The nationalised NHS model was doomed from the very start

I ‘don’t actually believe this statement from the Telegraph. What I believe is that with means related co-payments and a commitment to quality in what is done within the 4 systems, we can turn around UK’s degenerating services. Reducing choice (as in Wales) is not about quality! Free prescriptions encourage dependency and discourage autonomy. Other countries that were formerly like us have changed to gain sustainability. Covert rationing will no longer do in an open society. It has to be overt. We need to know in advance (if we want to) what is not covered.

The 28th November 2022: The nationalised NHS model was doomed from the very start – The Telegraph.
If demand for health care is nearly unlimited and cannot be rationed by price, it must be rationed in some other way. The NHS rations through shortages – of staff – and waiting lists. Additional rationing is achieved by those who “do not want to bother the doctor”, often at cost to their health, while large numbers go private, so creating the two-tier health system Bevan hoped to avoid – though he did not use an NHS GP but rather Sir Daniel Davies, physician to George VI.

http://archive.today/2022.11.29-042954/https://www.telegraph.co.uk/news/2022/11/28/nationalised-nhs-model-doomed-start/

Why has no other European country copied the NHS model?

No other European country has copied the NHS model in half a century. Almost all comparable countries use a mix of funding mechanisms, rather than relying on taxation alone, and most outperform the NHS in health outcomes.

UK cancer survival rates lag behind those of comparable countries, A&E delays are increasing, the number of operations being cancelled is dire, staffing rates are in freefall and the tick-box target culture is sending doctors and dentists screaming into the private sector. The UK has one doctor for 356 people, against a developed world average of one for 277.
The NHS’s archaic divisions of labour between GPs, hospital doctors, pharmacies and clinics is now indefensible. So too is the division between the NHS itself and social and domiciliary care. As any victim of these restrictive practices knows, treatment delayed is treatment denied.

Sooner or later, the pressure of demand (now from all age groups) will force the NHS to choose between rationing by some form of means-tested pricing or by further bureaucratic delay. Last year’s Guardian survey of foreign systems showed there were plenty of other ways to organise public health. Before the coming of the NHS, London’s (local) health service was regarded as the best in Europe. It is not that now.

So what are the alternatives?

In countries without the NHS what does healthcare and insurance look like for sick, older or poorer people? Are the rich able to purchase a luxury tier of healthcare and what happens if your insurer goes bankrupt in countries like the Netherlands, Switzerland, Germany, Belgium or Israel?

To discuss, the IEA’s Darren Grimes asked Dr Kristian Niemietz to join him, author of ‘Universal Healthcare without the NHS’.
4 thoughts on “Why has no other European country copied the NHS model?”
Posted 14/11/2019 at 09:13 | PermalinkIs the NHS too big and ‘established ‘ to change, even if it is wanted and needed?
Why wont the British public let go even though they know it doesn’t work?
A majority government needs to take it on. It will need massive planning. How about ‘test’ areas? Would this work? I was in Croatia where everyone has to pay the first 20%. No one in A&E! (What are their outcomes?).
. Who has the answers? People with money always get a better service anyway so why don’t we stop worrying about two tier systems? So many questions.

JOANNE ABSALOMPosted 07/02/2021 at 09:51 | PermalinkOf course the NHS needs improvement, but after years of entrenched underfunding the Service has not had the capacity to explore other avenues of development.
Its stuck in the model it’s in primarily due to poor funding and lack of clinical and operational development to aspire to a new way of working.
The NHS needs politicians to stop interfering in its operational structure and to allow the coalition of directors and business associates with excellent track records from across successful businesses and healthcare organisations to come together with innovative solutions towards transforming the NHS.
Innovation cant come from Whitehall…..that’s why we’re in the pickle we’re in.

ANDY GAVINPosted 17/01/2022 at 14:00 | PermalinkWhy do we assume the issues with the NHS is the funding model and there is a role for profit taking insurance companies? Isn’t it enough for government to ring-fence a portion of the National-Insurance contributions to fund the NHS. The issue then being how to manage demands on the system. Private insurance opening hospitals and paying more to the same specialists can create longer queues for NHS as this must cause costs to rise. Floating all medical procedures in a market will drive up costs for patients, as the NHS is able to negotiate down prices. Britain has long attempted to get value for money, partly through efficiencies. It doesn’t look to increase other things like “choice”. Value and efficiency may mean that the UK has fewer doctors. Comparing systems depends on the values each system is trying to achieve vs outcomes. Not outcomes alone, as these can be cherry-picked.

JANE ELLIOTPosted 29/10/2022 at 22:50 | PermalinkIt is not rocket science. It just needs someone to look at the system, see where the economy lies in administration and the main thing is the follow up in the community health system. If someone can be discharged from hospital they should only be discharged if there is proper care in the community which there is not. Many people are looked after in hospital because they cannot be cared for at home and this causes bed blocking. Release of hospital beds would help but sometimes there is just a refusal to acknowledge someone actually needs a bed. This is caused by the admin people not always by the health experts. However they often are doing the best they know how but are hampered by strategic
decisions not of their own making. Need I go on. I do not think underfunding of nurses is the simple answer for example.

The Herald Letters 2021: Our NHS is doomed. Scots voters must demand change

Care Opinion 2015 from Mr Connolly: “The NHS is doomed.” Re. William Harvey Hospital (Ashford)

Make the wealthy pay …. Populism means disagreeing with expertise, and rejecting the advice given.

