Category Archives: A Personal View

The reaality of cultural dissonance.. A GP Trainee recalls her hospital experience of discipline..

A letter in the Times from Dr Katie Musgrave 20th January informs readers of the reality of being a junior doctor in todays overmanaged health services. Read it at the end of this post.

The Bury St Edmonds terrorising of staff, threatening them with fingerprinting, and generally demoralising them further, is indicative of the whole of the 4 health services. 

The idea that managers can treat doctors as staff on a factory production line has led to this situation. Changing a culture is very difficult... especially for a state monopoly which most people still love the idea of… especially when the trust are all bust. No single person I have asked seems to realise that with the Brexit devaluation of the pound all costs have risen by 18%…

Add to this the overhead inherent in Wales (As opposed to Scotland and N Ireland) because of the Welsh Government..

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Bury St Edmunds Hospital in the dock. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn,

Missed appointments dont cost except in a factory model of General Practice. 20,000 missed appointments is actually welcome to most GPs. Now if there was a disincentive to make a claim….

Kent NHS ‘to send surgery patients to France’ – setting a precedent? Can the fragmented UK health services recover without some form of zero-budgeting and revolutionary reconfiguration based on overt rationing?”

Sir, Your report on West Suffolk Hospital (“Anger over ‘witch hunt’ in hospital”, Jan 17) will be shocking to many but did not surprise me. My husband (a GP) and I have just exchanged memories of times when, as junior doctors, we were both brought before committees accused of minor misdemeanours. He had logged into a results system online and forgotten to log out. Someone had subsequently used his account to look at a consultant’s personal medical results. He was made to “confess” and sign a document admitting his negligent behaviour. I was once accused of dropping a blood bottle into a regular bin rather than a clinical bin. The bottle had been traced to me and a committee put together to sanction me for this crime. At another hospital I was called to answer for having examined a child in the wrong clinical room. Apparently I had been anonymously reported. Such bullying tactics are widespread in the NHS and do indeed keep doctors from raising genuine concerns about patient safety. If, from your early years of training, you have been consistently threatened and undermined, it can be very difficult to maintain the resilience to speak up. We need independent advocates for NHS whistleblowers.
Dr Katie Musgrave, GP trainee
Loddiswell, Devon

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Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations

The experts on trends in health care, and especially private health care, and Private Medical Insurance (PMI) are Laing and Buisson whose reports cost a great deal.

Their reports into “Private Acute Healthcare, Mental Health Hospitals, Cosmetic Surgery, Children’s HealthCare Services, Digital Health and the UK Healthcare” are all “Market Reports”. This is a market where you pay for what you get, and sometimes for what you cant get. In the case of taxpayers at the peripheries of the country, these lacunae of services are greater than centrally. Especially worrying is the report on Private Acute Healthcare. British citizens may all have to consider choices and whether to travel long distances to centres of excellence, even for emergencies, in the next decade. The figures provided by the BMA in 2018 have got worse, and remember these only apply to England!

Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations, and the hard choices ahead for all of us. With obesity and diabetes the main demands.. But there’s always denial.

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PressReader and the Independent report 19th Jan 2020: Britons spend more than £1bn on private surgery.

The Nuffield Trust report in 2016 indicated that much more money was needed just to keep up with internationally comparable countries;

Since then (2009) , however, the gap has started to widen (particularly against countries that weathered the global financial crisis better than the UK) and looks set to grow further. UK GDP is forecast to grow in real terms by around 15.2 per cent between 2014/15 and 2020/21. But on current plans2, UK public spending on the NHS will grow by much less: 5.2 per cent. This is equivalent to around £7 billion in real terms – increasing from £135 billion in 2014/15 to £142 billion in 2020/21. As a proportion of GDP it will fall to 6.6 per cent compared to 7.3 per cent in 2014/15. But, if spending kept pace with growth in the economy, by 2020/21 the UK NHS would be spending around £158 billion at today’s prices – £16 billion more than planned.

