Category Archives: Commissioning

In a celestial world as outlined by the old NHS, there was universal, cradle to grave cover, with no barriers to access, free at the point of delivery, and without reference to means. Funny that we have so many medical charities then. And the greatest number of these charities is in the Hospice (Palliative and Terminal care) sector. These charities are mostly run from physical buildings, and hospices, but in the poorer areas of the country they are “Hospices at Home”. The idea to help elderly at home is a good one, BUT it overlaps so much with charitable providers. The perverse incentive for Trusts and Commissioners to offload as much as possible to these charities will inevitable mean there are large post code voids in cover. NHS reality does not object to this IF it is honestly discussed. The solution is a means based insurance based system, and since most of the assets in the UK are held by the elderly this would be more progressive.

Chris Smyth reports November 22nd in the Times: Rapid response teams will help elderly at home

NHS “rapid response teams” will be on call 24 hours a day, seven days a week to help frail and elderly patients who fall or suffer infections, Theresa May will say today as she promises to use extra health service cash to keep people out of hospital.

GPs will also get to know care home residents personally in an effort to keep them well at home. Such services will get an extra £3.5 billion a year by 2024 as part of a £20 billion boost promised to the NHS in the summer

Experts welcomed the ambition but questioned whether the NHS would have the staff to provide the services, and warned that such top-down initiatives often backfired…..

…Simon Stevens, chief executive of NHS England, said that guaranteeing the money for local services would help to make the plans a reality.

“Everyone can see that to future-proof the NHS we need to radically redesign how primary and community health services work together,” he said. “For community health services this means quick response to help people who don’t need to be in hospital.”

Sally Gainsbury, of the Nuffield Trust think tank, said: “This money will simply allow GPs and community services to keep up with demand over the next five years. That’s important but it means the new money announced today is not going to lead to a significant change.”

She added that there were “serious questions about whether the NHS has the right staff in the right places to carry this out”. She warned: “We would agree the NHS needs to focus on helping people more outside hospital and getting them home more quickly. But the idea of telling every local area to do the exact same thing has often backfired in the NHS, as it is bound to be less well-suited to certain places.”

Advertisements

NHS in Scotland is “not financially sustainable,” auditors warn. Do the Scots expect a bail out?

Is the Scottish Government expecting England to bail them out? Financial responsibility comes at a price, and it looks as if Scotland is not willing to pay that price – yet. Reality has not yet hit our politicians. Health has to be rationed…. Individuals can declare bankruptcy, but not state hospitals.

See the source image

In BMA news Bryan Christie on 25th October reports: NHS in Scotland is “not financially sustainable,” auditors warn (BMJ 2018;363:k4520 )

A stark warning has been issued about the future of the health service in Scotland in a critical report that says it is not financially sustainable in its current form.

Audit Scotland has performed its annual health check on the service and found a continuing decline in performance, longer waiting times for patients, major workforce challenges, and increasing difficulty among health boards to deliver services within existing budgets.1

Only one of the eight key national performance targets was met in Scotland in 2017-18 (for patients with drug and alcohol issues to be seen within three weeks), while only three of 14 NHS boards met the 62 day target for cancer referrals. And there has been a 26% rise since 2016-17 in the number of patients waiting more than 12 weeks for inpatient or day case surgery, to a total of 16 772 in 2017-18.

Total spending came to £13.1bn in 2017-18, a fall of 0.2% in real terms on the previous year, forcing NHS boards to use one-off savings or extra support from the Scottish government to break even. In the coming years projected increases in healthcare costs are expected to outstrip any additional funding for the service.

“The NHS in Scotland is not in a financially sustainable position,” said the report. “The scale of the challenges means decisive action is required, with an urgent focus on the elements critical to ensuring the NHS is fit to meet people’s needs in the future.”

The steps the report recommends include:

  • Moving away from short term firefighting to long term fundamental change

  • Ensuring effective leadership

  • Creating a more open system to encourage an honest debate about the future of the NHS

  • Carrying out detailed workforce planning, and

  • Improving governance and the scrutiny of decision making.

Caroline Gardner, auditor general for Scotland, said, “The performance of the NHS continues to decline, while demands on the service from Scotland’s ageing population are growing. The solutions lie in changing how healthcare is accessed and delivered, but progress is too slow.”

