Category Archives: Commissioning

Planning overall change without evidence that it will be effective, and the probability that it simply encourages duplication…

“Every patient deserves an examination”, or do they? These words were on the wall behind the patients head in one of my training practices. The GP recognised his temptation to omit, especially when hurried, the examination.

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I remember a “sore throat study” as a trainee, wen we were shown a number of mostly normal pictures of “sore throats”. With each case there was a description of symptoms, an occupation, and a social situation. If you had a wedding the next day, even if your throat looked normal, you usually got an antibiotic from most doctors. If you were a diabetic you were more likely to get one, etc. What I am trying to explain is the context in which a GP works, and the need not to offend. Sore throat is only a symptom, and everyone needs an examination. We know that throat examination alone cannot predict bacterial or viral infection, and that for the one patient in front of us, their only concern is a speedy recovery. I confess that, in the middle of a winter of excessive sore throats, I once chuckled when the lady in front of me complained of the same. Without allowing me to examine her she left the room indignantly.. When she saw another doctor he diagnosed tonsillitis and gave penicillin. I never assumed anything on sore throats from that point on. This allowed me to pick up several cancers (tonsil and tongue) which others had missed. We are looking at a “Skill Mix change” as the numbers of GPs declines over the next decade. We hope that sore throats will be seen by competent people, and that the occasional cancer, or glandular fever will be picked up correctly.

The Journal of the RCGP Pauline Nelson et al. from Manchester, in the February 2018 edition ends: “…Evidence about the wider system effects involved in workforce re-design is currently lacking but crucially important in light of the aspiration to new models of care. Given these challenges, Buchan and colleagues’ question ‘If changing skill-mix is the answer, what is the question?’11 remains a pertinent one to ponder in primary care today.” Skill Mix change and the GP workforce challenge..full

Just like the NHS 111 system, and the Apps planned to get access, we are planning change without evidence. Commissioners are doing the only thing they can, within the rules of the game, and it is politicians who set the rules. Watch for missed and late diagnoses, increased litigation, poorer outcomes, and perhaps, in view of increasing dental caries, for the return of Subacute Bacterial Encocarditis. The advice is not to fail to examine, but to stop prescribing. But WHO is going to examine, and will they be competent to make the rare but serious early important other differential diagnosis?

My surgery tried it with nurse triage as well.  We gave up... Duplication of effort….

Kat Lay in the Times reports 26th Jan 2018: Stop prescribing useless antibiotics for sore throats, doctors are urged.

Methods of rationing in the news… Telephone triage, scrutiny of referrals, larger practices, reducing standards, reducing access, excluding treatments. So many different and covert methods of rationing. No political party offers the honest option. No wonder we are disengaged.

Controlling antibiotics in farm practice is most important to reduce superbugs …. but doctors and planners can help.

Harassed doctors hand out antibiotics faster than ever – There are big inequalities in General Practice

Nurses and pharmacists to replace GPs for 1 in 4 visits

Primary care telephone triage does not save money or reduce practice workload

The apps attempting to transfer NHS 111 online

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The beds against the targets… Wrong flu vaccine is always on the cards. Why spend the money?

Kat Lay reports that the beds crisis might deepen because of the wrong flu strain in the vaccine. An alternative is to stop flu vaccines (unproven) and use the money elsewhere. Do we citizens underestimate the influence of Big Pharma on politicians and the Departments of Health. Commissioning groups could challenge this forced waste…

Flu outbreak feared after jabs targeted wrong strain (Kat Lay 4th Jan 2018 in the Times)

The NHS crisis deepened yesterday as health chiefs warned that people who had been vaccinated could still get the flu because the jab had targeted the wrong strain.

In a letter to GPs, Public Health England said the vaccine used by most of the NHS was not effective against the most common type of influenza B being picked up in its laboratories.

Two types of vaccine were available to British doctors this flu season. Quadrivalent vaccines offer protection against two types of influenza A and two types of B. Trivalent vaccines, which are cheaper and more often used in NHS surgeries, provide protection against one type of influenza B and two types of A.

Of 25 influenza B cases studied this year by Public Health England, 21 have been of the B/Yamagata type not covered by the trivalent vaccine. A letter warned doctors in the southwest: “It is possible that flu will be seen amongst individuals, both staff and patients, who have accepted this vaccination.”