When an expert such as the director-general of the Institute of Economic Affairs suggests a helpful solution, you might expect the government and politicians to respond thoughtfully rather than with immediate rejection, but rather like in the totalitarian regimes of China and Russia there are some subjects which cannot be aired in today’s UK. Denial is predictable. When the Brexit vote came around all the economic experts bar one opined that it would make lives harder, especially for the poorest. This regressive warning went unheeded in Wales, and NHSreality predicts Wales will be the last of the 4 Health Services to agree to change. Politicians in all Regions and Dispensations are populists. They might agree with you in private but never in public. Paying for health care is administratively expensive, but the return in increasing autonomy and reducing dependency is worth it.
Mark Littlewood opines in Times Business 29th November 2022: Making wealthy people pay for their healthcare is inevitable, not ‘sickening’
As the weather gets colder, we can be certain that the NHS will now enter its annual period of winter crisis. This year is likely to be worse than most. Dealing with the huge backlog that built up because of the prioritisation of Covid, the health service is struggling to function at anything approaching an acceptable level. Thousands of people every day are waiting for 12 hours or more for treatment in A&E. Ambulance response times are often disastrous, with one standout case of a patient waiting for nearly 60 hours before being attended to. Trying to get a face-to-face appointment with a GP feels like an impossible task in many parts of the country.
Of course, we are used to stories of the NHS being on the verge of collapse. Such headlines have been around for decades. However, we also know the NHS can’t collapse in the way standard businesses often do. It receives more than £200 billion every year in taxpayer funding. It might not use this money wisely or efficiently, but it will continue to be — in strict economic terms — by far the biggest business in the UK, as well as one of the largest employers anywhere on the planet.
Nevertheless, the disastrous levels of service now being experienced by so many patients finally appears to have put serious discussions of health reform on the agenda. The theory that all that is needed is enhanced state funding has been tested to destruction. Health spending in the UK amounts to more than £4,000 for every man, woman and child in the country, well above the average for the richer countries in the Organisation for Economic Co-operation and Development.
The financial inputs may be high, but the health outcomes have been truly dismal, even before the pandemic. If we could match Germany’s record on cancer treatment, we could expect to save 12,000 British lives every year. If we could match their treatment of strokes, we could save a further 5,000 annually.
Increasingly, those who work in the NHS seem to be considering root and branch reform. A few days ago, draft minutes of a meeting of Scottish NHS leaders were leaked into the public domain. The meeting appears to have been to brainstorm how to address the black hole in health finances. This this was blue-sky thinking rather than a firm policy proposal. Nevertheless, it came up with the eye-catching idea to oblige the affluent to pay for their treatment. Of course, this would amount to the abandonment of a founding principle of the National Health Service — universal care, free-at-the-point of use.
The political reaction to considering such a possibility, even as a kite-flying exercise, was depressingly predictable. Nicola Sturgeon insisted that such ideas “were not up for debate”. Humza Yousaf, the SNP health secretary, dismissed the proposal as “complete baloney”. Sharon Graham, general secretary of the Unite trade union, went further still, declaring that, “even discussing such a possibility is sickening”.
However, the bald truth is that whilst the NHS itself may not be a two-tier system, UK healthcare as a whole is emphatically just that. Those with the financial means to do so can access better healthcare than those on tighter budgets, and more rapidly, too. If we consider that reality to be morally objectionable, we would need to take some truly dramatic steps to end it. Paying for private care outside of the NHS system would need to become illegal. Presumably, we also would have to make it an offence to leave the country and seek private healthcare abroad. Assuming such draconian action is not on the table, we should avoid being in denial of the fact that those with greater means can secure better treatment.
Last week, the revelation that Rishi Sunak is registered with a private GP practice caused considerable consternation among some commentators. Most of us seemed wholly unsurprised. He is a very affluent man and can comfortably afford to pay for a £250 consultation.
Back in 1987, Margaret Thatcher, the prime minister, was wholly unapologetic about her use of private care. “Like most people, I pay my dues to the National Health Service,” she explained, “I do not add to the queue. I exercise my right as a free citizen to spend my own money in my own way, so that I can go in on the day, at the time, with the doctor I choose and get out fast.”
The issue at stake is not that the affluent can secure an enhanced package of healthcare, it is how to ensure that those without such means can still access high-quality medical assistance. By and large, at present, the NHS is failing to provide such a service. More than seven million people are on the waiting list for consultant-led elective care. Nearly three million have been waiting for more than 18 weeks for treatment. The average waiting time for an in-person GP appointment is ten days, by which time one may have recovered naturally from any relatively mild ailment anyway.
To reduce these absurd, dangerous waiting times, those with the means to do so should be encouraged to exit the queue. In many areas of government spending, we are told by politicians of all stripes that those with the broadest shoulders should expect to carry the largest burden. Only in the case of healthcare do we seem to positively encourage those with broad shoulders to add to the burden of the system.
There are a vast number of ways in which the NHS itself could be reformed to become a more efficient beast, but without contemplating yet another overhaul of its systems, we could help to ensure better, faster treatment by getting richer cohorts to opt for private care. Allowing private medical costs to be written off against tax would certainly help in achieving such a shift. The parlous state of the NHS is likely to make such apparently heretical ideas not merely contemplatable but inevitable before long.
Mark Littlewood is director-general of the Institute of Economic Affairs. Twitter: @MarkJLittlewood

PAYING FOR HEALTHCARE Times letters 30th November
Sir, Mark Littlewood is right to address the issue of paying for one’s healthcare (“Making wealthy people pay for their healthcare is inevitable, not ‘sickening’ ”, Nov 28). I am not in the same financial league as the Sunaks but when I get my annual autumnal bout of tonsillitis I need antibiotics immediately, not in three weeks’ time. And for that I am happy to pay a £75 consultation fee (and for the drugs). Recently I have noticed that this option has become very popular as the NHS system crumbles under the strain. This suggests that people in similar circumstances to mine would be willing to pay these consultation fees directly to the NHS, as this would surely provide a not insignificant source of income.
Moreover, I have provided private health cover for my family since 1982, thereby paying thousands of pounds into the private sector that could instead have gone straight to the NHS. It is surprising that none of the so-called NHS health gurus has yet latched on to this idea.
Malcolm Raven, FRICS
Director, Raven Green, London W1

April 2022: “Britain’s bureaucratic model of healthcare needs reform to meet patients’ needs and be financially sustainable”. The Times (gently) advocates co-payments.