The day before Audit Scotland’s report was released the Scottish government announced an £850m initiative over the next 30 months to shorten patients’ waiting times across Scotland. It seeks to achieve the 12 week treatment time guarantee for all inpatient or day surgery patients, which was introduced in 2012 but has never been met.

But Lewis Morrison, chair of BMA Scotland, said that this was the wrong approach. “We need to adopt a more mature, wide ranging way to assess our NHS and the care it delivers. Simply piling more political pressure on the meeting of existing targets that tell us little about the overall quality of care will do nothing to put the NHS on a sustainable footing for the long term.”

See the source image

 

I’ll pay later, and possibly with my life.. NHS trusts face a record £6bn backlog of repairs…

If there are 60 million souls in the UK (I know its more) the £6,000,000,000 bill equates at £100 each man woman and child. And you can be guaranteed its an under estimate. The trouble is that I don’t have the option to pay now, and prevent deterioration. I’ll pay later, and possibly with my life.. while successive governments think, and deny. Capital projects are decreed by devolved government in Wales, Scotland, and N Ireland, but centrally in England. 

Image result for your money or your life cartoon

The Times reports 23rd October 2018: NHS trusts face a record £6bn backlog of repairs

NHS trusts are sitting on a record-high backlog of almost £6 billion worth of repairs or replacements that need carrying out, official figures show.

About £1 billion of the outstanding repairs are “high risk”, meaning that they could result in “catastrophic failure, major disruption to clinical services” and are “liable to cause serious injury and prosecution” if they are not addressed immediately. Examples of maintenance required could include upgrading software on medical equipment, maintaining generators and boilers and ensuring the structural integrity of buildings.

In the year to March there were 17,900 incidents across England in which patients were harmed or put at risk of harm because of infrastructure problems, according to the data from NHS Digital. This is an increase of 800 in a year. Clinical services were delayed, cancelled or otherwise affected because of problems with buildings or facilities on 3,835 occasions, an increase of 1,500.

Chaand Nagpaul, chairman of the council of the British Medical Association, said that there was an urgent need for extra funding to address the NHS’s “impoverished infrastructure”.

The repair bill has risen every year since 2011-12, when it stood at £4 billion, while costs for outstanding high-risk works have more than tripled over the same period. NHS trusts spent a combined £404.5 million trying to reduce the backlog last year but the bill rose by more than £400 million.

Siva Anandaciva, chief analyst at the King’s Fund, a health think tank, said: “Deteriorating facilities and unreliable equipment can expose staff and patients to increasing safety risks, and make NHS services less productive as operations and appointments may be cancelled at short notice.”

For the past four years the Department of Health and Social Care has transferred money from the capital budget to use on day-to-day spending. A spokesman said: “Investment to tackle this maintenance work has increased by 25 per cent from £324 million in 2016-17 to £404 million in 2017-18. We are also investing £3.9 billion into the NHS to help transform and modernise buildings.”

Image result for your money or your life cartoon

Some countries are honest…. NZ has to ration dialysis

UK governments need to take note of the honesty of others.

Radio New Zealand reporter Gill Bonnett on 13th August 2018 reports: “We have had to ration dialysis” – Immigration NZ 

Some New Zealand dialysis patients have had their treatment rationed because of ineligible patients turning up for emergency care, according to government documents

However, the Ministry of Health says New Zealanders who need dialysis are not losing out due to ineligible kidney patients putting demands on the health services and Immigration New Zealand told RNZ there was no evidence treatment rationing was “currently happening”.

Documents obtained by RNZ from Immigration New Zealand (INZ) include slides from a presentation by its chief medical officer on the costs and demands on the health system, made in a meeting with the Immigration and Protection Tribunal last year.

Two pages discussed how some kidney patients were dying faster because their dialysis treatments had been cut back to allow urgent treatment of foreign patients.

Under the heading ‘Health Screening; Concerns’, one slide said “we have had to ration dialysis due to lack of resources to deal with demand.”

“When we get ineligible overseas patients turning up we are obliged to treat them urgently but we are often full in which case we will reduce the dialysis our existing patients are having in order to fit everyone one.”

INZs chief medical officer said at times staff said they have had to reduce dialysis sessions to twice a week and patients “get sick and die quicker” at that level.

INZ director policy integration and immigration Nick Aldous – in response to RNZ questions about the presentation – said there was anecdotal evidence of ineligible kidney patients, but did not say when it happened.