Last year’s flu vaccine was 66 per cent effective in children and 41 per cent effective in adults under 65. However, it had no effect on older people.

Although influenza B usually causes less severe illness than influenza A, the issue could have implications for an already stretched NHS, potentially increasing staff absence rates.

On Tuesday NHS England’s national emergency pressures panel recommended a halt to non-urgent operations until the end of this month, as well as postponing routine appointments, in anticipation of worsening weather and rising cases of flu.

NHS England has estimated that the measures could mean that up to 55,000 operations are deferred. Keith Willett, director for acute care at NHS England, said the move was necessary, adding that the health service had not been under such pressure since the mid-1990s. A poll of more than 100 trusts found that at least 16 had declared the most severe level of pressure — operational pressures escalation level 4 (Opel 4) — for at least an hour in their casualty department over the past week. Opel 4 means that pressure is so great in the system that the organisation is “unable to deliver comprehensive care”, meaning “there is increased potential for patient care and safety to be compromised”.

Official figures published yesterday showed that across Scotland waiting times in accident and emergency units remained below a key target in the week before Christmas as demand rose by almost 20 per cent on the previous year. More than 600 patients were delayed in A&E departments for eight hours or longer.

NHS England is expected to publish its weekly operational statistics today. Anecdotal evidence paints a picture of a system struggling to cope. Anu Mitra, a Charing Cross consultant, said that his department was practising “battlefield medicine” and that it would be the norm “for the next few weeks”.

The Royal College of Emergency Medicine said it believed that big A&E departments were only seeing between 45 and 75 per cent of patients within four hours, against a target of 95 per cent. In a statement, the college said: “At this level of performance there is a major risk to safety despite the very best heroic efforts of all staff and managers concerned.”

The BBC reported that two deaths in a casualty department in Dudley, West Midlands, were under investigation, including a man who died in the waiting room. The Dudley Group NHS Foundation Trust, which runs Russells Hall Hospital, said that it was not able to discuss individual cases.

Jeremy Hunt, the health secretary, called for the NHS funding cycle to be extended from five years to a decade. Asked if he would endorse a ten-year plan, he told Channel 4 News: “That is exactly what I think we do need.”

He said that the only long-term solution was to train enough doctors and nurses, adding: “Unfortunately it does take seven years to train a doctor and three to train a nurse so we’re going to have to ask staff to bear with us as we train those extra doctors and nurses.”

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Theres a horrible smell around the Health Service(s) battlefield: it’s more than an “ill wind”.

Its not just an “Ill Wind” but a horrible smell about the possibility of a conspiracy of denial when the politicians knew all along that this winter would foresee a disaster. The collusion of anonymity in responsibility is also growing, as more and more decisions on rationing based on judgements made by local commissioning groups trying to get away with the least adverse local publicity.

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Kat Lay on Jan 3rd reports in the Times : A&E doctors warn of risk to safety amid ‘battlefield medicine’

More importantly, the Leading Article: An Ill Wind

With thousands of appointments cancelled and hospital waiting rooms full to bursting, the NHS is in a state of crisis. Its funding model is not working

The NHS is once again in the grip of one if its worst winter crises in living memory. Managers have ordered the cancellation of all non-urgent operations this month and abandoned single-sex wards in an effort to free up beds. Many patients are waiting hours for admission, some stranded in corridors because of crowded waiting rooms. Explaining the situation, Jeremy Hunt, the health secretary, warned that “there is a longer-term funding issue that we need to address as a society”. He was right. These crises will persist until the public demands less of the NHS or pays more for it, either in taxes, charges or premiums.

If the NHS is akin to a national religion in Britain, the demand for a service free at the point of use is its call to prayer. The current financial settlement, however, is unsustainable. In November the chancellor announced £6.3 billion of extra NHS funding over the course of the parliament, including £1.6 billion this year. Health economists reckon that is scarcely half the amount required to maintain the present quality of care.

It is only going to get harder. Looking after an 80-year-old is five times more expensive than looking after a 30-year-old, and the number of octogenarians will double by 2030 to more than six million. A growing armoury of treatments has its price too. On present trends the King’s Fund, a think tank, expects an annual funding gap of about £20 billion by 2023.

