Category Archives: Commissioning

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

The breaking up of the old “National” health service into the 5/6 different health services (If we include London) is a form of self harm in many ways. The benefits of a large mutual in health, where we cannot predict our future diseases, or our own “lottery of life” ticket, were fully understood by Aneurin Bevan.

The NHS Executive (England) announced 26th October: NHS ahead of schedule for procurement savings but this is still small savings in relation to the potential. The Logistics Manager, Supply Chain reports 30th October: NHS Supply Chain delivers £250mn of savings, nearing £300mn …But the “Public Finance” site 9th November reveals the truth in its concern to compare: DoH to rank NHS hospitals in ‘procurement league tables’. You have to believe in the power of the mutual to understand the reduction in risk, as well as the potential savings. Devolving powers is all very well, and “liberal”, but if it reduces life expectancy by increasing risk, reducing choice and purchasing power, and makes a Regions (such as Wales) bust then it is not a public good.  Imagine if we were so “liberal” as to give each citizen a health budget of their own? The benefits of mutuality are lost as those lucky enough to avoid disease choose to lead hedonistic lifestyles at the expense of the unlucky. The post-code lottery is reality, but nobody knows it until they are a victim. Dead patients don’t vote.

With the inefficiencies in mind, one wonders why London has been approved as the 6th health system in the UK? The only explanation I can believe is that it muddies the water even further: it allows more comparisons, and less choice. Politicians of course, with access to London will always have access to the best! For the rest of us it will be second rate care or a private plan/ purchase option.Image result for the mutual health cartoonI wonder if the youngsters understand the principles behind a mutual organisation? It is not hard to find examples which we revere such as the John Lewis partnership. The question of “what is the John Lewis Model” was addressed in the Guardian. If you want to read and then answer questions on a “business case study” the opportunity is here.  In Insurance, such as the old NHS, the advantages are clearer still…

Oliver Wright reports in the Times 20th November 2017: No cash bailout until you make savings, Hammond tells NHS ( a reality warning before the budget ).

Health service leaders have failed to keep their promise to save billions of pounds to spend on frontline services, Philip Hammond claimed yesterday, as he ruled out a budget bailout for the NHS.

The chancellor rejected calls by Simon Stevens, the chief executive of NHS England, for a £4 billion funding boost, saying that people running public services often claimed “Armageddon” if they did not get the money they wanted from a budget.

He warned that although the government might find some money for “particular pressure points” in the NHS it would not be at the scale demanded by Mr Stevens. The chancellor is understood to be prepared to find the money to fund limited pay rises for nurses and some capital investment programmes but there will be no significant increase in total NHS revenues.

Mr Hammond’s comments came after Mr Stevens said that the government should honour the pledge of the Vote Leave campaign and hand some of the money “saved” by Brexit to the NHS…….

Drawing on analysis by the Health Foundation, King’s Fund and Nuffield Trust charities, Mr Stevens suggested that the NHS needed about £4 billion more next year to prevent patient care from deteriorating.

Mr Hammond said that the government had already agreed to provide the NHS with an extra £10 billion by 2020 — a figure requested by Mr Stevens in his five-year plan.

“That plan is not being delivered,” Mr Hammond said. “We need to get it back on track.” He added: “In the run-up to budget, people running all kinds of services come to see us and they always have very large numbers that are absolutely essential, otherwise Armageddon will arrive.

“I don’t contest for one moment that the NHS is under pressure. We have been doing some very careful work with the Department of Health, with the NHS, to look at where those pressures are, to look at the capital needs of the NHS, to look at where the particular pressure points around targets are. And we will seek to address those in a sensible and measured and balanced way.”

His remarks about the five-year plan irritated NHS England, which sent out a series of tweets shortly after Mr Hammond was interviewed on The Andrew Marr Show on BBC One, citing “evidence” that Mr Stevens’s reforms were working. The shadow health secretary, Jonathan Ashworth, described Mr Hammond as out of touch. Mr Ashworth said that an extra £6 billion was needed to avert “Armageddon”.

He told Sunday With Niall Paterson on Sky: “It’s incredibly serious and if I may say so I’ve seen Philip Hammond doing interviews today, being dismissive of the calls for more money for the NHS, saying well you know it’s not going to be Armageddon.

“This is happening now, today, in the NHS, and if he doesn’t realise that, he’s completely out of touch. We are calling on the chancellor to put aside an extra £6 billion in this budget.”

NHS England declined to comment but is understood to reject suggestions that the plan it set out for NHS efficiency savings is not working.


Image result for the mutual health cartoon


The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

Devolution of health to Wales was a mistake?

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

The democratic deficit. Applies to health as well as devolution, and to leaving the EU. The first honest party should get public support.

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….