Jan 2022: Gambling is an example of a service that means tested co-payments could be applied to.

Oct 2021: A GP rants his spleen: assertive (Amazon Prime) patients are a problem in a system that pretends not to be rationed. Co-payments please..

Oct 2020: Hearing matters. Aids reduce dementia. If we are to “ration” then means testing recipients and adjusting co-payments would be fair. Rationing should not be based on Post Code.

June 2020: True Liberals find it difficult to address gambling addiction and harm… An ideal service for co-payments..

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

Taking more risks is incompatible with getting it right first time! The real question is “how do we change electoral system so that we get the right people?”

Its impossible to get everything “Right first time”, and we try pilots and discussion groups beforehand, and even then, we make mistakes. The idea that we should take more risks with health services is fine – if you are prepared to fail and change direction when needed. Unfortunately, our political system means that its a completely different group of people, with completely different fundamental beliefs, who get that chance. So small incremental changes in direction, as we need in health policy and strategy, prove impossible. The current 4 Health Systems are fossilised because of the fear of failing to make an improvement, and the fear of electoral punishment afterwards. The current administration has nothing to lose, as they are going to be decommissioned at the next election anyway, so why not be remembered for a sensible change? Two books (below) by Aeron Davies and Isabel Hardman get to the root of the problem. We have a system that gives us the wrong people as leaders. The real question is “”how do we change electoral system so that we get the right people?” To this I put my hand up “I am not brave enough”. The risk of destroying a marriage and a family is too high if we cannot vote from a distance, and if separation for long periods of time is an essential. Distant voting would encourage many more people to take an interest in politics. Localising medical education would help the supply of nurses and doctors..

Kat Lay reports in the Times 29th November 2022: Health secretary Steve Barclay says NHS must overcome its fear of new technology

The health secretary Steve Barclay says that the NHS is often too risk-averse to introduce new technology to help patients, pledging to take on the “vested interests” blocking change.
He suggested that the potential harm of bringing new technology into hospitals, such as using machine learning algorithms to interpret patient scans, was lower than the risk posed by staff shortages in the NHS. Speaking at The Spectator Health Summit this morning Barclay also said rising numbers of excess deaths were driven by patients not getting timely care and that the NHS should be more transparent about the problem.
In a speech in which he said that a more efficient NHS would improve the speed and success of treatment for patients as well as saving money, Barclay added: “I believe the NHS scores the risk of innovation too high when compared to the risk of the status quo. And I think that needs to be recalibrated. “This is because innovation tends to be judged in isolation in a silo. Take for example the risks around introducing machine learning on its own, it may carry some risk, but this should be judged against the basis of the status quo where there may be long delays due to staff shortages. “And so the speed of treatments and the ability to better target valuable resources needs to be weighed as part of the risk assessment of that innovation.”
He said the NHS also needed to have a greater risk appetite for transparency “because only once we’re transparent about the challenges we face will we empower greater patient choice, particularly in the context of vested interests, which are inevitable in a budget of £182 billion.” Those vested interests, he added “will often be more trusted, dare I say it, than the politicians making the case for change”. The need for transparency included transparency about excess death figures, Barclay said.
Figures released by the Office for National Statistics (ONS) consistently show deaths running at higher than the average for pre-pandemic years. In England and Wales there have been 8 per cent more deaths recorded this year than the 2015-19 average.
He highlighted an increase in middle-aged people with heart problems. “It’s the result of delays in that age group seeing the GP because of the pandemic and in some cases not getting statins or hypertensives in time, which when coupled with delays to ambulance times, we see this reflected in the excess death numbers”, he said. “In time we may see a similar challenge in cancer data.” He said that to meet the scale of the health challenges we face, “we must ensure we don’t slip back into old habits”.
There are more than 7 million patients on NHS waiting lists in England, while performance on A&E and ambulance waiting times is at record lows. Barclay said he wanted employers to encourage workers to come forward for checks. He also called for greater adoption of at-home testing, and said advances in technology could one day lead to computer chips in urinals flagging up health problems before symptoms appear. He was speaking shortly after the government announced a £113 million fund for research into cancer, obesity, mental health and addiction. The health secretary also highlighted “demographic headwinds” facing the NHS with a huge rise in pensioners and fewer working people to pay for their care. He warned: “On average, treating an 80-year-old is four times more expensive than treating a 50-year-old.”

Aeron Davis: Reckless Opportunists: Elites at the End of the Establishment (Manchester Capitalism)

Why do we get the Wrong Politicians: Isabel Hardman Paperback – 4 April 2019  by Isabel Hardman

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

Neglect of maintenance and repair. Who would do it to their own home? Ireland pay system encourages autonomy, and justifies the expense of managing payments.

