spending. Taking account of the announced increases, that figure is set to reach 44 per cent.

The drivers of this spending have been on both the demand and the supply side: an ageing population requires more healthcare, and advances in medical technology make it feasible to provide novel treatments that are effective but costly. Hence spending on the NHS is roughly four times the amount spent on defence. Though the NHS costs less than health systems in many other advanced industrial economies, this is a sign that sophisticated treatments are strictly rationed rather than that they are provided cost-effectively.

This cannot feasibly go on without crowding out other essential services. The NHS is a provider of services, which are labour-intensive. There is little scope for generating increases in productivity. Yet government planning for health spending assumes there are efficiency gains just waiting to be realised through better organisation. Though there are undoubtedly ways of mobilising existing resources, such as ensuring that GPs are available to provide in-person appointments, curbing costs requires altering the ways healthcare is provided.

There are innovative ways of meeting future demand that politicians should be openly talking about. First, a system of universal treatment paid for out of present tax receipts is vulnerable to external shocks such as a novel coronavirus. The NHS ought to have an element instead of pre-funding, under which private insurers collect premiums from people of working age. Second, the state should provide tax subsidies for private health insurance. This is money already being devoted to health spending. Subsidised insurance for private treatment would reduce strains on the NHS. And third, a greater part of health spending could be derived from local rather than national taxation, as is common in Scandinavia. Devolved control of health spending could ease the stress on community-based preventive measures.

These are modest proposals that are widely adopted in European health systems. For all the romanticism that attaches to the NHS, no other country has adopted it as a model for healthcare, and with good reason. Charging patients for their treatment is a cost-effective and equitable way of providing care.

Prescription charges have been part of the NHS for almost 70 years, and dentistry typically involves subsidy rather than being free at the point of use. The burden of rising costs of treating people in the NHS requires a strategy for meeting it. The government should not shy away from a hard-headed message that extra resources must be accompanied by structural reforms.

Helen Puttick 4th October 2021: NHS needs radical surgery to survive, claims ex-chief

Oliver Wright 25th October 2021: Billions promised but is it enough to save NHS?

Sir, Your leading article “Ailing Health” (Oct 26) makes an excellent case for changing the source of NHS funding from direct taxation (plus a few extra charges for prescriptions and dentistry, etc) to a mixed model of tax and insurance, as in most other countries. The inexorable progress of treatment methods and the rising expectations and age of the population will continue to result in ever-increasing crises. The uncontrollable demand in any system cannot be controlled with a fixed amount of income.

The principal obstacle to changing the system is political. All the major political parties know that changes need to be made but are scared of initiating the debate on what these should be. The slogans “the NHS is safe in our hands” or “selling the NHS off” prevent any useful dialogue, especially between the Conservatives and Labour. Unless politicians get together to forge a consensus nothing will change and we will continue to lurch from crisis to crisis.
Hugh Ogus
Ret’d consultant maxillofacial surgeon, Alresford, Hants

Sir, We should be wary of the unintended consequences of incentivising the use of private healthcare. The availability of consultants in the UK is finite and the majority of private consultants also work in the NHS. Shifting demand to the private sector does not solve the problem of limited overall capacity but may incentivise more consultants to spend more time in their private practice and less in the NHS.

Patients (quite reasonably) expect personalised care from a consultant in the private sector, whereas in the NHS they may be seen by a nurse or junior doctor who, while absolutely capable, may not have the option of private practice. This will further shift demand on to consultants. The majority of EU countries have more practising doctors per head of the population than the UK and hence greater capacity, which may limit the validity of comparing systems.

Although the structure of healthcare funding in the UK may well need reviewing, we should tread carefully.
Dr Toby Garrood
Consultant rheumatologist, Reigate, Surrey

Sir, Your leading article offers a pair of recommendations on private health insurance. The first relates to “prefunding” by private insurers collecting premiums from working people: this already exists. A King’s Fund report in 2014 estimated that about 11 per cent of the UK population has some form of private insurance. But the nature of taxpayer funding for the NHS is itself “prefunding”, so a lack of prefunding is not the problem. Indeed the NHS itself, through its contracts with private providers, has become the biggest single payer for privately provided health care.