“The scenario [in the two pages] was based on anecdotal evidence from an earlier point in time. We don’t have any evidence that this is currently happening.”

The Ministry of Health on Monday said there was a small number of ineligible patients receiving dialysis but this doesn’t affect treatment for New Zealanders.

“People who need dialysis are receiving it according to clinical need.

“Dialysis services are under pressure because of the growing population as well as obesity and type 2 diabetes,” a spokeswoman said.

Patients ineligible for publicly funded healthcare include tourists, except for those from the UK and Australia, which have reciprocal health agreements with New Zealand.

However, detailed immigration medical assessments before visas are issued are not compulsory for many temporary immigrants.

And ineligible patients do not have to pay for healthcare costs upfront.

Official information

Slides from the INZ presentation, obtained under the Official Information Act, refer to the world-wide numbers of diagnosed diabetes cases, many of which come from New Zealand’s immigrant source countries in Asia and the Pacific. There are also a number of undiagnosed cases.

The slides also looked at the cost of mental illness among immigrants on the health system.

“We have had to stop training patients for home dialysis which has meant more hospital beds full up and at times we have had to limit patient dialysis sessions to two per week per patient.

“The minimum acceptable standard is three sessions per week, below that, patients get sick and die quicker.

“But we have had to ration dialysis due to lack of resources to deal with demand.

“So the care our patients receive is impacted when we are working above our capacity.”

Kidney Health New Zealand’s national education manager, Carmel Gregan-Ford, said dialysis was rationed a few years ago but she has not heard of it more recently, although ineligible patients are still an issue.

“I have people who ring me on the 0800 line who are telling me, coming from overseas, telling me they’ve got friends coming next week and they need a place to dialyse,” she said.

“And I say to them you can’t come, there’s nowhere you can dialyise and they’ll come anyway and present to emergency clinics and hospitals and they have to be dialysed, so I don’t know how that can be prevented.”

Immigration ‘scenario’

Immigration New Zealand director policy integration and immigration Nick Aldous said the presentation – referred to in the official information – was given in mid-2017.

He said the slides were part of a “scenario” designed to provoke discussion about health service costs and demands.

“It uses dialysis treatment as one example for the scenario.

“This scenario was based on anecdotal evidence from an earlier point in time.”

According to Ministry of Health guidelines, district health board renal services must all offer home dialysis.

The National Renal Advisory Board published guidelines on access to renal replacement therapy which says that home dialysis is most cost effective and provides people with the best quality of life.

In 2016, there were 2750 dialysis patients in New Zealand, but there is no data on how many were overseas’ patients.

About 400 people died while on dialysis in New Zealand that year.

It is not clear how many DHBs are affected, and by how much overall, although the three Auckland DHBs receive partial compensation from the Ministry of Health for the cost of treating ineligible patients for all health conditions, where the immigrant or tourist has not repaid that debt. Last year that was $5.5 million.

On notice

The comments on health rationing were made at an annual training session of the Immigration and Protection Tribunal.

The tribunal, which can overturn deportation on humanitarian grounds, had until last year commonly been granting immigrants needing dialysis temporary visas on appeal, to allow them to continue their treatment.

But in a decision in June last year, it put future appellants on notice that they should not presume that would continue and said it was preferable that they put their cases to the Immigration Minister.

And since then it has ruled in two cases that immigrants had exceptional humanitarian circumstances but said that was outweighed by the public interest in minimising health costs and upholding the integrity of the immigration system.

The most recent one, in April, ruled that a Fijian man married to a New Zealander but who failed the visa requirements and was going to be deported, can stay for a year so that he can sell land he owns to pay for dialysis or a transplant.

In a statement, INZ said it introduced eMedical in 2014, an immigration health screening system that allowed for greater oversight of applicant health information, better decision-making on applications, and the monitoring of health changes over time.

It said it had a Memorandum of Understanding with several district health boards, which allowed DHBs to confirm the eligibility of patients for treatment, and had been working with DHBs to improve understanding of the criteria for eligibility, and how they were applied.

Editor’s note: This story has been updated with additional responses from government agencies and clarifies that treatment rationing isn’t happening currently, but has happened on a small scale in recent years.

Advances in Diabetic care are rolled out at different speeds in different post codes.