The London School of Economics opines 1st October 2019: Flawed data? Why NHS spending on the independent sector may actually be much more than 7%

,,,the amount spent by NHS England on the independent sector was around 26% of total expenditure, not 7% as widely reported. 

Cannabis is not a frontline drug, but some people seem to benefit.. Just like with dementia drugs the value is very small.. Andrew Ellson in Jan 2020 reported in the Times; More than a million Britons buying cannabis illegally to treat illness

The French have rationed out dementia drugs, and will be able to give much more care. The same argument may apply for cannabis, depending on numbers, and remember demand always increases once a service is free.

The Scottish Daily Mail (Pressreader) points out that there are 3700 visits to A&E every day (In Scotland alone) which could have been dealt with by GPs is there were enough of them, with enough time and resources. What an incentive to start private general practice.

Mailonline December 2018 reports that: Patients spend a record £1.1BILLION on private healthcare to avoid soaring NHS waiting times which leave them ‘let down and suffering’ and this has been updated for just surgery by the Independent.

The BMA opines 7th Dec 2018 on: Hidden figures: private care in the English NHS (and its got worse since)

Breaking Point, NHS info graphics
Do (ISPs) independent sector providers give good and good value care? NHS spending on (ISPs) independent sector providers keeps increasing.

The health service in England is facing the greatest financial challenge in its history, and yet the independent sector is increasingly involved with the provision of patient care within the NHS.

The English health service is heading towards a projected £30 billion funding gap in 2020/21; the government has committed £10 billion to help mitigate the situation, although the BMA has argued that in real terms, and factoring in the cuts to other services, the figure is closer to £4.5 billion. Within this climate, one of the few areas where funding is increasing is amongst ISPs (independent sector providers) of NHS care.

We want to find out what this means for the provision of patient care.

Key points

Building on our 2016 report on privatisation within the NHS in England we’ve looked into the data behind these headlines.

Our analysis uncovered the following key points:

  • NHS spending on non-NHS and independent sector provision grows each year (there was an increase of £2.6 and £2.1 billion respectively between 2013/14 and 2015/16);
  • The proportion of the total Department of Health budget spent on ISPs is also increasing (from 6.1% in 2013/14 to 7.6% in 2015/16);
  • There needs to be more transparency about the level of private provision of NHS services;
  • The principal area of spending on ISPs is in the community health sector;
  • The NHS relies very heavily on a small number of ISPs despite acknowledged risks from individual ISPs having an excessive market share;
  • CCGs spending a higher proportion of their budget on ISPs received worse ratings from NHS England than their counterparts.

Claire Milne for Full Fact reports before the election on How much public health spending goes to the private sector? 

…..This takes as its starting point the £13.7 billion figure from the DHSC accounts.

The £1.3 billion spent by NHS trusts on services from non-NHS organisations is added to that.

Added to that is the £14 billion the NHS spent on commissioning primary care from the private sector. This includes things like GP services, pharmacies, and opticians. This may not be what everyone things of when they think of the NHS spending money on private providers, but technically they all are. Mr Rowland acknowledges there is “genuine debate” as to whether the provision of GP services fall under private spending “given that they derive almost all their income from the NHS”.

Finally, it includes the £830 million the NHS in England spends on social care services and a lot of these are provided by private organisations.

Another health think tank, the Nuffield Trust, has used a similar method to determine that, over the last decade, between 20% and 22% of annual public spending on health in England has gone towards procuring healthcare services from private providers.

Sensible rationing of dementia drugs – a lead from France

‘Wasteful practice’ CQC says is due to ‘ongoing issues with poor recruitment, training and safeguarding processes’ Private ambulances and Taxis: The Independent reports 27th August 2019. 




A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades

We need investment in buildings, plant and people. The crisis is here and now. A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades.