Your second recommendation is for tax subsidies for private health insurance. This would mean the less well-off subsidising those who take out private insurance — the opposite of “levelling up”. Your third recommendation, regarding local tax funding, may be worth further exploration, though the existing social care arrangements do not seem to offer an encouraging start.

The statement that these proposals are “widely adopted in European health systems” is disingenuous as many of these systems rely on social, rather than private, insurance to fund their healthcare, and they differ widely in relation to local funding.
Andrew Creese
Ret’d World Health Organisation economist, Darley Dale, Derbyshire

We need a truly National Health Service. Not separate purchasers..

2019 – Doctors to see groups of patients – is probably madness. The fox is waiting..

The 4 Health Services: “an outdated and unsuitable management model”.

2020: Reverse the devolution of health.. Now is the time to combine the 4 health services to give us efficiency, equality and unity.

2019: The “end game” for the UKs 4 health services? The ethical issues involved in the politics of training doctors

2017: No party is offering a credible alternative….. the future of the 4 UK Health Services may lie in social media

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?

 2016: The Independent. “Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS” Youssef El Gingihy, GP and author writing in the Independent online, 10 March 2016. The World Health Organisation (WHO) doesn’t have a definition for what makes a ‘national’ health service.

Looking at other systems: New Zealand

• Summary. New Zealand was one of the first countries to establish a universal, tax-funded national health service. The Historic Chronology of the NZ health care system is here.
• Introduction. In 1938, New Zealand was one of the first countries to establish a universal, tax-funded national health…
• History of the New Zealand publicly funded health system. The Social Security Act of 1938 provided the legislative…
• Updated health system: changes as of 2019. New Zealand spends around 9% of gross domestic…

Between 1938 and 1983 the New Zealand health system developed as a dual system of public and private provision.Social Security Act 1938. 1983-1993 Gradual establishment of 14 Area Health Boards (AHBs) funded by a population-based formula.Area Health Boards Act 1983. Partly based on the original “N”Hs and before devolution in the UK, New Zealand refashioned health care in the late 1970s. The immigration service explains. Paying for health care services is considered acceptable as it reduces unwarrented demand. The system is self funding and sustainable, unlike the UK.

New Zealand’s healthcare system has three levels of care: primary, secondary, and tertiary. Primary healthcare includes the family doctor, dentists, pharmacists, and allied health, which encompasses physiotherapists, podiatrists, counseling, and other medical services. If you are injured the Accident Compensation Commission provides personal injury cover for all New Zealand residents ( and visitors to New Zealand. )
The charges are variable and higher in the cities. Citizens are encouraged to enrol in a GP practice. “General practices are private businesses and set their own fees for consultations and other health services.” To book an appointment patients use a computer system called ManageMyHealth (which has all sorts of other records such as lab results), but you can book by telephone, and can use any GP in a practice but one GP is nominated as their doctor. Charges in cities are @ $65 a visit, but in rural areas people pay @ $19. (Visiting a Dr or Nurse and Enrolling). It’s generally free for under 14 years old depending on the practice. Some practices offer home visits, but it usually comes at a cost, most practices discourage home visits. Instead there seems to be a kaumātua (older people) van which brings the client to the doctor or hospital. There is a High Use Health Card system “To qualify for a High Use Health Card, a patient must have received at least 12 health practitioner consultations within the last 12 months for a particular ongoing medical condition(s).” Most prescriptions have a charge of $5 and the NZ formulary shows the natioanlly purchased generic choices, but for some medications citizens have to pay full cost. If they have to pay full cost then they can shop around for the cheapest.
There is also a Community Services Card if you are on a benefit, which reduces all health costs. If your GP visit is due to an accident then ACC will subsidise it. Eg: dropped a log on a toe, the GP visit cost reduced to $7 and patient sent to the hospital for an Xray, which was covered by ACC. The ACC (since 1974) has reduced the expense of litigation and redress, as there is a range of standard compensation payments for accidents and medical accidents.
This link advocates various schemes to help pay for consultants fees where needed.