Michael Goodier and Denis Campbell report that the “Cost of eradicating NHS repairs backlog hits £10bn for first time – The guardian 13th October 2022 – NHS in England would need to spend £10.2bn to bring rundown buildings and kit up to standard, figures show“ and a month later, in Jersey, the Balliwick Express says its really twice this! John Appleby in the Nuffield Trust comments 11th November as the : “Chart of the week: The cost of NHS backlog maintenance hits an all-time high”.

And remember this is almost certainly only “NHS England”!! We never get comparisons for the other dispensations. Saffron Cordery, interim chief of NHS Providers, called for a step change in the government’s capital investment after figures from NHS Digital showed it would cost £10.2 bn to meet the backlog of upkeep and repairs to restore NHS buildings and facilities to safe standards. The bill is up by 11% on last year. She also called for “urgent clarity and commitment about the delayed new hospital pro=gramme”. Nearly 2/3 of trust leaders have said that delays to the programme affect their ability to deliver safe and effective patient care. ( And thats on top of the staff deficit, and locum payments). A resilient NHS cannot be built by ‘patching’ it up, health leader warns The Independent

ireland-charges-for-healthDownload

Bringing in the army wont help!

Charging as in Ireland would help, and follow what New Zealand and Scandinavia discovered 40 years ago.
Life expectancy is the average age of death in each country. The global average is 72.8 years. Ireland’s life expectancy is 82 against a global average is 72.8 years and a UK average of 81 .

NHS at risk of “complete collapse” – that was a month ago – but nothing will be done. Deliberate self-harm on a national demographic basis?

One of my family went to see a consultant and I attended. (We all need an advocate) The consultant had left the Welsh Health Service, moved away to an English area with more affluent people, and visited Wales for private practice once a week. He no longer works for the state, and has given up on his pension. He is about 50 and feels his life is now “under control” again. Poor management meant he felt on a treadmill, uncherished and not even listened to. He resigned last year and has not had an “exit interview”. He is one of many as the BMJ reports. The result of decades of manpower mismanagement and ostrich like political behaviours has led to this situation. He is not yet replaced. Locums, often from overseas, often with communication difficulties and cultural appreciation problems, are the only choice for the Trust trying to cover his absence. This locum cover is expensive, and the Economist points out that it is not just money that influences. I was “on duty” more often than not for most of the Christmas and New Year periods of my first 20 years as a junior doctor and a GP. This is not acceptable any longer to today’s doctors. .. “The BMA has urged the government to avert a major exodus of senior hospital doctors in England after a survey of almost 8000 doctors revealed that four in 10 consultants and half of surveyed consultant surgeons plan to leave or take a break from working in the NHS over the next year.The BMA warned that such a “tidal wave” of resignations would leave the NHS “in danger of complete collapse” . Note that the BMA talks about England! There is no NHS, but the situation is the same or worse in the other dispensations.

locum-motives-nhs-economist-nov-2022Download

NHS at risk of “complete collapse” from exodus of consultants, BMA warns  BMJ October 2022;379:o2465.

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..

There are so many stories of failure, and of juniors being asked to take on too much responsibility.

Wales gets £120 for every £100 spent on each person in England. The total per annum is £4500 extra per person over that spent on English residents. I would argue that we have voted for self-harm in two plebiscites, both decided by narrow margins, and seemingly irreversible. Devolution was the first and has reduced choice and life expectancy compared to our neighbours, despite their apparent generosity. Part of this is because of the funding difference compared to Scotland. The second is Brexit has made our recession worse than the rest of Europe, and the UK has lost control of its borders rather than taken it back! The third and threatened self-harm would be a referendum on independence. Given the populist self-destructive tendencies of the past a confirming vote is very possible. There is a Welsh Health Service (called NHS Wales), but not much remains that is “National”. Free access and the same pension scheme come to mind. We rarely see comparators with English or Scottish outcome parameters. The WHO since 2016 will no longer report on an “N”HS but rather on 4 health systems! Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS”

One vote is bad luck, twice is unfortunate, and a third just has to be deliberate self-harm .  Pride comes before a fall…….

I suspect a missed diagnosis of Quinsy in this case from Rotheram... He was probably seen by a junior who had never seen this condition before – Nhsreality has repeatedly opined that standards are falling. This story is repeated all over the country..

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Failing IT infrastructure threatens patient care, and management information remains inadequate. Carry your own notes.

It seems amazing that there is no joined up medical record, even now. It was 1996 that I suggested this for my Trust in Wales when I was on the board. There has been no improvement since then, and real time records, especially relevant for drug addicts and mental health care, are absent. The ability to search for meaningful real time accurate data is absent. How can management cope? How should Trust Boards respond? Yes, failing IT infrastructure threatens patient care, and management information remains inadequate. Patients take note. The sudden and frequent failure of IT when you are being seen, or the loss of the written notes, will mean it’s worth asking for summaries and printouts whenever something changes, like a pathology report. Carry your own notes! Self employed GPs never used to let this happen when they owned their own systems, but recently in Wales the computer service is centrally managed and owned by the state.
An editorial in the BMJ by Joe Zhang, clinical research fellow & Sanjay Budhdeo, opines: Failing IT infrastructure is undermining safe healthcare in the NHS BMJ 2022;379:e073166

Improvement is an urgent priority

Earlier this year, information technology (IT) systems at one of the largest hospital trusts in the NHS stopped working for 10 days.1 This was the latest in a long history of NHS IT system failures across primary and secondary care.23