The government can alleviate some pressure by making the service leaner. Proposals to close hospital units and concentrate care in specialist centres, for instance, are often met with a great clamour of local opposition. But the evidence shows that this approach saves money and lives. Likewise directing more patients to their local pharmacist would save doctors valuable time.

However, these efficiencies will not correct the fundamental mismatch between demand and money. Already that imbalance is leading to rationing. In December Simon Stevens, chief executive of the NHS, warned of more missed waiting-time targets this year. The service may also curb treatment for conditions such as hearing loss.

Ministers could embrace the vision of a less ambitious NHS, and try to shift some of the burden of care from the public to the private sector. This would mean expanding private insurance coverage. At present only 10.5 per cent of the population has cover, in most cases through their employers.

Equally, the government could seek other sources of revenue. The NHS charges for dentistry and prescriptions but not much else. Even Sweden and Norway, paragons of social democracy, charge for visits to GPs. Germany charges for each day of a stay in hospital, France for X-rays and laboratory tests. Many countries charge patients for treatments such as physiotherapy.

In rich countries these charges tend to be subsidised and come with exemptions to ensure that the poor get care, but small sums can still make a difference. Charging for missed appointments could generate revenue, too. This week we reported that missed appointments cost the NHS nearly £1 billion in the last financial year.

It is also worth considering mandatory social insurance of the kind used in much of western Europe. In Germany 14.6 per cent of each employee’s gross income is collected by insurers and used to fund care. This functions like a hypothecated tax. Moving in this direction would be a radical change, but it deserves a fair hearing given that raising ordinary taxation is politically toxic.

Politicians often dance around the issue of NHS funding with euphemism and obfuscation, warning of the need, in the long run, to have a public conversation about the tough choices that lie ahead. The sooner, the better. When this winter crisis abates, hospitals will begin counting the days until the next one. This cannot go on for ever.

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More than 17000 people rally to stop the deportation of a ‘hard …working respected doctor”

Sheffield MP campaigning to keep NHS services open The forge

Birmingham Mail: Thousands sign petition for Birmingham doctor at risk of deportation

Op cancellations up by more than half at NHS Borders, figures reveal

16900 people in a week kept in NHS ambulances waiting for …

NHS crisis sees office workers on cleaning duty in hospitals and GP …
Scottish Daily Record5 hours ago

Ravi Jarayam in the Independent: I’m an NHS consultant and I can tell you exactly what caused this winter crisis

There’s increasingly hare-brained ideas being thrown around to handle this ever-growing NHS crisis, such as admitting adults onto children’s wards

The Guardian 3rd Jan 2018: The Tories knew there would be an NHS winter crisis but did nothing


The Patients’ Association and the Charities should challenge, and define what is happening in the courts… Crawley: NHS “not rationing” hospital treatments and operations.

Denial in the Shires. Of course the Health Boards / Trusts / Commissioners cannot admit to the “R” word. They are “prioritising”, “restricting”, “reducing”, “limiting”, and “excluding”, different services for different people in different post-codes in different years. So no citizen can find out what, consistently, will NOT be available in his or her area of the country. Ask a retired consultant or GP or Nurse, or Physio in an exit interview whether Rationing is happening and they will almost all say yes. But there are no exit interviews… If policy does not conform with delivery, we have a collusion of denial. This is why the health service staff are disengaged. We need honesty in use of the English language before we can progress, so NHSreality calls for the Patients Association and the Charities together to challenge and define  what is happening in the courts… They may find GP commissioners, infuriated at the current “rules of the game“, help them in their case, and want to change them.

Joshua Powling reports for the Crawley Observer Friday 8th December: NHS “not rationing” hospital treatments and operations. 

Hospital operations and treatments for West Sussex patients are not being rationed, according to health chiefs.

Government reforms put clinical commissioning groups (CCGs), which are led by GPs, in charge of planning and buying healthcare from 2013, but all three organisations covering West Sussex are in special measures in part due to financial deficits.

The three CCGs are part of a new regional NHS initiative called clinically effective commissioning, which looks to standardise policies for when patients should undergo certain treatments and procedures.

According to a recent West Sussex Health and Social Care Committee (HASC) report, the aim of the project is to make sure commissioning decisions across the region are consistent, reflect best clinical practice, and represent the most sensible use of resources.