Most GPs will refer you to a particular consultant if you have a preference.

Doctors’ practices set their own fees. Check how much you will pay with the practice directly.

Looking at Oncology and Radiotherapy the NZ plan 2017-2021 ends this year, and for 5m persons there are 6 public centres. This is one for 850,00 persons, which is approximately half as many people per unit as the UK’s health services at one for 1.5m

“The New Zealand Cancer Plan refers specifically to the predicted growth in cancer-related
activity and cost associated with the growth and ageing of the population. Spending on cancer
treatment services in 2008 was approximately 6 percent of publicly funded health costs, with
the overall spend projected to increase by 20 percent by 2021. Given such high projected
increases in cost, the New Zealand Cancer Plan strongly emphasises the need to improve
productivity and make cancer services sustainable by:
 focusing on innovative models of service delivery
 increasing the capability and capacity of the cancer workforce
 ensuring quality by developing standards and protocols to guide care.
The New Zealand Cancer Plan addresses the growing burden of cancer, inequity of access and outcomes, and accelerated growth in costs…….”

Looking at other systems: Cuba is population health dominating individual health and the doctors are revolting..

Looking at other systems: The Netherlands have universal coverage provided by private insurance companies. Why not here in the UK?

The Historic Chronology of the NZ health care system is here.

Update: The Times letters 24th Jan 2023: FEE TO SEE A GP
Sir, Sajid Javid is to be congratulated on his courage in challenging the founding principles of the NHS but he is wrong to assume that charging for a GP appointment will reduce unnecessary consultations and he overlooks other important consequences of his proposals (letters, Jan 23). When I left Scotland to work in New Zealand as a GP 16 years ago I wondered if I would ever see the common cold again, as surely no sensible Kiwi would pay £10 to £25 to be told that was their problem. Far from it. My surgeries remained full of minor, self-limiting illnesses.

More concerning was that financial constraints resulted in patients often presenting late and very unwell, sometimes requiring hospital admission. Important follow-up appointments were missed and emergency care, which is free in New Zealand, was overwhelmed. The poorest, often Maori and Pasifika, suffered most and their appalling health statistics reflect that.

Effective health education, perhaps through public service TV broadcasts featuring telegenic doctors, nurses and pharmacists, might be helpful. Charging will not.
Dr David Mitchell
Edinburgh

(Part) Payment for services is not privatising the 4 Health Services.

End of life care and the perverse behaviour of consultants who wont stop ” inappropriate investigations and futile treatments that prolong a patient’s suffering”.

NHSreality has long suggested that, if there were enough GPs, they could be usefully added into specialist clinics, and particularly oncology.

The Times letters 27th October 2021: END-OF-LIFE CARE
Sir, A significant proportion of my time as a senior hospital palliative medicine consultant is spent advising medical and surgical colleagues in hospital to withdraw or stop inappropriate investigations and futile treatments that prolong a patient’s suffering without adding any dignity or quality to their life. This is called good medical practice.

I get increasingly frustrated when I see terminally ill patients who are in their last weeks or days of life being kept in hospital and overtreated. Because we can treat a medical condition does not equate to having to treat it. A greater emphasis is needed on teaching medical students and trainee doctors on the ethical importance of beneficence versus non-maleficence (good v harm).

If we stop overtreating these palliative patients then many more will have a more dignified death and can spend their last precious moments with those whom they cherish in a place of their choosing rather than in an NHS hospital. Stopping such futile treatments is not euthanasia (as it does not accelerate death) but allowing the terminally ill patient to die naturally. This is an important distinction.
Dr Nicholas Herodotou
St Albans

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

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

Money wont solve the Health problems. Long term planning is needed, but how do we retain and keep healthy the staff we have now…

Matt Mathers reports in the Independent Friday 8th October 2021: Three-quarters of NHS staff consider leaving health service, survey says – Mental health and wellbeing cited as major concerns

Nearly three-quarters of NHS workers have considered leaving the health service in the past 12 months, according to a new survey. Research by the Healthcare Workers’ Foundation (HWF) charity and its partner NHS Million found staff were increasingly concerned about their mental health and wellbeing…

The Shropshire Star today 26th October: Call for urgent plan to address crippling NHS staff shortages and Oliver Wright in the Times reports: No guarantee extra billions will clear NHS backlog, Javid warns

The Ipswich Star 22nd October: ‘You can’t carry on like this’: How mental health leave soared in the NHS. Just as we need rationing to address Global Warming (Janna Lumbley in the Times), we also need it for Health Services. There will never be a sustainable solution unless we ration. and the hearts and minds of a majority of the professions will never buyinto the current system.

