Category Archives: A Personal View

The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse.

In the last few days I have had some close connection to the health service in Wales. Welsh NHS as it calls itself, is under tremendous pressures. The response times are appalling. The banal nature of phone triage has caught me out on two occasions in the last month.

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The first time was when NHS111 advised me to ring a GP surgery when the problem needed quick hospital assessment for a post natal problem, which turned out to be an infection needed immediate antibiotics. The second was for a lady who collapsed and needed full assessment to exclude serious conditions, but there was no transport for 4 hours. Both these patients were taken to hospital by relatives. They were lucky to have transportation. Delays in either case could have led to serious problems.

I have been told stories of GPs who have decided it is better to ask a lay person to ring the ambulance in any situation. This is because the services are so stretched that the telephone operators are advised to assume that a GP surgery is a safe place to be. The fact that GPs are never exposed to emergencies, and that emergencies are outside their contract ( and their competency in many cases ) does not occur to them.

The result of all this, all over the country, is that private services will take hold, and flourish. The health divide will get larger. The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse. Don’t live in the wrong area.

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Access is the most important point, and even this is failing.


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If you had CF would you think health and drugs were rationed, or not?

The cheapest long term way to treat (and eliminate  Cystic Fibrosis may be by genetic testing, but in the interim we have a problem: If you had CF would you think health and drugs were rationed, or not? Far better to be honest…. The drug will probably be treated the same as many others: unfunded until near it’s patent expiry, when the price will fall. This is not a good way to treat the drug companies, and this implies that those with means have better treatment options than those without. Negotiations are really about finance at governmental level.

Jacqui Wise reports in the BMJ: NHS and Vertex remain deadlocked over price of cystic fibrosis drug (BMJ 2019;364:l1094 )

Both sides of the stalled negotiations on the provision of the cystic fibrosis (CF) drug Orkambi (lumacaftor/ivacaftor) accused the other of inflexibility while giving evidence to the Health and Social Care Committee’s inquiry this week.

Vertex Pharmaceuticals has been in dispute with NHS England over the high price the company wants for Orkambi—£105 000 (€123 000; $138 000) per patient per year. There has been mounting frustration from patients over the impasse. The committee received 334 written submissions to the inquiry, mostly from patients.1 After the hearing there was a demonstration by relatives of patients with CF and campaigners in Parliament Square.

Jeff Leiden, chief executive officer of Vertex Pharmaceuticals, told the committee he is meeting the health secretary Matt Hancock on Monday 11 March and would put forward some “new ideas” for getting through the stalemate. He suggested they could discuss a deal similar to that agreed in Scotland, which would see Orkambi supplied to NHS patients at a discount to the list price, pending further discussions about how to measure the drug’s cost effectiveness.

In July 2018, after 12 months of negotiations, NHS England published what they said was a “fair and final offer” of around £500m over five years for all of Vertex’s approved drugs and any that are approved in the future. Vertex rejected the offer and has also withdrawn Symkevi (tezacaftor/ivacaftor), a therapy that was in development, from the approval process.

Leiden told the committee: “It’s not that we won’t take that offer, it’s that we can’t.” He said every other country will want that same offer which amounts to around £10 000 per patient per year and that wouldn’t allow it to develop the next generation of CF drugs.

Leiden said Vertex had done successful deals in 17 countries over Orkambi and that NHS England is being offered the “best price in the world.” In his evidence Leiden criticised the National Institute for Health and Care Excellence’s (NICE) cost effectiveness assessments saying the system was 25 years old and not fit for purpose.

John Stewart, national director of specialised commissioning at NHS England, called Vertex an “extreme outlier” in terms of their behaviour when compared with other pharmaceutical companies. He said all Vertex were interested in was trying to change the NICE appraisal process and had made absolutely no movement on price.

Stewart said they had “overpaid” for Vertex’s other drug Kalydeco (ivacaftor) by £40m a year or £200m over the five years of the contract that has just ended. But he denied that NHS England is trying to “reclaim” that overpayment in their current negotiations over Orkambi.

Leiden faced pointed questions about his salary of $17m a year and the fact that the pharmaceutical company had a turnover of £5.3bn in the five years to the end of 2017 but paid virtually no UK corporation tax. He replied that the company would not pay corporation tax in the UK or the US until it had paid off its operating costs.