There is a history of rationing new advances in medical care differently in different post codes and regions. Some things are too important for this type of random care. If it was open and honest, and announced in advance, for some cheap services rationing is appropriate: but of course it is not allowed to be talked about. The perverse incentive for commissioners to get away with what they can is too great..

Judy Hobson in the Mail in 2010: The alarm that can save diabetics’ lives (so why is the NHS rationing them?)

Faith Eckersall reports in the Daily (Dorchester) Echo 12th October: Diabetics to confront councillors over postcode lottery DORSET diabetics – including some children- will be part of a delegation at the county council on Wednesday to campaign for new testing technology free on the NHS.

Currently people with Type 1 diabetes must use the painful and inconvenient pin-prick method to check their blood sugar levels but Flash, which must be paid for in Dorset, works on a pain-free patch and scanning device.

The protestors are angry that despite the government’s NICE drugs and medicine rationing committee approving the use of Flash Glucose Monitoring on the NHS, Dorset Clinical Commissioning Group has not made it freely available, as has happened in adjoining health areas.

The CCG is running a six-month pilot of the Freestyle Libre blood glucose monitoring device for 200 people in three specific groups of diabetic patients in the county. But protestors point out there are 5,000 diabetics in Dorset who could potentially benefit and say no further testing or pilot is needed.

Diabetes UK south west regional head, Phaedra Perry, said: “The Dorset Clinical Commissioning group should make Flash available immediately to all people with diabetes in the area who can benefit, and not to just a very limited group of 200 patients for six months.

“Commissioners here are out of step with neighbouring CCGs which have agreed to prescribe it. Dorset is one of very few areas in the south west where Flash is not available and is effectively imposing a postcode lottery on diabetes technology.”

Call to end NHS rationing of HIV prevention drug PrEP

Once we accept that we have to ration health care, we can start discussing how. Prevention can be expensive, and so can a lifestyle. NHSreality feels that means related co-payments would address this issue well, and even the poorest should pay something for prevention. Commissioners are not allowed to do this, anywhere in the 4 UK health systems, and the official line is that there is no rationing , and indeed we can provide “Everything for everyone for ever for free”.

Image result for free lunch cartoon

The News and Star (Cumberland News) reports 12th October 2018: Call to end NHS rationing of HIV prevention drug PrEP

A charity has called for more gay and bisexual men to be given access to the HIV prevention drug PrEP, a year on from the start of a major trial into the treatment.

The National Aids Trust (NAT) said many men were being turned away from clinics, and some would contract HIV as a result.

Last year, a study funded by NHS England found that a quarter of new HIV cases in England could be prevented by giving high-risk men pre-exposure prophylaxis (PrEP) treatment.

The programme could save the NHS millions as a result of fewer men
getting infected and needing a lifelong supply of drugs to stop them
succumbing to Aids, researchers said.

The first clinic in the PrEP Impact trial opened on October 13 last year.

The three-year trial aims to provide PrEP to 10,000 people, but the NAT said all the allocated places for gay and bisexual men were filled by March.

Since then reallocation of places and a boost of a further 3,000 places on the trial has allowed clinics to reopen, but this provides only temporary relief, and it is expected that most clinic places will be filled up by early next year.

NAT chief executive Deborah Gold said: “PrEP is 100% effective at preventing HIV when taken as prescribed.

“NHS England’s decision-making process concluded that PrEP should be commissioned and just last month the cost of the drug has substantially reduced as a result of court judgments on the patent.

“It is therefore completely unacceptable for people in need of PrEP to be denied it by the NHS.

“NHS England and local authorities must urgently agree a national PrEP programme to start as soon as possible in 2019.

“The Government should play its part by increasing funding to public health so that we maximise the sexual health benefits of the PrEP programme.”

NHS England initially refused to pay for PrEP, arguing that responsibility for HIV prevention lay with local authorities.

It agreed to fund the study at selected clinics after a High Court judge upheld a judicial review application challenging the legality of the original decision.

The treatment involves a pill containing a combination of two anti-HIV drugs, emtricitabine and tenofovir, taken daily or around the time of sexual activity.

A spokeswoman for NHS England said: “While it would be wrong to prejudge the PrEP Impact trial, it is already expanding with the number of places available increasing this year by 3,000 to 13,000.