John Fly for the Mail reports today: NHS moves one step closer to a strike over pay: Union will ballot medics about taking industrial action over ‘insulting’ 3% salary hike as health staff demand FIVE TIMES more

The Coventry Telegraph today: Care home workers moving to NHS for better pay amid growing staff crisis and in the Times Oliver Wright reports: Public-sector pay rise may not beat inflation, minister admits

Jeremy Hunt in the Spectator 25th October 2021: Money alone will not fix the NHS -The former health secretary and the current chair of the health and social care select committee says the health service’s staffing crisis should be a catalyst for change.

While we are all relieved to be seeing the tail end of the pandemic, for the NHS the aftermath hasn’t meant the end of the trauma. Exhausted staff want to heave a sigh of relief and get back to normal. But “normal” is not on the table, unfortunately. They face a backlog that is unprecedented in the history of the NHS –  with a figure of 5.6 million on the waiting list actually being closer to ten million when you account for those who have not yet presented, and 6,000 people waiting more than two years for their treatment.

Rishi Sunak’s £12bn “health and care premium” shows welcome pragmatism. We now have a transparent mechanism for the big increases in health and care spending that will be needed over the decades ahead. At every election we can now have a more sensible debate about what funding the NHS and care system will need over the coming parliament, separate to the more general issues around public spending.

If there is one thing I wish I had known at the start of my time as health secretary, it is that money alone is not enough to solve these kinds of issues. You can give £8bn a year more to the NHS, but if you do not have the equivalent in additional doctors and nurses, the money will tend to bid up the salaries of locum doctors and agency nurses rather than fund more treatments. Even if the money is attached to targets, the effect can often be to suck clinicians from one part of the NHS to another – more money for elective care meaning fewer cancer doctors or GPs, for example.

We have a shortage of doctors in nearly every single specialty. The Health Foundation estimates it will take 4,000 more doctors and 18,000 more nurses to clear the backlog, but so far there appears to be no plan to find them. Immigration is no longer an option; other countries have their own backlogs. There is a global shortage of 2.1 million doctors according to the World Health Organization.

This NHS workforce crisis should exercise all parts of the political spectrum. It is key to tackling burnout, improving working conditions, getting through the backlog and making sure the additional funding actually delivers what it is meant to.

Some people reading this will say “you were the longest-serving health secretary, so why didn’t you address these issues”. I do not pretend to have got everything right and my failure to deliver the target I set for 5,000 more GPs was as disappointing for me as for the profession. But I did establish five new medical schools and increase doctor, midwife and nurse training places by 25 per cent, the biggest-ever single increase. However, because it takes seven years to train a doctor, the impact of those changes is yet to be felt on the frontline – which is why I have come to the view after leaving office that we need a new system that operates outside the Westminster parliamentary cycle.

In the short term, we should throw the kitchen sink at getting more doctors and nurses into the system. As a first step, we should relax all immigration restrictions for qualified clinicians, as well as offer generous incentives to overseas medics. The NHS and care system would simply fall over without clinical staff from overseas and we should welcome them with open arms. However, we should recognise there is an element of moral hazard in this approach: such recruits often come from developing countries where their services are required even more. So, depending on immigration from poorer countries should never be a long-term strategy.

We can also do much more to retain staff, starting with fixing the pension tax taper that is causing consultants to retire early or limit their hours. We should also devise a generous incentive scheme to persuade some of the retired clinicians who stepped up to help during the pandemic to extend their service again.