But last Friday James Walsh, vice-chairman of the HASC, asked: “What exactly is being proposed? Is this some form of rationing or delaying treatment?”

He explained that rather than dealing with statistics, they were talking about patients who had problems, many of which interfere with their daily lives.

Geraldine Hoban, accountable officer for the Horsham & Mid Sussex CCG and the Crawley CCG, explained the changes were bringing in more consistent thresholds for treatment.

She said: “We are not doing this for arbitrary reasons or to save money. This is based on up to date clinical evidence.”

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She added: “This is about people having procedures which we do not believe adds the clinical value they need.“It’s not rationing, it’s about adhering to the clinical evidence.”She went on to outline the ‘significant financial challenge’ facing the healthcare system in West Sussex, and how these changes were taking place before ‘we starting making some difficult decisions about difficult services’. They also found that previously some procedures had no formal policy, while in others such as orthopaedics activity the area was a significant outlier.

Other revisions were required were policies did not improve outcomes or patient experience. So far the clinically effective commissioning programme is split into three tranches. The first two have been reviewed by all the CCGs and updated where necessary in line with National Institute for Health and Care Excellence guidance.

Changing the rules of the game


In Wales they really can waste money: £68m unveiled for health and care hubs

BBC News reports 6th December: £68m unveiled for health and care hubs

The profession will not see this as positive. It marks the beginning of the end for self employed GPS. It is probably a waste of money, and it is part of the direction of travel, where fewer and fewer people have access to the expertise needed when they are ill. Differential diagnosis, risk analysis and safety netting are all part of a Drs training, and in the case of GPs, living with uncertainty so that good gatekeeping ensures minimal waste. These GP “Geese” who laid those golden eggs are not here now….

But it may be attractive to part time GPS with families often married to other doctors.

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ITV News 6th December covers the initial reaction of the profession: Plans for 19 new health and care centres…..

…Dr Charlotte Jones, chair of the BMA’s General Practitioners Committee says she’s concerned about the lack of involvement of local clinicians:

Whilst we welcome improving access to services closer to people’s homes, it’s difficult to assess the impact this will have without knowing the intricacies of how it will work. It’s concerning to us that the initial reaction from LMC members suggests that they haven’t been involved in the design of the scheme.

It’s vital that local clinicians, who understand the needs of the local community, are involved in service design to ensure that patients receive the services they deserve.

As part of the work to improve access to local services, investment is desperately needed to ensure the GP estate is fit for purpose. Robust premises strategies must be developed, with the full involvement of LMCs. – Dr Charlotte Jones, Chair GPC Wales

Dr Ian Lewis reports 26th November in Walesonline another money spend, mostly from charitable fund raising, which will cut out the GP. By deskilling the GP how does society gain? This is the opposite of utilitarianism. (Greatest good for the smallest number) and brings back the suggestion of the Court Report in the 1970s#; A child health centre in West Wales could be created 20 years after it was proposed – The venture has been in the pipeline for almost 20 years and is estimated to be worth £2.5million

Just as there wont be enough Doctors, there won’t be enough care homes. There are many opinions, but NHSreality fears that Wales is pouring money into a number of buckets which have holes in them. There are just not enough trained people: GPs, Nurses, Physiotherapists, Psychologists, OTs, Psychotherapists, Radiologists, Anaesthetists, you name them…

Mark Smith reports in Walesonline 4th December: The Welsh care homes under threat for not meeting standards – Care homes in Wales are under threat of being suspended or de-registered

BBC News 21st September: NHS reform can cut costs, says local council leader

BBC News 4th December: Cash ‘ploughed into NHS’ preventing change, AMs warn

BBC News 5th December: Welsh Government ‘sticking plaster’ on health services

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After promising to clone GPs, and failing, Mr Hunt promises to “make” more radiologists… Importing them will block our own for years. Exporting films abroad is an option…

The strict and high standard training of radiologists has been threatened by cutbacks, just like GPs. Numbers have been insufficient for years, and although “Intelligent computerised reading” may reduce the numbers needed in the longer term, but short term there is a terrible risk. Will patients be asking for their X rays to be read by a consultant, and if this is not possible in their DGH then they should ask for the films to be read privately… The result of long term under capacity rationing is here and now: a two tier health service. Trusts who insist patients who go privately are put at the bottom of NHS waiting lists might have a problem with patients already admitted to hospital. Will they send them home again? Instead of recruiting from abroad, and blocking our own youngsters from Radiology careers, the films should be sent abroad pro tem. (Commissioning export?)