As “paperless” is now the default operating mode for many healthcare systems globally, IT failures block access to records, prevent clinicians from ordering investigations, restrict service provision,4 and bring to a halt the everyday business of healthcare. Increasing digital transformation means such failures are no longer mere inconvenience but fundamentally affect our ability to deliver safe and effective care. They result in patient harm5 and increased costs.6

This year’s 10 day outage occurred during a record breaking heatwave, but the immediate climate related trigger masked the root cause: chronic lack of attention to IT infrastructure,7 the physical resources underpinning an organisation’s software and data. These vital resources include computers, servers, and networks, as well as the supporting processes and staff to ensure their usability, stability, and security. Unlike the procurement of electronic health records, for example, investment in infrastructure is rarely prioritised and easily viewed as a cost to keep down rather than an investment that increases productivity.8

The consequences are substantial. A recent survey of NHS trusts commissioned by NHS England9 shows that electronic health records do not improve user experience in settings with unreliable, slow IT. Inefficient or unavailable systems compromise patient safety, and the BMA estimates that a substantial proportion (27%) of NHS clinicians lose over four hours a week through inefficient IT systems.10 The BMA report also found deficiencies in investment and lack of clinician engagement in procurement.

Outdated infrastructure is also a risk to data security. UK central guidance recommends backing up healthcare data off site.1112 However, without a transparent audit process, it is unclear how well providers conform to these guidelines. The unprecedented duration of the most recent incident indicates that data security procedures at the affected trust were inadequate.

There is a growing disconnect between government messaging promoting a digital future for healthcare (including artificial intelligence) and the lived experience of clinical staff coping daily with ongoing IT problems.13 Digital capabilities exist in a strict hierarchy, with IT infrastructure as the foundational layer. This digital future will not materialise without closer attention to crumbling IT infrastructure and poor user experiences.

How to do better

There is no one-size-fits-all solution. However, the NHS can learn from approaches taken elsewhere. In the US, for example, the effect of health IT on end users is an active area of research, particularly on how functionality of IT systems affects clinician burnout and effectiveness.14 Federal oversight of healthcare IT infrastructure (through the Office of the National Coordinator) can identify problems and coordinate a response.

To facilitate a transformation of IT infrastructure in the NHS we need to start with systematic and transparent measurement of IT procurement, capability, and functionality at the level of clinicians, organisations, and commissioners. Higher level data paired with outcomes from end users, including clinicians and patients, would help identify gaps between procurement decisions and the effectiveness of infrastructure on the ground. Transparency will facilitate sharing of best practice and allow independent scrutiny of the health and economic effects of IT failures (much as serious cybersecurity events such as Wannacry have been dissected15). In the NHS, the What Good Looks Like framework sets national standards for such granular assessments.16

Armed with this understanding, quality improvement cycles must become routine in IT governance, as they are in clinical care. This means developing local cultures amenable to learning and change, along with commissioning body oversight of any variations in practice and quality among regional providers. IT problems—including single incidents that compromise care—should be flagged as quality and safety concerns for urgent attention. Regular re-evaluation of provider performance against peers nationally will introduce regular pressure for improvement.

A centrally directed “carrot and stick” approach could create incentives for change. Government must provide the investment needed to identify and rectify poor performance but also demand accountability, with minimum standards for IT function and stability. Adoption of key standards in areas with known safety and security implications should be enforced through legislation. The NHS has no dedicated health IT regulator, but inclusion of digital issues in the Care Quality Commission’s assessments of quality and safety is long overdue.17

We must not tolerate problems with IT infrastructure as normal. Poorly functioning IT systems are a clear and present threat to patient safety that also limit the potential for future transformative investment in healthcare. Urgent improvement is an NHS priority.

Footnotes

• Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: JZ acknowledges funding from the Wellcome Trust (203928/Z/16/Z) and support from the National Institute for Health Research (NIHR) biomedical research centre based at Imperial College NHS Trust and Imperial College London. SB acknowledges funding from the Wellcome Trust (566701). Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.

The Manpower Planning or Workforce plan has an impossible short-term task…. Let’s hope it inspires ..

There is no way the promised workforce plan will affect anything for a few years, and possibly even a decade. It is perfectly possible that opportunities for UK trained doctors and GPs might be blocked in a decade because places are filled from overseas. A salaried service option is attractive to today’s GPs, and this might be a possible solution to employing them all and rationing of medical places should cease… Private medical training will gradually replace state training as it does in most of the Asian and N Americal world, and the medical caste will thrive.
Gareth Iacobucci in the BMJ: Hunt must keep promise to deliver NHS workforce plan, say leaders BMJ 2022;379:o2496

Healthcare leaders have urged the UK’s new chancellor, Jeremy Hunt, to make good on his previous commitments to fix the NHS’s workforce and pensions crises and not to cut spending on health services amid the current economic turmoil facing the country.

Hunt was appointed to replace Kwasi Kwarteng on 14 October by the beleaguered prime minister, Liz Truss, who has seen her premiership unravel in just a matter of weeks after her government announced a series of radical and unfunded tax cuts in its “mini-budget” last month.

Hunt was health secretary for England for six years between 2012 and 2018 and more recently has served as chair of the House of Commons Health Committee since January 2020. In this most recent role he has been a vocal advocate for a full NHS workforce plan and for fixing the damaging pension taxation rules that are prompting many doctors to retire.

But he has been appointed to the Treasury to try to calm the fiscal storm, and in a statement issued on 17 October he reversed most of Truss’s mini-budget,1 while warning that “more difficult decisions” on tax and spending would be needed to regain economic and financial stability. “Some areas of spending will need to be cut,” Hunt said.