But this is surely the moment for some more profound changes to set the NHS up for the longer term.

Too often the number of doctors and nurses we train is the very last thing discussed in spending review discussions between a chancellor and a health secretary. Given any decision will not impact the NHS for around eight years it is rarely a priority for either. Even worse, because it does not count as “frontline” NHS spending it is not ring-fenced in the core NHS budget, but in a budget held separately by the Department of Health. Often it gets cut as part of a deal to help fund increases in the more politically sensitive NHS England budget.

The Office for Budget Responsibility has proved to be an important reform that keeps chancellors honest with their budgets. We need similar objectivity when it comes to doctor and nurse training places. Health Education England should be given the statutory duty to produce independent workforce forecasts for the needs of the NHS and care systems for the next ten, 15 and 20 years – with estimates as to the numbers we should be training now. It would be up to ministers to decide whether to fund the need, but at least there would be transparency on whether we are or are not training enough doctors and nurses. The royal colleges, NHS Providers and health think tanks have put down an amendment to the Health and Care Bill to deliver this, which I strongly support.

We should also consider further structural changes such as removing the caps on places at our often world-class medical schools to allow them to expand into global centres of medical training. We should look at the contents of the curriculum and the length of courses, something that has not been reviewed for many years. Now is also the time to reconsider some of the traditional demarcations between professions. Much hangs on the ability of ministers to take immediate action to fix the workforce crisis. But frontline staff know that there is no immediate fix for many of the shortages they see every day. What they want is the comfort of knowing there is a plan in place to make sure the current pressures will not be permanent. After what they have done for us all in the past 18 months, it is the least we can give them.

This article originally appeared in our Spotlight on health. To read the full supplement click here.

NHSreality first post in 2007: ‘NHS should not treat those with unhealthy lifestyles’ say Tories and then 2010: Out of Hours Service To Undergo Shake-Up and October 2010: “Dismantling the NHS”
In 2013: A new and very different type of NHS in England (BMJ 2011) and 2012: The Nuffield Trust in February 2012 asks if it is time to set out more clearly what is funded by the NHS. and March 2012: 100 Voices on NHS Reforms

Money without a workforce plan won’t help the NHS – FT October 2021

Medical Aptitude: A base level of knowledge, application and industry. good sense, empathy, stamina, communication skills and humility

Times letters 26th October 2021: MEDICAL APTITUDE
Sir, I agree with the attack (letter, Oct 23) on the “poaching” of doctors from low and middle-income countries and would add that if we wish to improve our doctor numbers by increasing recruitment to medical training by 50 per cent, as suggested by the Medical Schools Council (News, Oct 20), we should start by reviewing the ridiculous and pointlessly stringent entrance requirements for UK medical schools. Medicine is not a conceptually difficult subject and simply requires, after a base level of knowledge, application and industry.
What are also important attributes are good sense, empathy, stamina, communication skills and humility. The present generation of entrants, all armed with a welter of A* grades at A-level and numerous extracurricular activities available only to applicants from the more prosperous areas and schools, contains a significant proportion of youngsters who are simply going to be in the wrong job when they become doctors.
Christopher Wilson
Consultant trauma and orthopaedic surgeon, Cardiff

A GP rants his spleen: assertive (Amazon Prime) patients are a problem in a system that pretends not to be rationed. Co-payments please..