Andrew Dillon, chief executive of NICE, acknowledged that Orkambi works but said it was not cost effective. He said NICE had to be consistent with the methodology it uses for all drugs and that Orkambi at around £300 000 per quality adjusted life year was 10 times higher than its threshold. He called on Vertex to demonstrate flexibility.

Caroline Elston, director of the adult CF service at King’s College Hospital NHS Foundation Trust described the delays as “extremely frustrating.” She told the committee that although Orkambi’s effects on lung function are relatively modest it has a large impact on exacerbations and reduces hospitalisations. She said it stabilised patients so kept them well enough to hopefully be able to take advantage of the promising next generation triple therapy drugs in the pipeline.

In her closing comments, the committee’s chair Sarah Wollaston, said: “I hope that in all negotiations all parties will put patients front and centre.”

Waiting times for important conditions get worse, especially in parts of the UK where prescriptions are free. Too few staff, and poor manpower planning. It is getting worse.

My own cancer took 3 months to diagnose… and that was over 10 years ago. Rationing has got worse, but you wont know what is unavailable until you need it. Waiting times for important conditions get worse, especially in parts of the UK where prescriptions are free. Too few staff, and poor manpower planning. It is getting worse. NHS waiting times in England hit five year –‎ (Health UK)


Chris Smyth reports 15th March 2019 in the Times: Quarter of new cancer patients left waiting too long to start treatment

Almost a quarter of cancer patients face delays to starting their treatment as NHS figures show the longest waits since records began a decade ago.

The health service has missed its main cancer target for more than a thousand days. The latest data also shows lengthening waits for emergency and routine care, days after NHS chiefs announced plans to scrap the targets that measure them.

In January 76.2 per cent of cancer patients started treatment within two months of a GP referral. The 85 per cent target has not been hit since December 2015. Fran Woodard, of Macmillan Cancer Support, said: “Behind the numbers are real people who tell us how delays cause anxiety for them and their loved ones at a time when they are already trying to deal with the many worries cancer is throwing their way.”

Because the population is ageing and detection rates are improving, the NHS saw 90 per cent more cancer patients in January than in that month in 2010, but the number waiting too long tripled.

Emma Greenwood, of Cancer Research UK, said: “These figures show an NHS under continued strain, with many patients waiting too long to get a diagnosis and start treatment. For anyone going through tests and treatment for cancer it’s an incredibly anxious time, and delays can make that worse. There simply aren’t enough staff.”

This week NHS England set out the most radical overhaul of hospital standards in more than a decade. It included plans, disclosed by The Times, to test replacements for a target that 95 per cent of A&E patients should be admitted or discharged within four hours.

Figures for last month show that only 84.2 per cent of patients were dealt with in four hours, the worst proportion since comparable records began in 2010. The previous low was 84.4 per cent, in January. The target has not been hit since July 2015.

Professor John Appleby, of the Nuffield Trust think tank, said: “We’re in favour of testing the radical overhaul of A&E targets announced by NHS England last week because there is a risk that the current one is driving poor behaviours. But it will be hard for . . . the public to have faith that this isn’t just lowering the bar.”

Six-month waits for surgery are up by a third in a year as hospitals miss a routine care target that is also likely to go. More than four million patients are on waiting lists for surgery and other routine care, with 552,219 waiting more than 18 weeks. The target that 92 per cent should wait less than 18 weeks has not been met since February 2016.

Professor Derek Alderson, president of the Royal College of Surgeons, said: “While we support NHS England’s plans to pilot new targets and measurements that could improve care, changing targets will not solve the underlying challenges our health service faces.”

NHS England said: “Almost a quarter of a million more people have been seen within four hours in A&E this winter compared with last year . . . More people than ever are coming forward, with a quarter of a million more getting checked for cancer this year and thousands more being treated within the two-month target.”

Thousands of patients “yo-yo” in and out of A&E in their final days. Analysis of NHS data by the charity Marie Curie showed that in 2017 more than 26,000 people went to A&E at least three times in the last 90 days of life. A lack of palliative care and doctors’ reluctance to broach end-of-life care have been blamed. Joan Brooks died last May aged 98 after going to hospital three times in her last month. Her daughter-in-law, Lynn, said: “I called it the yo-yo effect. We knew when we were taking her home that she would be back.”