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Nick Triggle for BBC news 13th December reports: Every major A&E misses wait target for first time

and BBC produced a report on the “Accident and Emergency crisis”.

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The search for waiting time failures in A&E reveals an epidemic of failures.

New builds, particularly under the PFI initiative have been catastrophes of long term mis-management and perverse incentives leading to perverse outcomes. These are exposed by Louise Clarence-Smith in the Times 17th Jan 2020: Soaring costs and delays expose lack of scrutiny at Carillion hospitals and “Beware the real costs of Hospital Failures”

one of which is demand for Private Treatment centres….

In The Guardian opines that A&E wait times matter. But the key issue facing the NHS is investment


The costs of hospital failures extend to morale in all areas of the 4 health services.

All hospitals are now failing. Just because we hear about some (Like Bury St Edmunds) does not mean the rest are clean. The endemic failure to provide sufficient people is compounded by insufficient new builds, old plant needing replacement and inadequate imaging facilities, and of course the professional radiologists to read these images. Wales has avoided PFI but all its buildings and equipment, with a few exceptions, is stone age. Its people will be asked to travel further than ever to get help, and choice is absent. The complaints alone are epidemic, and the costs set aside for future litigation are enormous. The costs of hospital failures extend to morale in all areas of the 4 health services.

Alistair Osborne opines 17th Jan 2020 in the Times: Beware real cost of hospital failure

evolutionary zeal is not a trait typically associated with the Conservative Party. But at least Boris Johnson is promising an “infrastructure revolution”. What it entails is anyone’s guess, apart from spending £100 billion over five years. So, it’s lucky that the National Audit Office has popped up with a handy guide — on how not to do it.

It’s had a poke around the Midland Metropolitan and Royal Liverpool University hospital projects: a duo as sick as you might expect given they were being built by the now bust Carillion under the similarly kaput private finance initiative. Naturally, the patients are still waiting to see either hospital.

The 646-bed Liverpool scheme, due to open in 2017, is now running at least five years late, costing £1.06 billion to build and run: not the budgeted £746 million. Meantime, the 669-bed Midland Met, due to start operations in October 2018, will cost at least £988 million, up from the initial £686 million. It opens in July 2022.

Not the finest advert, then, for injecting private capital and expertise into the delivery of public projects. Except for one thing: the NAO reckons the taxpayer is barely out of pocket — because “the private sector has borne most of the cost increase”. It’s lost £603 million, shared between investors in the PFI companies, Carillion and insurers. Indeed the NAO believes that the taxpayer will be 3 per cent worse off with Midland Met and 1 per cent better off with Liverpool. And that includes the 30-year running costs.

It seems barely credible, given what’s gone on. After Carillion keeled over in January 2018, the health trusts and government wrongly assumed that “the PFI companies would complete the hospitals, as contractually required, by replacing Carillion”. Instead they had to terminate the PFI schemes and “use public finance to complete the hospitals with new contractors”. Consulting engineer Arup then found that the Liverpool work was so shoddy that the new contractor “had to strip out three floors of the building” to reinforce its structure.

So, how come the taxpayer’s no worse off? Simple, really. Because the government held the PFI investors to their contract — not paying for hospitals they’d failed to deliver. It then inherited two half-built hospitals that taxpayer funds are finishing off. True, the health department coughed up £42 million to avoid a “lengthy contractual termination process” in Liverpool: a sum it could have dodged given its rocketing costs. But that’s hindsight.

Does it all prove, then, that PFI works? Well, not really. The real cost is that both hospitals are years late. And there’s still a risk that the final price will exceed NAO estimates. Moreover, the affair says much about the government’s addiction to picking the lowest cost contractor. As the NAO notes over Liverpool: Carillion’s pricing may have been “too low to meet the required specification”.

Still, at least there’s a lesson here for BoJo: infrastructure revolutions are harder than they look.

Sensible rationing of dementia drugs – a lead from France

The first country in Europe to act on concerns over limited effectiveness In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state.