Saffron Cordery, interim chief executive of NHS Providers, which represents NHS hospitals, mental health trusts, and community care and ambulance services in England, said that, although trust leaders understood the need for economic confidence and stability, budgets were “already cut to the bone,” given the diminishing public funding caused by soaring inflation, the cost of pay awards not fully funded by the government, and cuts in funding for dealing with covid-19.

“Jeremy Hunt understands better than most the pressures on NHS staff and budgets in the face of ever growing demand,” Cordery said. “He has been a vocal advocate for a badly needed long term workforce plan for the NHS, without which severe staff shortages will continue piling pressure on already overstretched services and affect the quality of patient care.

“Efficiency targets in the NHS are already very stretching. Having to hunt for yet more savings will be extremely hard to do and can only impact on patient care. It’s vital that capital budgets aren’t raided to fund day-to-day spending.”

Matthew Taylor, chief executive of the NHS Confederation, which represents all NHS healthcare organisations in England, Wales, and Northern Ireland, said, “Carrying 132 000 vacancies and with an exhausted workforce grappling the huge weight of patient need, this is Mr Hunt’s moment of truth.

“In recent months he has frequently called on the government to bring forward a now desperately needed, fully funded plan for an NHS workforce fit for the 21st century, so all eyes will now be on him to now deliver this, something he will know well.

“Put simply, to ensure economic growth and prosperity the government must now act for the long term and invest in the health service as the country’s economic backbone and fully recognise that it is a key driver to economic stability. The time to act is now.”
References
↵Morton B. Jeremy Hunt: We will reverse almost all mini-budget tax cuts. BBC News. Oct 2022. https://www.bbc.co.uk/news/uk-63284391.

Gemma Mitchell in the Nursing Times :Hunt: NHS will get ‘independently verified’ workforce plan 18 NOVEMBER,

Chancellor Jeremy Hunt delivering his 2022 autumn statement

…”The government has finally committed to publishing “independently verified” forecasts of how many nurses and other staff the NHS needs, as part of a long-term workforce plan.
The creation of such a plan has been campaigned for by a coalition of around 100 health and care organisations including nursing and doctor unions but has repeatedly been rejected by Conservative MPs.
Chancellor Jeremy Hunt had also supported the campaign in his previous role as chair of the Health and Social Care Select Committee.
Earlier this year, Mr Hunt accused his own Tory party of shying away from independent forecasts because he said it knew these would show it needed to be training more nurses.

David Oliver: Stop naming and blaming hospitals for whole system problems BMJ 2022;379:o2724

NHSreality on Manpower planning failure of all political parties

NHSreality pon private medical schools

An increasingly “caste” system in medicine. Increasingly doctors train abroad & privately: litigation correlates. Sad that no politician will take responsibility or tell us the truth and plan long term.

Fixed hours for self-employed people? A sure way to de-professionalise GPs? Which health region will take the hit, and salary GPs first?

I obviously live in the past. The pride of running my own business, creating the team ethic strong enough to withstand the changes imposed on Primary Care by different political philosophies at regular election intervals, and the financial controls needed were all motivators. Hiring, and occasionally firing, staff was always part of the job, and the recruiting of partners suitable in a competitive working environment, along with the training of upcoming doctors, all contributed to the mix. An enjoyable and fulfilling job resulted. My wife was a home mother for the first 10 years of my life as a GP from 29-39 yrs old.
The new world, where most GPs are part time, and usually have children, is different. They have “learned” that having children is expensive. The best time to have children is whilst working in hospital and training posts (salaried), because the financial penalty in General Practice (self employed) is considerable. Many do delay a family until their late 30s or 40s. Many take salaried posts rather than partnerships, and then they can negotiate a fixed ending time. This motion simply demonstrates these are now in the majority.
Many of the older ones in the profession will be aghast at this motion, passed at a conference which few attend and of which little notice is usually taken. The criticism is that by fixing hours even less work will be done overall, and the result is inevitably a salaried service, longer waiting lists, and more paramedics trying to be diagnosticians. More mistakes, and more litigation will result. Which region will take the hit, and salary GPs first?

Kat Lay reports in the Times 25th November 2022: GPs demand nine-to-five working hours and say that the working environment is not female friendly.
GPs will lobby the government to cut their core hours to 9am to 5pm after statistics showed that hundreds of surgeries were still conducting less than half of appointments face to face. The figures from NHS Digital also showed a fall in the proportion of consultations happening on the day they were requested. A fifth were delayed by more than two weeks. Yesterday a conference that influences the British Medical Association (BMA) negotiating position with health bosses called for a new contract to cut core hours from 8am to 6.30pm.
A second motion passed at the conference of local medical committees called for the withdrawal of an extended hours contract, which came into force last month. It requires GP networks to see patients between 9am and 5pm on Saturdays and weekday evenings from 6.30pm and 8pm.
Most agreed that the current arrangements “indirectly discriminate against GPs who wish to have families”, saying that “due to the still-patriarchal nature of English society, this is discrimination that mostly affects female GPs”. A new contract is due from 2024. Dr Kieran Sharrock, chairman of the BMA GP committee for England, said that GPs should prepare to take industrial action if negotiations did not produce a contract to give them control of their workload, increase investment and reduce the bureaucratic burden on practices. Dr Paul Evans, from the Gateshead and Tyneside committee, who proposed the 9 to 5 motion, said he knew “too many GPs” who refused permanent roles “because of the hours and because they cannot see a way to make it work with childcare opening hours and with family life”.