Stroke survivors ‘are dumped by the NHS’. Dead patients don’t vote, and those near death don’t appear to count…

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it


Bringing back fear, and suffering. A return to 19th century inequalities.. How quickly politicians destroyed what was the best safety net in the world?

The health service is becoming an apology for a service “In Place of Fear”:  A Free Health Service 1952 Chapter 5 of In Place of Fear. Aneurin Bevan is in shame.. No politician seems to be able to address the fundamentals – “What is a health service for, and what is it better that it does not cover/.” The temptation to ration services which cause the least media riot is extreme. Different Commissioning Groups will take different decisions depending on what they think they can get away with. The mentally ill, prisons, the elderly disabled and the demented are soft targets, but now even the joint replacements have 3 year waits, and therefore increased risk of obesity and heart attacks.. We only pretend to offer a palliative and terminal care service free as these have to be covered by charities. Its going to get worse. Suffering will increase. Inequalities will rise, along with waiting lists, and the life expectancies of the different regions will only become evident retrospectively when the WHO reports. If Nick Triggle for BBC News 7th November reports: NHS staff ‘working on edge of safety’ then you can take it that it is already unsafe.

BBC News reported 8th November: Deaths used as ‘propaganda’ for Huddersfield hospital shake-up ( Will the elderly in Huddersfield get the same service if they have a heart attack away from the specialist unit?) 

Chris Smyth reported in the Times 7th November A&E unit for elderly to tackle waiting times and bed blockingwill Norwich citizens get the same emergency care ? This sounds a better solution to the elderly tsunami than the Huddersfield suggestion. 

Image result for health unsafe cartoon

Most importantly, Simon Stevens is warning the politicians, and is having to be disingenuous in his own use of media. He knows that a cash boost is just window dressing. It is staff that matter: 

Million more on waiting lists unless NHS gets £4bn boost, Simon Stevens warns (November 9th in the Times) and            Patients in Peru get more time with their GP than in Britain

Honour Brexit cash pledge for NHS, says Simon Stevens (November 8th in the Times)

The Observer lead article on 7th January was: The Observer view on the crisis in the NHS

It warned us again on 22nd October: Observer view on NHS funding and ends:

…”Ward staff are becoming increasingly stretched due to a shortage of nurses, compromising the quality of care. The independent health thinktank, the King’s Fund, has warned that health trusts across the country are planning on cutting too many beds from hospitals in their areas, further restricting capacity in a system whose average bed occupancy was 92% between January and March this year – far above the safe level of 85%.

The NHS is far from perfect: the terrible quality of care once on offer at Mid Staffs is testament to that. But it has been declared one of the best health systems internationally, despite spending much less per head than many other wealthy countries. That is being jeopardised by the government’s sustained underfunding.

There are difficult choices the government should be making in the forthcoming budget to alleviate the pressure on public services from hospitals, to prisons. At the very least, it should abandon all further planned tax cuts, and divert the savings to patching up some of the damage that has already been done. But the risk is that just as Brexit will continue to dominate the political debate in the years to come, so it will frame the economic decisions that will shape the health of our public services over the next decade.

Things are bad, but the depressing truth is, the worst could yet be to come.”

Carolyn Wickware in Pulse 3rd November reports: Half of CCGs are planning to increase NHS rationing, finds survey

Child cancer results improving. In a “cradle to grave” Health Service we are not doing badly at cradles.. but we are doing badly as patients approach their grave.

Desperate situations require desperate measures. Virtual consultations are without evidence, risk GP burnout, errors for patients, and increased litigation costs..

Update 8th November 2017: Huw Pym 2 days ago for the BBC News: Online GP consultation: Opportunity or threat?

NHSreality has told readers that it is going to get worse. The evidence of a fractured system is in front of us all. When I was a trainee GP in Sussex, my Trainer had a weakness: when under time pressure he would not examine patients. The result was the odd error, late diagnosis or mistake. Patients in the 1970s did not expect perfection, and he got away with it, because he knew every patient and their families. Disgruntled patients are much more likely to sue and complain about someone they do not know, as is the case in todays Primary Care.  So over the patients head, on the wall behind them, was a reminder: “Every patient deserves an examination”. This helped him to reflect and to avoid playing to his weakness. Now we have a government encouraging “no examination”. As with telephone triage, all that happens is the demand and expectations will rise. Many GPs tried triage and found they could not live with the increased uncertainty of not examining the patient. Some doctors will take to the change naturally, until they have a complaint and litigation gets involved. Desperate situations may require desperate measures, especially in rural and remote areas without doctors. But virtual consultations risk GP burnout, errors for patients, and increased litigation costs, without any evidence it is any better.. The young and healthy are not the patients who take up most time, but they still deserve an examination.. The Times letters 7th November are correct…. and “simple needs” are what patients should be trained to look after themselves. 

Image result for smartphone cartoon

Chris Smyth reports in The times 6th November: The doctor will see you now: NHS starts smartphone consultations

Millions of NHS patients will be offered the chance to consult family doctors around the clock by smartphone as the first “virtual GP” goes live.