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The Times December 5th reports: Hunt promises 300 more radiologists for NHS England

The NHS will take on 300 more radiologists in England, Jeremy Hunt, the health secretary, has said. The pledge is part of the Cancer Workforce Plan, intended to tackle what one charity called a “crisis in the diagnostic workforce”. Another 200 clinical endoscopists, who use tiny cameras on flexible tubes to investigate suspected cancers inside the body, will also be appointed. It is hoped that the new staff will be trained by 2020, according to Health Education England.

Mr Hunt said: “We want to save more lives and to do that we need more specialists who can investigate and diagnose cancer quickly. These extra specialists will go a long way to help the NHS save an extra 30,000 lives by 2020.” However, the all-party parliamentary group on Cancer said that NHS England would “struggle” to achieve ambitious plans to improve cancer care. John Baron, the chairman, said that the cancer strategy was in danger of being derailed and added: “Corrective action now needs to be taken.”

They dont really care – they have known about the shortage of Radiologists coming for decades..

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

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Brexit effects: Pharma may leave, and the severity of the financial rationing is evident, and will get worse. The fears of the Kings’ fund and the Nuffield Trust are not reduced… Listen …

The Nuffield Trust and the Kings fund were urging the chancellor “to address the critical state of health and social care” in the autumn budget. They have comment on the Budget and it’s implications for the Health Services in the UK. The impact of severe financial rationing on commissioners will lead to more post code and covert rationing.

“With the budget this week committing around £2 billion extra for the NHS next year, Nigel Edwards said it will bring respite for patients and staff, but is only around half of what’s needed. In a Q&A about the budget live on Facebook, John Appleby appeared with Anita Charlesworth (Health Foundation) and Siva Anandaciva (King’s Fund) to discuss what it all means for the NHS and social care. You can watch here.”

The economist November 18th reports: Withdrawal symptoms – Pharmaceutical firms trigger contingency plans for a no-deal Brexit – An industry with long production timelines cannot afford to wait any longer

ONE of the first tangible consequences of Britain’s exit from the European Union will be made clear on November 20th, when the EU announces the new home of its drug regulator, the European Medicines Agency, which is currently based in London. The agency will have less than 17 months to pack its bags before Britain leaves the EU in March 2019, whereas by its own reckoning it needs a transition period of at least two to three years.

The agency’s relocation is not the only worry facing one of Britain’s most important and most globalised industries. Pharmaceutical firms on both sides of the English Channel warn that time is running out for the EU and Britain to reach an agreement that allows them to continue operating without a hitch after 2019. Companies would need several years to adjust if such a deal were not made. Even agreement on a transition period, to smooth the first years after Brexit, may come too late to be of use to an industry with long production timelines. Firms are thus already preparing for an outcome in which Britain operates outside the EU’s medicines regulations. Some in the industry say they are arriving at an “accidental no-deal”.

Britain has some reasons to be optimistic about the future of its science industry. The pharma business depends more than most on research and development (see chart), which in turn depends on centres of academic excellence such as Cambridge, Oxford and London, which are not going

nywhere for now. Britain still ranks ahead of other European countries for the amount of biotech venture-capital investment that it receives.

Yet its contribution to manufacturing supply chains could dwindle. The Association of the British Pharmaceutical Industry, a trade group, says that if progress on post-Brexit arrangements is not made by December, an increasing number of pharma firms will activate costly “no deal” contingency plans to avert problems in the supply of medicines. AstraZeneca, an Anglo-Swedish company, and Eisai, a Japanese one, have already started to duplicate their testing and approval procedures elsewhere in Europe, in order to ensure access to the EU market after 2019.

Eisai says the work is costing many millions of pounds—money that it notes will offer “no gain” to patients. Pascal Soriot, the boss of AstraZeneca, says his company has an entire team working on Brexit contingency plans. Another large European pharmaceutical business with facilities in Britain says it is “on the cusp” of making a decision to move activities out of the country. GlaxoSmithKline, Britain’s largest pharma firm, will start spending on contingency plans from the end of the year.