What a sensible approach. Without the expensive drugs we can have more carers. Trust Boards and Commissioners take note. The trouble is that these drugs are effective in some people, but the utilitarian approach taken by France is correct. 

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France removes state funding for dementia drugs | The BMJ 30th December 2019 and 18th January 2020 BMJ 2019;367:l6930

The first country in Europe to act on concerns over limited effectiveness

In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state. The decision followed a long campaign by the French therapeutics journal Prescrire, which subsequently declared, “The days are over when support for patients and their struggling caregivers was based on drugs raising false hopes.”

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The following month, the National Institute for Health and Care Excellence (NICE) published updated dementia guidance.2 This recommended combination therapy for the first time, advised not stopping drugs simply because the condition progressed, and relaxed regulations on primary care prescribing. In short, drugs for dementia would no longer be supported in France but would be further promoted in England and Wales. France is the only European country to take this step,3 although authorities in Belgium are considering following suit.4

Acetylcholinesterase inhibitors inhibit the breakdown of acetylcholine, a key neurotransmitter involved in memory, attention, and sleep that is often depleted in adults with dementia.5 Memantine works on a different and less well understood target thought to be involved with cognitive decline, blocking N-methyl-D-aspartate receptors to prevent toxic overstimulation and subsequent neuronal damage.6

Alzheimer’s dementia is the only licensed indication for these drugs, but NICE recommends off licence use for adults with dementia with Lewy bodies.2 No other drugs are available for any of the common dementia subtypes, and disease modifying agents remain elusive.7 These drugs are therefore the only available pharmacological treatments for dementia.

The French health authorities cite several reasons for their decision, including concerns about the clinical meaningfulness of their effects on cognition, no proved benefit for behavioural symptoms, quality of life, or time to institutionalisation, and real world indications of a rare but increased risk of bradycardia requiring hospital admission.8

Little benefit

Broad consensus exists that drug treatments for dementia produce statistically significant improvements in cognition for at least six months, but these improvements are small. A 2018 Cochrane review of donepezil trials9 reported a mean difference between treated and control groups of just 2.7 points on the cognitive section of the Alzheimer’s disease assessment scale (ADAS-Cog, scored out of 70), and 1.1 points on the mini-mental state examination (maximum score 30) at six months, favouring treatment. Cochrane reviews of the other drugs have reported cognitive benefits of similar magnitudes.101112

Whether these changes are meaningful for patients remains unclear. Researchers have attempted to quantify a threshold for a clinically important difference by triangulating changes in cognition scores with changes in clinician assessment and functional outcomes.13 But this assumes that any improvements in clinician assessment or functional outcomes equate to meaningful benefit for patients and their families, which remains debatable. Nevertheless, the authors concluded that a benefit of ≥3 on ADAS-Cog was clinically important. This uncertain finding on cognition is consistent with Cochrane reviews reporting similarly small, albeit statistically significant, changes to functional outcomes and clinician assessment.

Frustratingly, there are few qualitative or quantitative studies reporting quality of life (for patient or carer) or patient reported outcomes. Uncontrolled observational studies have suggested that drug treatment can delay nursing home admission by at least several months, although these study populations are likely to be skewed by indication bias.14

Change of emphasis

To justify depriving patients of the only available drugs when they are well tolerated and known to produce benefits (albeit of uncertain clinical relevance), there must be a clear idea of what is to be gained. The French health authorities argue that these drugs divert the attention of clinicians, researchers, and policy makers away from non-pharmacological approaches to dementia care. They expect that the decision will shift priorities from a drive to ever earlier diagnosis and treatment, to a more person centred approach, more research on non-pharmacological management options, and increased scrutiny of policy makers and commissioners to ensure adequate support for patients and their caregivers.15

They believe these changes will lead to overall benefits, although the potential merits remain hypothetical. What should the UK do now? Following France’s lead would require careful consideration of the best way to manage wholesale deprescribing, alongside a systematic evaluation of the effects. A more pragmatic approach is to “watch and wait” to see whether the hoped for benefits are realised in France.