In systems other than the 4 UK ones, with an origin coming from a universal liberal philosophy, there are always co-payments, and these control most abuse.
Milo Clay and Sophie Halle- Richards report in the Manchester Evening News 25th October 2021 after an interview with a GP Jonathan Griffiths; Cheshire GP warns NHS pressure is building because patients have ‘Amazon Prime mentality’ – The doctor said that people’s ‘inability to wait’ is causing problem for healthcare services
A GP has warned that patient’s with an ‘Amazon Prime Mentality’ are adding to the ‘increased pressure’ on doctors and A&E staff. Dr Jonathan Griffiths, a GP in Winsford, Cheshire, says Emergency Departments are trying to deal with an ‘increased demand,’ with the number of people attending ‘higher than ever.’ The GP has documented his views on his personal blog, where he talks about issues within the NHS, Cheshire Live reports.
The senior doctor has now published a blog article titled “The Emergency Department,” where he reflects on a chat with an Emergency Department consultant. Dr Griffiths said: “They are trying to deal with the current increased demand into the NHS, just as we all are. “There has been an increase in numbers attending the Emergency Department (ED). “During the first wave of the Covid-19 pandemic numbers attending dropped significantly, but numbers have been slowly rising since then and now are higher than ever.”We cannot escape the fact that there has been an increase in numbers of patients attending who would usually have been expected to have been managed in Primary Care.”
Dr Griffiths says he and the consultant spoke about about what is driving the increased pressure and claimed there are ‘multiple factors’. One factor that Dr Griffiths refers to is primary care patients presenting themselves to A&E and says he spoke about the ‘Amazon Prime mentality’, which is the inability to wait. He said: “We talked about the ‘Amazon Prime’ mentality that we all now have – high expectations and inability to wait for anything. “There are significant numbers of people aged 30-50 presenting to the ED with undifferentiated symptoms that are possibly better managed by GPs. “These individuals do not want to wait for GP assessment and want everything investigated and sorted in one trip. This is what they get in the ED.” The GP says that patients may spend all night in the department but but will receive blood tests, scans, ECGs and X-rays, so they recommend visiting to their friends. The blog read: “By and large, they have nothing wrong with them and should never have been there in the first place. “In our conversation we were both concerned that people seem to be less able to self-manage minor illness and seem to be presenting at earlier stages. “This is certainly true in General Practice where we are seeing patients seeking help after a few hours of a sore throat or cough. “It seems a proportion of these patients are also heading to the ED.” The GP goes on to say that some patients may have ‘struggled’ to speak to their GP and have the ‘false perception’ that the surgery is shut. “Sometimes people are not prepared to wait (I think on occasion people are speaking to GP reception in the morning and being offered an afternoon appointment and going to the ED instead – where they will wait all day anyway).” the blog post read. “Sometimes GPs are sending patients to the ED rather than direct to a more appropriate speciality. “I don’t believe GPs really want to do this, but it can sometimes be tricky to know what to do when there are barriers to doing the right thing. “When GPs find it hard to get their patient seen by the appropriate speciality they will, sometimes, just send them to the ED.”

Dr Griffiths offers some potential solutions that could make a ‘positive difference’ to the issues GPs and emergency services are facing. The solutions he states include the need for the NHS to work together, more public facing communications as he feels there is a ‘disconnect’ between expectations and the reality of what NHS services are currently able to provide.

Update 2nd November 2021: Times Letters PRIME HEALTH
Sir, Further to Carol Midgley’s Notebook (Oct 30) on the “Amazon Prime mentality” to healthcare, years ago a medical colleague lamented the duties of the “tuppence doctor”. All that was required to summon a doctor, day or night, was to go to a red phone box, put 2d in the slot, dial and press button “A” to request a visit by the family doctor, who would duly appear. Amazon Prime could not have matched it. Dr DW James Market Rasen, Lincs

Update from the Times letters 10th November 2021:

Sir, It’s actually rather tiresome being a GP in an affluent area. I only ever did this briefly as a locum, preferring longer-term posts in more deprived areas, where there was more appreciation. The work might be harder in some ways but not in others. Affluent areas have lots of patients who are educated in their own field but not in medical matters. However, they tend to lack insight into this, which makes for a demanding, sometimes difficult-to-engage patient group, who mistake their Google search for a GP’s training and experience. I would also venture that there is an increased probability of working with empathic, kinder colleagues in the more derived areas. Finally, given the arrangements for out-of-hours cover, a GP is not compelled to live in their practice area and could live in a leafy suburb while commuting to a more deprived area to work. There are numerous advantages to not living in the practice area — not being seen in Lycra by patients in the local gym being one of them.
Dr Jessica Jones
Ret’d GP, Sunderland

Many GPs are retiring. If covid vaccinations are to be mandated for staff, so should exit interviews – the latter won’t happen – the opposite of a “learning organisation”.