“The NHS will look at evidence from the trial to expand prevention services in the most effective way.”

170,000 victims, and nobody takes the blame!! Typical of a nationalised health service…

Just as we need to change the onus of proof on Agricultural products, we need to do the same with non drug medical products. The licensing of the mesh repair products is a case in point, and all 4 health systems should be ashamed of not reporting side effects and complications systemically (all together). The reporting of such problems is just one reason for a large mutual in health. Devolution means smaller numbers and lower standards. The commissioners and the Trust Boards are all to blame, but so is central government. Will any careers be finished? They should be.. Mesh is a foreign body, and as such the default is rejection, and possible infection.

See the source image

Hernia mesh complications may have affected up to 170 000 patients, investigation finds ( BMJ 2018;362:k4104 )

Up to 170 000 patients who have had hernia mesh operations in the past six years could be experiencing complications, yet NHS trusts in England have no consistent policy for treatment or follow-up with patients, an investigation by the BBC’s Victoria Derbyshire programme has found.

Around 570 0000 hernia mesh operations have taken place in England over the past six years, figures from NHS Digital show. Leading surgeons think that the complication rate is between 12% and 30%, meaning that between 68 000 and 170 000 patients could have been adversely affected in this period.

Patients who had had hernia mesh operations told the programme about being in constant pain, unable to sleep, and finding it difficult to walk or even pick up a sock. Some patients said that they felt suicidal.

The Department of Health and Social Care and the Medicines and Healthcare Products Regulatory Agency (MHRA) continue to back the use of mesh for hernia repair. The use of surgical mesh for stress urinary incontinence is under ongoing review after it was suspended in July in response to pressure from campaigners and MPs.1 Campaigners are calling for a similar review into the use of hernia mesh.

Owen Smith, a Labour MP who chairs the all party parliamentary group on surgical mesh implants, said that he feared the UK could “potentially have another scandal on our hands.”

He added that the MHRA was not doing enough to listen to the experiences of patients affected. “It reflects the flawed system we have in place,” he said. “Neither the regulators nor the manufacturers have to follow-up on problems.”

Ulrike Muschaweck, a private hernia surgeon, told the programme that she used a suture technique instead of mesh for most hernia operations, but this method was dying out because young surgeons were rarely taught it. She said that she had performed 3000 mesh removals because of chronic pain—after which only two of the patients had not gone on to become “pain-free.”

Suzy Elneil, a consultant urogynaecologist who was a leading voice in the campaign to halt the use of vaginal mesh, said that the mesh used in hernia was the same product. She estimated that treating those who have had complications with hernia mesh would cost a minimum of £25 000 (€28 000; $33 000) a patient—a similar amount to that predicted for vaginal mesh complications. This includes the removal of the mesh, a further operation to treat the hernia, and follow-up care. She said that the manufacturers should be covering the cost rather than the NHS.

The Royal College of Surgeons pointed to a 2018 study, which found that both mesh and non-mesh hernia repairs were effective for patients and were not associated with different rates of chronic pain.2

A spokesperson for the college said that “complications range dramatically from minor and correctable irritations to the more serious complications highlighted [on the] programme. Complications can also occur with non-mesh hernia repairs and by not operating on a hernia at all.”

They said that the college and regulatory authorities would continue to listen to patients’ experiences. “It remains vital that surgeons continue to make patients aware of all the possible side effects associated with performing a hernia repair,” the spokesperson said.

Kath Sansom from campaign group Sling the Mesh told the programme that a lot of the studies into complications were flawed or had short follow-up times. Quality of life questionnaires, for example, asked only about whether the hernia was fixed and not about new onset pain or other complications.

In a statement, the MHRA said: “We have not had any evidence that would lead us to alter our stance on surgical mesh for hernia repairs or other surgical procedures for which they are used. The decision to use mesh should be made between patient and clinician, recognising the benefits and risks in the context of the conditions being treated and in line with NICE guidance.”

An MHRA spokesperson added, “We encourage anyone—patient, carer, or healthcare professional—who is aware of a complication after a medical device is implanted, to report to us via the yellow card scheme, regardless of how long ago the implant was inserted.”

… following hernia repair with an Ethicon Proceed patch have resulted in a product liability lawsuit against the manufacturer
This was caused by what should have been a simple 45-minute operation to fix a hernia … of patient filed lawsuits. “For the ..