Dr Manu Agrawal, from south Staffordshire, said that he supported the idea, which would “reduce running costs” but urged negotiators to “make sure that the current funding does not reduce by reducing the current hours”. Sharrock said that GPs could restrict their working times by following BMA safe working guidance, and added: “[The committee] is already considering what a new GP contract for England should look like once the current five-year contract framework comes to a conclusion in March 2024, and conference debate and resolutions will be important in shaping these discussions.”

• Plea to blur lines between doctors and nurses amid NHS staff crisis
• ‘Two-tier healthcare’ as more patients pay to go private

He accused ministers of trying to “name and shame” practices by publishing data on appointments at surgery level for the first time. There were 36.1 million appointments with GPs and their teams last month.

National data shows 71.3 per cent of appointments last month were in person, still below 80.7 per cent before the pandemic. In some areas all appointments are face to face and in others only 10 per cent. Steve Barclay, the health secretary, said publication of the data would help patients to decide which GP to register with. Of 6,357 surgeries in England with data provided, 821 said that less than 50 per cent of their appointments were in person. A further 2,982 recorded between 50 and 75 per cent, and 2,509 levels between 75 and 100 per cent. Sharrock said factors including patient choice and the size and age of the populations served by a surgery were likely to play a role in variation. “None of these nuances are taken into account in today’s data and rather than this being a useful tool to aid patient choice, it is really no more than a way to name and shame practices when the morale of dedicated staff is at rock bottom,” he said. The government’s autumn statement reiterated an expectation that everyone who needed an appointment should get one within two weeks, and that urgent appointments should be carried out on the same day. Last month, 38.9 per cent of appointments were carried out on the day they were requested.

Behind the story
Anthony Beach, 61, a lorry driver, was not surprised to hear that the GP surgery he uses had one of England’s lowest rates of in-person appointments (Kat Lay writes). Nene Valley Hodgson Medical Practice in Peterborough recorded only 20.9 per cent of appointments last month as face to face. Beach said patients faced long telephone queues when calling for an appointment. “It’s a consistent issue,” he said. On one occasion recently, he went to A&E. “I was treated there in three hours.” His job makes it hard to take calls for a telephone appointment. Some patients said they had no issues getting appointments, and a surgery representative said sickness in the team was affecting capacity. There are questions over the quality of the data released yesterday. It pulls in data automatically from GP computer systems and appears to have had more success with some than others.
The NHS figures showed Ruiz Medical Practice in east London as performing only 22.8 per cent of its appointments face to face, but a manager there was surprised by the figure. Trevor de Sá, of Carshalton Fields Surgery, which had only 22.2 per cent of appointments listed as face to face, said the data did not take into account how different practices managed appointments. “We operate a triage system where every patient will have a telephone appointment first to assess urgency,” he said. “Even if we then offer a face-to-face appointment, we shall never be higher than 50 per cent.”
Dr Richard Van Mellaerts, of the BMA’s GP committee, whose own practice held 81.9 per cent of appointments in person, said: “If there are not enough doctors, sometimes practices will divert their resources towards those patients who need it the most. They will adopt more active screening, with patients offered brief phone appointments as a form of triage.” He said of his Fairhill Medical Practice in Kingston upon Thames: “Our patients are in a condensed area, which is only mile or two from end to end, so it is easy to come in.”

Doctors in distress. Is continuity of care to be “historic” only, and do the public really benefit if we have a salaried service?

An allegory for the 4 health services, and General Practice in particular? When will private GPs thrive nationally as private dentists have since their failed contract?

Current health services management needs to go into administration…

The Health Services should not have to bear the full costs of some services – Gambling and inevitable head injury related dementia for starters..

There are some Health Services that deserve less state support than others. Gambling is promoted by advertising, particularly in sport where children and young people are exposed to continuous exposure. Logos on shorts and advertising hoardings in particular. NHSreality has commented on gambling. Another issue is sporting related head injuries. In some sports these are inevitable, such as boxing and rugby, and why shouldn’t obligatory insurance cover pre senile dementia in these sports? Ok they could go “underground” because of the expense, but insisting on cover would give a message, and other sports where brain injury was not inevitable might replace them. The argument that inner city kids have no other outlet no longer applies. The same space could be used for Tai Cj or Judo, and local transport solutions are cheap and available. My prediction is that the big bucks of the financiers will be trumped by the sensible mothers who choose other sports for their kids: they have a “cash cow” industrial formula, but this is the start of the run down. It could be a post code lottery with different areas of the UK addressing the problem with different rules.
Eleanor Hayward reports 22nd November 2022 in the Times: Big rise in gambling addictions putting suicidal young men in hospital – NHS lambasts ‘predatory’ betting firms amid 42% increase in demand for specialist clinics &
The Times view on gambling addiction 24th November: Bad Bet -The NHS should not have to bear the cost of the crisis

There was a time when betting was considered such a harmful vice that bookmakers were barred from opening on high streets, had to darken their windows and were forbidden from marketing themselves. It was not until 1986 that they were allowed to sell drinks, paint their walls or install seats and televisions. Today gambling is ubiquitous, not just on high streets but everywhere and anywhere via smartphones, which provide round the clock access to betting opportunities, while bookmakers lure punters via advertisements plastered over football shirts and on the television. The result is not just a personal calamity for the vast and growing numbers of gambling addicts, but a societal crisis too.
As The Times reported yesterday, the NHS is increasingly having to pick up the tab for the rise in problem gambling. Doctors complain of a surge in suicidal “young men in football shirts” turning up at A&E departments after losing all their money in online gaming sprees. In response, the health service has this week opened two new specialist clinics in Southampton and Stoke, adding to a network of five commissioned in 2019. These will offer addiction therapy, including medication usually given to opioid users to reduce cravings.