BBC News 14th March 2019: NHS let me down, says health manager with cancer



Decriminalise unintended erreros…. And initiate no-fault compensation…

New Zealand has been ahead of the UK in many ways, for the last 40 years. No fault compensation (ACC) was started in the 1970s, and there are co-payments. Despite all this effort to ensure a sustainable health care system, the legal risk has not been controlled enough. So the new legislation has been introduced. The NZ system was initially based on the UK but they have moved with the times, and necessity. Another public good related to drugs, where NZ limits the choice to the cheapest generic, but still allows citizens to pay the extra if they so wish. (Universal list of medicines). This is what NHSreality calls “overt rationing”.

Criminalisation of unintentional error in healthcare in the UK: a perspective from New Zealand

  1. Rohan Ameratunga, adult and paediatric immunologist and honorary associate professor1,
  2. Hilary Klonin, consultant paediatric intensivist2,
  3. Jenny Vaughan, consultant neurologist34,
  4. Alan Merry, deputy dean and specialist anaesthetist15,
  5. Jonathan Cusack, honorary senior lecturer6

Key messages

  • Healthcare systems should provide an adequate and effective response to patients who have been unintentionally harmed while receiving care

  • To improve patient safety we need a greater focus on learning and resolution rather than retribution and blame, recognising the importance of protecting confidential personal reflective practice while encouraging open disclosure and system transparency

  • In line with the recommendations from the Williams review, England and Wales should have a higher threshold for criminal prosecution in response to deaths that arise despite conscientious efforts to care for patients under difficult circumstances

  • We urgently need to improve the clinical working environment and resourcing for safe functioning of hospitals

The perverse incentives for government and university are too great…. A different long term plan is needed..

It is expensive to train medics, and the “cost” as shown below, is only a fraction of the real cost. The last estimate I saw was £260,00 in 2016. The market for medics is world wide, made worse by a global shortage and, in the case of the UK, made worse by the universal language of medical science – which is English. With rationing, we have to date given 2 out of 11 applicants places, and the odds have reduced to 1 out of 3! We need them all, and a virtual medical school could supply. Graduate entry is more efficient for the state, and gives males a better opportunity against females, as the men mature later. All this is recorded in NHSreality. ( See links below) The Perverse Incentives for government to apply short term policies, and the universities to generate income before providing the people needed are driving the situation worse. Along with this current doctors are bullied, harassed and overworked. At junior level repeat mistakes are endemic, and if all were recorded as “critical incidents” these doctors would not have time to work. In many countries, especially those from where we import doctors, they are predominantly private and admission is through wealth. These countries have created a caste system in health care, and the best is usually private. The articles below have interesting graphics…..We are already heading there, but it will take a longer term view to turn the juggernaut around.

Britons lose out to rush of foreign medical students Sian Griffiths

….The number of British first-degree students training to be doctors in the UK dropped by more than 500 from 2013-14 to 2017-18, while medical schools increased non-EU student numbers by 12%. While UK students pay £9,250 a year for their medical degree, non-EU students can pay up to £35,000 a year. The courses generally take five or six years….

Exeter, Glasgow and UCL medical schools also increased their overseas undergraduate numbers between 2013-14 and 2017-18 while UK student numbers fell at Durham, Liverpool, Edinburgh and Plymouth.

Jessica Ologbon, 20, said she had felt “numb” when she was rejected by four medical schools after achieving 10 A*s at GCSE and four As at A-level….

…He said: “It’s about money, at the end of the day. You would feel that you were losing out to somebody else who was paying their way in with a chequebook, but the universities have to balance their books somehow.”

Mark Britnell The Sunday Times Med Schools – an opportunity to “train the world” and an advert for his new book:

…We are heading for a global workforce crisis in healthcare. It’s estimated that the world will need an extra 18m health workers by 2030 as the population grows and ages. In the short term the UK is in danger of making a bad situation worse.

…In Britain, frustratingly, there were 20,730 applications to UK medical schools last year but only 6,500 places available. We did not fare much better in nursing: more than 50,000 students applied for 30,000 nurse training posts.

Of course quality is more important that quantity, but we have the opportunity to achieve both. There is a pressing global shortage of health workers, we have a strong NHS brand internationally, we lead the world with our universities and we have some of the best intellectual property — forged over centuries — for education and training at our command.