Some companies based outside Britain are looking at ways to avoid passing their products through the country, in order to sidestep the costs and delays they might encounter should Britain leave the EU’s single market and customs union. Many drugs sold in continental Europe are primarily made in Ireland and then sent through Britain, where they are packed, tested, given marketing authorisation and released. Tommy Fanning, head of biopharmaceuticals at IDA Ireland, which promotes foreign investment in the country, believes that this British “bridge” to Europe could collapse if no deal is struck.

Continental Europe, too, has cause for concern. On November 9th the European Federation of Pharmaceutical Industries and Associations, a trade group, issued a warning to Brexit negotiators. Just under half the group’s member firms expect delays in the trade of medicines if Britain and the EU fall back to trading according to the rules of the World Trade Organisation. Over 2,600 medicines are at least partly manufactured in Britain, which supplies 45m packs of medicine to other EU countries every month, while 37m come in the other direction. Any Brexit settlement which disrupted these flows would be a bad prescription for patients on both sides of the channel.

This article appeared in the Britain section of the print edition under the headline “Withdrawal symptoms”


Sam Coates in The Times reports: Budget 2017: Hammond’s NHS boost ‘far less generous than it looks’

Philip Hammond’s cash injection for the NHS is far less generous than it looks and will be cancelled out by the growing and ageing population, says a leading financial think tank.

Health chiefs at NHS England are heading for a confrontation with ministers after declaring that the chancellor’s £2.8 billion boost in Wednesday’s budget was insufficient.

They are holding a board meeting next week to decide whether to step up rationing of services. One Whitehall source expressed surprise that NHS England was mounting what they viewed as an overtly political campaign to challenge the Treasury.

The Institute for Fiscal Studies (IFS) said that the NHS was in the middle of the toughest decade since its creation. “Real spending is essentially unchanged between 2009-10 and 2022-23 after accounting for population growth and ageing,” it added.

Carl Emmerson, the IFS deputy director, said: “The increase in spending does not mean good times for the NHS. The increases are far, far below what it is used to in previous years.”

He said that the £1.6 billion extra allocated for 2019-20 should be seen in the context of the total £125 billion budget. “So if we adjust not just for population but also age, we can see the increases look far less generous and pretty flat even if manifesto commitments are delivered,” he added.

YouGov polling for The Times suggests that increasing money for the NHS was the most popular measure in the budget. Some 62 per cent supported it as a top priority, against 23 per cent for the housing package and 18 per cent for the abolition of stamp duty for first-time buyers on properties of less than £300,000.

Mr Hammond said that the NHS needed to do more to cut waste so more was available for the front line. His aide, the Tory MP Kwasi Kwarteng, complicated the issue by saying that the NHS could receive the extra £350 million per week promised by Leave campaigners during the referendum. “I think actually that we could deliver that. That’s my own view,” he told the BBC.

The IFS also said that the £44 billion housebuilding package could not be relied upon to deliver a big impact.

Mr Hammond told the Commons he wanted the UK to build 300,000 homes a year, although this will largely be done by the private sector rather than a big public housebuilding programme preferred by some cabinet ministers.

The IFS said: “It is impossible to say with confidence how many houses it will deliver.” It questioned the chancellor’s claim that £44 billion was being spent on housing, saying “we haven’t worked out how that’s calculated”.

A former permanent secretary to the Treasury has said that the government’s stamp duty break for first-time buyers was a naked attempt to shore up support and would do little to help young people on to the housing ladder.

Lord Macpherson of Earl’s Court described the measure as a “relieving tax” for the government’s core supporters.

“The vast majority of young people can’t afford to buy any house and probably won’t for many years to come but the proportion of the population who can, no doubt with help from their parents, is the classic sweet spot of Tory middle England,” he said. “People who claim it is bad value for money get it wrong, this is all about shoring up political support.”

The IFS also said that Mr Hammond’s increase in duty on high-strength cider would only affect 9 per cent of the market. “Cider is still the most tax efficient way to get drunk,” said Helen Miller, associate director of the IFS.

There is also an income effect generator in the Times