Of course, the NHS has little option but to try to help these addicts recover in the same way that it would respond to any other public health crisis. But the cost of tackling this epidemic of addiction is one that the NHS could do without. Demand for places at the clinics is soaring, with 599 patients referred in the past six months, a 42 per cent rise on the same period last year. There are an estimated 2.2 million people who are problem gamblers or at risk of addiction in Britain, the majority men in their thirties, and there are more than 400 gambling-related suicides every year.
Nonetheless, the NHS can only tackle the symptoms of this crisis, not the cause. That is the responsibility of the government. Yet planned reforms to the gambling laws, first promised in 2020, have now been delayed four times, most recently this summer. Among the changes that campaigners are demanding are a ban on betting logos on football shirts, restrictions on bookmaker ads on television, an industry fund to contribute to the cost of treating addiction, stricter checks on customers, including age verification and sharing of data with other bookmakers on problem gamblers, and a clampdown on VIP packages involving free bets, enhanced odds and hospitality used to induce regular customers to spend more.
The government should delay no more. It is not nanny-statism to try to limit the damage caused by an activity that costs the state many millions of pounds a year. If the industry cannot take greater responsibility for the health of its customers, and public health more widely, beyond its pledge of £100 million to fund research and education, the state has a duty to intervene.
The danger is that instead, the World Cup will provide bookmakers with an opportunity to lure in many more punters, some of whom will become tomorrow’s addicts. Viewers are being bombarded with advertisements for gambling websites, while the rise in in-play betting means that the opportunities to bet during a match on anything from who will score the next goal to which side will be awarded the next penalty are continuous. No one should be denied an innocent flutter, but the NHS should not have to bear the cost of society’s bad bet.

Politicians neglect gambling. Is it because they are gamblers (and Reckless Opportunists) themselves?

NHSreality has commented on gambling many times.

NHSreality on head injuries

Rugby and Dementia pugilistica…. an unfair cost on the health service

Update from Times letters 28th November 2022: GAMBLING HARM
Sir, Your leading article “Bad Bet” (Nov 24) made depressing reading for those suffering from gambling addiction. The government has postponed the publication of its gambling white paper four times, during which time 1,200 more lives have been lost as a result of problem gambling. Meanwhile the gambling industry has privatised the profits and nationalised the costs, with taxpayers footing the bill for the devastation caused by problem gambling. For an industry that makes such massive profits, it is only right that it should pay for the damage it causes. At the same time the government needs to take a public health approach to the problem and transfer responsibility from the Department for Culture, Media and Sport to the Department of Health and Social Care.
The Right Rev Dr Alan Smith
Bishop of St Albans

No way we can reform health without a prolonged debate..

Letters in the Times 23rd November 2022 reveal the inability to reform, and the inability to learn from reasonably argued reports – both recent and long past. (Swann report 1969) Scottish news media reported a possible change in financing health, only to be rejected immediately by those in political posts, who realise that they will lose their seats if the change is not agreed across the parties, and therefore a debate becomes essential. Their perverse short term incentives dominate their attitude…In effect the politicians and commissioners have been “gagged” from talking about rationing of any sort..

Reform of the NHS
Sir, Given the need for greater investment and efficiency in the NHS (letter, Nov 22), perhaps the time has come to consider compulsory health insurance, or at least hypothecated taxation. It would also help if there were a single integrated computer system (GPs have two or more) for seamless communication between hospitals and GP surgeries: paperwork should have had its day.
Tim Williams, FRCS
Waldron, E Sussex

Sir, Further to your report “I’ll protect NHS, says Sunak after talk of fees for wealthy” (Nov 22), why not allow those of us who can, and wish to, contribute money to the NHS as we use it, on a voluntary basis, but with no compulsion to do so. Say £10 each time we visit a doctor, £30 each night in hospital, or smaller amounts. If some cannot afford it, fine, but millions of us can, and with no administration costs it would be a simple source of extra funds and could become significant.
John Williams
Edinburgh

Antibiotics hazard
Sir, Further to your report “Antibiotic-resistant bugs found in rivers” (Nov 22), in 1969 the Swann Report (“The use of antibiotics in animal husbandry and veterinary medicine”) was published. One of the key conclusions was that “the use of antibiotics in farm livestock, particularly at sub-therapeutic levels, poses certain hazards to human and animal health”: in particular antibiotic usage had led to resistance in enteric bacteria of animal origin. The need for World Antibiotic Awareness Week (Dr Mark Porter, Times2, Nov 22) and the finding of antibiotic-resistant bacteria in rivers indicates that we have learnt little in 53 years. I was born at the start of what might be termed the antibiotic era (1946) and have benefited from their usage throughout my life: it seems increasingly likely that my grandchildren will not be so lucky.
Dr Peter B Baker

Too little, too late. The enquiry must ask why no notice was taken of these reports..

Reports commissioned by Government and others – but not acted on. A shame on all politicians for their short termism.

Alex Massie November 14th 2022: Where does the buck stop for Scotland’s NHS woes? and The Times view on Scottish NHS failings: Critical Condition
John Jeffay Listen to staff about Scotland’s NHS crisis, Humza Yousaf told
Will Millar in Edinburgh News today 23rd November: NHS leaders in Scotland discuss ‘two tier’ proposal that would see wealthy patients pay for own treatment – NHS leaders in Scotland discuss ‘two tier’ proposal that would see wealthy patients pay for own treatment and the same on BBC News