We should start by putting our own house in order, but, beyond Brexit, we can show the rest of the world that health is wealth. After all, isn’t that what Brexit has asked of us?

Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

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


NHS failure is inevitable – and it will shock those responsible into action. “Get ready for the penny to drop.”

The problem with defining failure in a state service is akin to defining bankruptcy in a nation state. If the state can print its own money it can never be bankrupt. If it defaults on it’s debts (usually dollars) it becomes a pariah. But it continues, as Zimbabwe or Venezuela…. The failure of the four health services is apparent to all doctors and nurses. If they can afford it, and have no idealistic scruples they may have PMI (Private Medical Insurance) but if they haven’t they KNOW that they may have to pay up front privately. The media will not be interested in a sustained assault on the “idolatry” which the nation has, and it wont tell us plebeians that there is no “N”HS. The costly measures when the penny drops will not be popular…

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opines in the Guardian 6th April 2018: NHS failure is inevitable – and it will shock those responsible into action

Health service facilities and staff are being stretched to a breaking point that will take costly short-term measures to fix
The author asks why we don’t acknowledge the failure:
I think the explanation lies in the fact that NHS healthcare, unlike, say, the Grenfell Tower disaster, doesn’t give us a calamitous across-the-board failure. It is so varied and comprehensive that while many services may be on their knees or worse, particularly at times of maximum pressure, others will be delivering adequate or even great services at the same time. There is a mixed picture. And for those who don’t want to see or face up to the hard facts, the possibility of highlighting other ones, and carrying on as before, presents itself.
And assuming the slide into mediocrity continues:
If this is where we are now, and there is much evidence it is, the performance of the NHS will now quickly get much worse. And this will, sometime soon, become clear to all. At that point something will have to be done – and will be done.

What will that be? It won’t be a promise to give the NHS an unspecified level of long-term funding some time. It will have to be immediate service increases and improvements with extra resources, to stem the flood of failure here and now: more money, yes, but more facilities, and more staff, all immediately, and, with costs guaranteed by government, feasible using quick-fix and stop-gap means. It will be quite costly, though the extra amount you can usefully spend in the short term isn’t huge.

But the alternative at that point will be a collapse of the NHS. And the sobering lesson is that had the warning signs been heeded and action taken before things came to this pass, the cost of putting things right would have been far less. The breaking point would have been avoided. Once the collapse has been prevented, we can all look at how we get things sorted permanently. Get ready for the penny to drop.

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Over 40% of GPs intend to quit within five years: new survey

A new survey by Warwick University foretells the end of easy access to a qualified diagnostic practitioner. The “Independent medical practitioner” is a thing of the past, and yet this is what “registration” implies.

The reasons are multiple, but not easily corrected in a short timespan. Recruitment from overseas could help short term, but these doctors will be recruited to the less desirable and popular areas of the UK, and perpetuate the health divide by having poorer communication skills and cultural awareness. In addition, they will block our own doctors from the jobs they are hurriedly recruited to, and if we train enough the excess will have to go elsewhere or change career. This is the end game following disastrous manpower planning, over many dispensations. Rationing of medical school places has led to the post code lottery, and with 80% of undergraduates women (because they perform better at 18) the problem is only going to get worse. 

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Owen K, Hopkins T, Shortland T, et al. : Over 40% of GPs intend to quit within five years: new survey – 

  • University of Warwick researchers describe a ‘worsening crisis’ in GP retention as workload increases
  • New survey identifies an increase in GP intentions to leave or cut hours since 2014; almost half of GPs are bringing forward their plans to retire
  • GPs report that they have felt little effect from recent NHS initiatives to relieve pressures on their workload; most GPs reported that they were working more hours and that morale had worsened compared to 2 years earlier
  • NHS Long Term Plan announced in January may help stem the tide of low morale and early retirement, but some policy initiatives, such as video consulting, are viewed negatively

A new survey of GPs has revealed that over 40% intend to leave general practice within the next five years, an increase of nearly a third since 2014.

The survey of 929 GPs conducted by the University of Warwick has revealed that recent national NHS initiatives are failing to address unmanageable workloads for GPs and left them unconvinced that the NHS can respond to the increasing challenges facing general practice.