Caroline Wheeler reports 24th October that: Sajid Javid will force NHS staff to have two Covid jabs but exit interviews are not! At the time of writing a straaw poll in the Times gives 89% in favour and 11% against. I suspect a similar majority would favour exit interviews for staff & board members. The Sunday Times leader supports Javed’s bullying of GPs, but it will not earn him goodwill. On line comment includes comment on GP pay but it is not the pay that is the problem; its the shape of the job. There were 110 medical students in my year. All have now retired. Not one got an Exit Interview.

As many of my former colleagues reach retirement age I and they reflect on the changes which we have jointly experienced in Health Care Systems. When I started as a GP trainee in 1976 there were Lloyd George cardboard insert notes in a small folder about 1/2 A4 size, which grew in thickness as one grew older. The first change was an age/sex register with disease colour codes for Diabetes, Heart, Mental Health (Black!) etc. The next change was a move to problem orientated records, and then to A4 notes. I became a GP trainer in 1982, and a stipulation at the time was all the above and moving towards A4 notes. Notes were kept in horizontal racks at first, and then in stacked rotary files as we moved to A4. (Many practices still store these as they are still used when patients move on…. Destroying them all could lead to improvement, but only once all systems are integrated)
After building a new surgery we were able to move entirely to A4 notes, and then within a few years computers arrived in General Practice. I spent a week’sstudy leave in Sussex offering to trial the different systems as a “free locum” in various practices. The winner as a company called AAH Meditel, which is now SystemOne.
Computerisation of written records is a problem, and we decided to embrace the change by askign the patients to be tolerant as we learned on the job, but all partners and staff agreed that from day 1 we would only look at the old record, but all new note entries would be on computer. We agreed to summarise as we met patients, and of course children usually had minimal notes anyway. Within 6 months were were up and running, but it took another 6 years to summarise all the records. We used Medical Students and Trainees and our own children (if training to be medics) and this summarisation still needs to happen as new patients arrive because there is no connectivity between practices and systems.
In or @ 1996 I was on the health board and tried to persuade my colleagues in all General Practices that we should all move to one integrated system. I had no support from the management at the time, and after a debate I lost the vote. This would have marked the single largest improvement in data collection and managerial potential in Pembrokeshire. Knowing in real time what services are being provided, how many people are waiting, and what people are presenting and dying with is important to Trust Boards. They get this informtion much too late, and inaccurate and only partial, so that decision making is made in a cloud of uncertainty. Add to this Health Board’s predisposition to listening to Single Interest Pressure Groups without an overall strategy, and managers who are unable to tell the truth about “rationing”, or “win” in any long term way, and the reader can understand a little of the culture within the 4 health services.
Health Board officials serve and retire without Exit Interviews. So do consultants, nurses, paramedical occupations and General practitioners. The Exit Interview, if done properly can illuminate weaknesses and suggest means of improvement. If the staff are disillusioned or retiring or moving for a reason that is personal (Bullying, Gagging) this should emerge. Depersonalise it and if it repeatedly comes up its definately a problem.
Trust Human Resources (HR) are busy. There are rotas, many of which are collapsing because fo staff shortage. I recently heard of a Paediatric Team where there are meant to be 10 consultants, but there are only 5, and one is always on holiday, one is off sick, so the remaining three are working much too hard with every third night and weekend on call, and a full working week. Lack of locums or staffing leads to disillusion, and lack of trust. Although manpower planning is centralised the lack of faith percolates down, and only an outside and independent HR would now be trusted. Add to the above sickness and absenteeism, which the UK’s health services are world leaders in, contracts, and advertising/recruitment problems, and HR is busy. Take away the Exit Interviews which they have never done and we might get some honest feedback (and debate) to Trust Boards.
My GP friends tell me that they still write letters to consultants/departments, but that the letters back are depersonalised and just to the practice rather than the referring doctor. The result is that staff have to divide incoming letters by the number of working doctors on the day, and these Drs have to check the letters and forward those that a partner might have a particualr interest in. Since more and more are part time continuity of care has virtually disappeared. The continuity is even being challenged in hospitals, where an absent consultant’s (often covid or stress) work has to be picked up by another colleage. All the professions in medicine are used to “lifelong learning” but the lack of organised, systematic feedback to the Trust Boards is negligent. This feedback should be summarised for politicians, as they have shown that they have no understanding of General Practice or the way GPs work with uncertainty, whist the Consultants deal with certainty. In farming terms we sort the wheat from the chaff, whilst the consultants look at the wheat in dephth.
The honesty needed for a modern organisation to develop sensibly and believe in itself is not present. When I started working I was on alternate nights and weekends, and worked every daywith one half day per week. Hard work is not what demoralises doctors, but the shape of the job.