Medworm: Re: France removes state funding for dementia drugs

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Bury St Edmunds Hospital in the dock. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn,

It is going to be impossible to rescue the gagging cultural demise of the health service without a form of “zero budgeting”. This was used by accountants to help turnaround a business financially, but now we need consultant teams to take over hospitals, change the rules so that everything is no longer free, and take the best out of various overseas systems.

Not only devolution has failed, but also the Four Health Services. Covert rationing is no longer acceptable.

Chris Smyth reports in the Times 17th Jan 2020: Anger over ‘witch hunt’ for whistleblower after death at West Suffolk Hospital – Managers demanded fingerprints from doctors

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Downing Street today warned the NHS to protect whistleblowers better after hospital bosses carried out a “witch hunt” against doctors in an attempt to identify which one had raised concerns about a woman’s death.

Inspectors are due to report within weeks on an incident in which staff were asked to provide fingerprints and examples of their handwriting to try to establish whether they had written an anonymous letter to a widower informing him about failures in his late wife’s care….

..Jeremy Hunt, the former health secretary, said yesterday that a punitive approach to staff who owned up to problems was a key reason why the NHS operated on the wrong part of someone’s body four times a day…

Eastern Daily Press: It was soul destroying – man criticises hospital for lack of basic care 

Matthew Weaver and Dennis Campbell report: Staff say hospital bosses misled them in hunt for whistleblower – Doctors told a patient’s widower about the failings in an operation that led to her death

The Times view on efforts to expose a whistleblower at an NHS hospital: Healthy Disclosure – Shameful efforts to expose a whistleblower at Matthew Hancock’s local hospital raise worrying questions about NHS culture

ealth secretaries speak warmly of whistleblowers, as they should. After scandals that centred on NHS cover-ups, Matt Hancock, said that he wanted “more people to feel they can put their head above the parapet”. His predecessors in the post, Jeremy Hunt and Andrew Lansley, also talked of ending a culture of fear and installing a culture of learning. Yet now Mr Hancock’s own local hospital has become the latest in a long line of NHS institutions to be mired in a scandal over its treatment of staff — and all because they tried to call attention to serious clinical mistakes. The case raises worrying questions about the culture of the NHS.

This latest scandal follows the death of Susan Warby after a bowel operation at West Suffolk Hospital in August 2018. Her widower was sent an anonymous letter which claimed that there had been errors in her procedure. The letter was made public in an inquest that began yesterday. It claimed that Mrs Warby had been given an intravenous glucose rather than saline drip and that a “tricky”procedure in which she suffered a punctured lung had been carried out by a junior member of staff.

Rather than come clean about the mistakes, the trust had instead instigated a hunt for the whistleblower. In the process it employed “bullying” tactics, including coercing staff into taking handwriting and fingerprint tests, according to doctors who passed concerns to the Care Quality Commission. At a meeting last month, senior doctors further accused the trust of misrepresenting its demands as “voluntary” in a statement it made to a newspaper in December. The trust has now apologised to staff for “stress and upset caused”. It has said that by the time the letter was sent to Mrs Warby’s widow an investigation into her death had already begun. Meanwhile it maintains that it was simply looking into a data breach.

Not everyone claiming to be a whistleblower has a valid complaint. Yet the health service’s long history of cover-ups is an argument for reforming the way that staff concerns are handled. Among scandals that have come to light is one dating back to the 1970s and 1980s, when the health service allowed some 4,800 haemophiliacs to be infected with blood contaminated with HIV or hepatitis C. In the cover-up that followed, diseases were allowed to progress and victims unwittingly infected others. Medical records went missing and when patients transferred from one doctor to another, doctors wrote notes to make sure patients were not accidentally told of their condition.