The survey conducted in the Wessex region follows up a similar survey in the same region in 2014, allowing the researchers to identify changes in attitude over time.

Published today (28 February) in the journal BMJ Open, it reveals that 42.1% of GPs intend to leave or retire from NHS general practice within the next five years compared to 31.8% of those surveyed in the same region in 2014, an increase of almost a third.

Workload was identified as the most significant issue with 51% of GPs reporting that they were working longer hours than in 2014. This has been linked to the size of the GP workforce not keeping pace with the growing healthcare needs associated with the changing age profile of the UK population, with more people living with complex long-term conditions such as diabetes, hypertension and stroke. In addition, as community and social care services are being cut back or stretched, more pressure is put on general practice as patients have fewer options to turn to.

The researchers argue that the survey paints a picture of GPs feeling increasingly demoralised and looking towards either reducing their hours or retiring altogether.

Lead author Professor Jeremy Dale, from Warwick Medical School, said: “GP morale and job satisfaction has been deteriorating for many years, and we have known that this leading to earlier burnout with GPs retiring or leaving the profession early. What this survey indicates is that this is continuing and growing despite a number of NHS measure and initiatives that had been put in place to address this over the last few years. Many GPs clearly feel that this is ‘too little, too late’ and have failed to experience any benefit from these initiatives and are unable to sustain working in NHS general practice.

“Intensity of workload, and volume of workload were the two issues that were most closely linked to intentions to leave general practice, followed by too much time being spent on unimportant bureaucratic and administrative tasks.

“There’s a worsening crisis in general practice. The situation is bad, it is getting worse and GPs are feeling increasingly overworked and increasingly negative about the future.”

Their paper highlights a number of national policy initiatives that since 2014 have sought to relieve pressures on general practice through targets such as recruiting large numbers of doctors from overseas, changes to governance such as the Quality and Outcomes Framework, an expanded role for allied health professionals and the streamlining of services through measures such as sustainability and transformation plans (STPs).

The NHS also launched its Long Term Plan in January 2019, with increased investment and support for primary care, a reduction in bureaucracy, and 22,000 proposed new allied health professionals and support staff working in general practice.

Professor Dale said: “Views from our survey would suggest that many of the changes in the Long Term Plan, such as greater funding for general practice, increasing the GP workforce, and increasing clinical and support staff in general practice, are desperately needed. But in the context of low and worsening morale and job satisfaction, the question is can these be introduced quickly enough now to stem the flow of GPs who are bringing forward their plans to leave the NHS.

“Recent NHS schemes to recruit more GPs haven’t paid dividends and the consequence is that GPs are still saying that their workload is getting more intense and increasingly difficult to cope with. It’s not perceived that the NHS has taken seriously the crisis facing general practice, and that some policy-led changes in themselves are actually making the workload within general practice less sustainable.

“The point that came through repeatedly in the survey was that GPs felt that we’ve gone a long way down the road of insufficient investment and insufficient reward. Turning this around will be a mammoth task. The initiatives that were thought most likely to bring benefit included greater investment in practice nursing, closer working with and support from hospital specialists, investment in technology, expansion of the GP workforce, and streamlining CQC practices.”

The survey received responses from 929 GPs working in in the Wessex area and is broadly representative of the demographic of GPs working in the NHS, with a slightly larger proportion of responses from older GPs.

Professor Dale added: “A number of recent surveys have shown similar issues to be prevalent across the whole country. Even in an area like Wessex, which in the past would have been considered an attractive place for GPs to work, we can see the effects of chronic under-investment in general practice, and how this is driving GPs to want to retire or reduce their hours of work.”

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: “GPs are under intense strain – our workload has escalated in recent years, both in terms of volume and complexity, but we have fewer GPs than we did two years ago.

“There is some great work ongoing to increase recruitment into general practice, and we now have more GPs in training than ever before – but when more family doctors are leaving the profession than entering it we are fighting a losing battle.

“The NHS long-term plan has aspirations that will be good for patients – but we will need the workforce to deliver it. The forthcoming NHS workforce strategy for England must contain measures to help retain GPs in the workforce for longer – steps to reduce workload to make working in general practice more sustainable and removing incentives to retire early for GPs who might not necessarily want to would both be sensible places to start.”