NHSreality has opined on the punishment of GP practices, (Pulse report on worst 20%) and the use of Performance Related Pay in primary care. The winding up by the media with false and hateful comments on GP practices leads to conflict. (GPonline – Dr locked in consulting room by patient demanding FTF consultation)

Public policy relating to IT in health is a constant failure… Time to let the GPs take over? The self employed make fewer mistakes… and GP systems work.

GP A&E Triage – would be a good idea if we had planned for the numbers needed. We have not.. and GP partnership and continuity of care is in decline

The Sunday Times Leader 24th October: Javid is serious about the NHS and GPs must work with him

This has been a tough time for the National Health Service, and those who work in it have been rightly praised for their efforts during the pandemic. The NHS still basks in the nation’s gratitude.

Now, however, one group of NHS professionals, general practitioners, risk un- doing that good work. Their union, the British Medical Association, is threatening industrial action. Its GPs’ committee is to ballot members on such action.

The BMA, never good at reading the public mood, is upset about an NHS document, Our plan for improving access for patients and supporting general practice, published on October 14. The £250 million scheme covers increasing GP capacity, improving patient access and clamping down on abuse and violence against staff. It pays a compliment to general practice, calling it “the bedrock” of the NHS.

What concerns the BMA is what it sees as pressure to increase the number of face-to-face appointments. Though Sajid Javid, the health secretary, denies that GPs will be “named and shamed” some doctors see plans for league tables, including data on face-to-face appointments, as a reflection of a government “out of touch” with realities.

GPs should think again. In places, GP appointments are like gold-dust and face-to-face appointments even rarer. For older people, an online consultation can be difficult. In his short stint as health secretary, Mr Javid has been a champion of the NHS, securing more money with the new health and social care levy. If GPs do not increase face-to-face appointments, it is they who will be out of touch. They should work with the health secretary, not engage in unnecessary strike action.

and comment on line: “”[The NHS document] pays a compliment to general practice, calling it “the bedrock” of the NHS. That’s the problem: general practice doesn’t need platitudinous “compliments” but concrete and immediate action to reverse its recruitment/retention crisis. The number of GPs per 100,000 patients – already low by European standards – continues to fall and the Tories’ promises in 2015 and 2019 to provide thousands more could be shortlisted for the Booker Prize. Understandably general practice is an unpopular career choice amongst young doctors and those who wish to pursue it can do so in other countries which offer much more attractive contracts. No doctor is obliged to be a GP in Britain and if this country wants GPs it must make the role more attractive. It’s a buyer in a sellers’ market – there are many other career options for doctors.”
In the same paper: Matthew Syed:The ills of the NHS won’t be cured until its protective halo is removed – Our sanctification of the health service means its mistakes and weaknesses are seldom admitted and Caroline Wheeler reports: Sajid Javid’s hospital pass: can he defuse the NHS time bomb? – This week’s budget will make clear how nervous the Tories are about waiting lists. Sajid Javid says he has a plan

The underlying problem for immediate attention is the money, where it comes from, and how much goes into the “unlimited demand” Health pot. But longer term we need exit interviews so politicians find out the truth that all the profession knows: all 4 are unsustainable.

gambling-on-tax-rises-caroline-wheeler-in-the-sunday-times-oct-21Download

The gambler Boris, is putting it all on “Health”, but he’s out of aces, as there are too few staff. He is right about it going to get worse though…..