Other scandals have followed the same pattern of mistakes and neglect followed by cover-up. Between 1989 and 2000 at least 456 elderly patients died at Gosport War Memorial Hospital in Hampshire as a result of being given powerful painkillers. Likewise between 2004 and 2013 neglect at Morecambe Bay NHS Trust led to the deaths of at least 11 babies and one mother. In the Mid Staffs scandal, hundreds of people were feared to have died as a result of abuse and carelessness at Stafford Hospital between 2005 and 2009. In each case, whistleblowers were fired, gagged or blacklisted.

It is clear that warm words will not be enough to steer the NHS on to a better course. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn, along the lines of the Office of Special Counsel in the US which has the power to protect whistleblowers and hold institutions to account. Laws should also be strengthened to help whistleblowers contest the loss of jobs or promotions. Those found to victimise them should face penalties. NHS whistleblowers provide a vital public service. Quite apart from the lives they can save, they can help their institutions avoid far bigger scandals down the line.

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A service run ragged – and meaningless pledges for mental health provision

The perverse incentive for health boards and commissioners to prioritise oncology or surgery above psychiatry is disturbing. Whenever we listen to the politicians and managers watch out for the word “priority” or “prioritisation”: it means rationing. And remember, the spending plans (outlined at the end – graphic|) dont apply outside of England. MIND can help, but it can only fill some of the gaps..

Andrew Molodynski is the BMA consultants committee mental health lead and opines in the BMJ Doctor supplement: Mental healthcare – a service run ragged

Mental health staff face unmanageable workloads, depleted teams and poor access to training, BMA research finds – with government promises of new recruits sounding ever more hollow. Keith Cooper reports

Bold pledges to recruit vastly more members of staff, as a means of easing the pressure in mental healthcare, are often deployed with aplomb by politicians.

More than 10,000 extra would be recruited this year, said the Conservative manifesto in May 2017.

Its opponents back then believed it was based on ‘thin air’, they told the BBC. Two months later, the Government’s official plan, Stepping Forward to 2021, pushed the figure up to 19,000 additional staff.

Leap forward to 2019 for an even more ambitious scheme. The NHS England Mental Health Implementation Plan called for a further 27,000 staff, a mix of psychologists, psychiatrists, nurses, social and peer and other support staff, to make up the ‘multidisciplinary’ approach it envisioned. An influx of new staff into mental health would certainly help the patients who suffer the traumatic, sometimes tragic, consequences of shortfalls and those in the service who struggle to cope with ever-rising demand….


20190746 thedoctor January issue 17

…Mental health has been high on the political agenda for some years now, with bold promises from Government in recent times: more staff, more services, more funding, no patients being sent around the country for care, reduced waiting lists, fewer suicides. However, what we have seen outlined in this article and numerous academic and mainstream publications is essentially the opposite: longer waiting lists; increasing out-of-area placements; slimmed-down services that cannot cope with demand; and most worryingly a rising suicide rate for the first time in decades.

In microcosm, my own team (a general community team for people like you and I with mental health problems) has recently been audited as having 50 per cent too few staff. We knew that already. Will things be put right? Almost certainly not. If we were an oncology or paediatric team would they? Almost certainly yes.

…BMA recommendations on parity of resources, access and outcomes – what does it look like?

On funding: Clinical commissioning groups should double expenditure on mental healthcare. More should be spent on mental health wards, research, and in primary care and public health.

On access: Standards for access to services which are fully funded. Reviews of all trusts who place high numbers of patients in beds far from their homes.

On workforce: Realistic and measurable workforce goals. Targeted recruitment campaigns for the hardest-to-recruit sub-specialties, such as old-age psychiatry and learning-disability psychiatry.

On prevention: A cross-government body established to draw up a joint strategy on public mental health. National and local Government adopt a ‘mental-health in-all policy’; mental health impact assessments for all new policy proposals.

Read the BMA report