Video consultations are promised within two hours by doctors who say that they are finally bringing the health service into the digital age. However, the project has raised fears among senior GPs that it will create a two-tier NHS, disrupting personal relationships and siphoning off fit, young patients, leaving traditional practices to deal with the frail, elderly and mentally ill.

However, NHS bosses have signed off the scheme, saying that “one size does not fit all” for GP care.

Mobasher Butt, a partner in the “GP at Hand” service, said: “We do everything from grocery shopping to our banking online yet when it comes to our health, it can still take weeks to see a doctor and often means taking time off work. With the NHS making use of this technology, we can put patients in front of a GP within minutes on their phone.”

The scheme involves a deal between an ordinary NHS surgery in Fulham, west London, and Babylon, a technology company that offers a smartphone GP consultation service to private patients.

Like any other NHS GP practice, GP at Hand is paid a flat rate for every patient who is registered with it, but uses the money to sub-contract to Babylon, saying that it will not cost the health service “a penny more” than traditional surgeries.

“I think this is the beginning of the end for the old-fashioned way we use healthcare,” Ali Parsa, founder of Babylon, said. “It’s like going from a Nokia to an iPhone. Maybe next year 10 per cent of people will have one and in five years it will be everybody.” He argued that using a symptom-checking artificial intelligence chatbot and more efficient systems could free GPs from paperwork, allowing them to see patients more quickly. “I think normal NHS GPs will see this works and convert to doing things this way,” he said.

After a pilot scheme involving 3,000 patients, the service is opening to any NHS patient in London who wishes to register. If a patient needs a face-to-face appointment, they must travel to clinics in commuter hubs. The virtual practice has set no limit on how many patients it will accept, saying that this will be guided by how many it can safely treat.

Matt Noble, another of the GP partners, said that the promise of seeing an NHS doctor within two hours at any time would not lead to the service being overwhelmed by minor ailments. “People do value the fact that they can see a GP when they want to, but it doesn’t lead to a massive increase in demand. What it does do is ensure people are seen much quicker,” he said.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that despite benefits for commuters it could make family doctor shortages worse by “luring GPs away” from surgeries.

She said: “We are really worried that schemes like this are creating a twin-track approach to NHS general practice and that patients are being ‘cherry-picked’, which could actually increase the pressures on traditional GPs.”

The service accepts that it is not necessarily suitable for people with dementia, mental health conditions or who are pregnant, but Professor Stokes-Lampard said that these were “the essence of general practice”.

NHS England said: “GP practices are right to carefully test technologies that can improve free NHS services for patients while also freeing staff time.”

Image result for health smartphone cartoon

This is the second time Ali Parsa has tried to shake up the National Health Service (Chris Smyth writes). He sometimes struggles to hide his frustration with inertia in the NHS and makes no secret of his view that within a few years computers will perform better than doctors at making diagnoses.

Mr Parsa is also undaunted by the experience of Circle Health, the company he founded after leaving finance. Billed as the John Lewis of health because it was half-owned by its staff, Circle became the first private company to take over management of an NHS hospital, Hinchingbrooke in Cambridgeshire.

However, despite positive initial reviews, Mr Parsa was ousted amid disappointing financial results. The hospital was then slated by inspectors before Circle abandoned the contract, saying it was no longer financially viable. Mr Parsa insists that this time it will be different.

Q&A: Don’t smartphone GPs already exist?
Yes, but this is about letting patients make it their main NHS GP.

How can this service offer appointments so quickly?
Babylon says that 40 per cent of queries through the app are dealt with by an AI symptom checker.

Surely some consultations need to be face-to-face?
The service estimates that only about a fifth of problems need a doctor physically present.

How can the NHS afford to do this?
GPs are paid an average of £151 a year for each registered patient but Babylon charges private patients £50 a year.

Can I get this service without switching GPs?
No but Babylon is hoping that demand for it will force other GP practices to strike similar deals.

What about the elderly?
GP at Hand concedes that its service will not be suitable for some patients.

Julia Kellewe on Sunday 2nd August in the Guardian: Dr Now: the smartphone app that puts you in touch with a GP – for a fee – New health apps exploit gaps in overstretched NHS by offering subscribers virtual consultation with a GP

Chris Smyth reports 7th November: Virtual surgeries ‘favour young and generally healthy’

Virtual GPs and consulting by smartphone (Times letters 7th November)

Sir, In your report (Nov 6) on the NHS starting consultation by smartphone, Ali Parsa, the founder of Babylon, says that “this is the beginning of the end for the old-fashioned way we use healthcare”. He hopes that in five years everyone will be consulting by smartphone. This is my idea of a nightmare. Some patients will like a quick call to an anonymous GP but this is likely to increase demand on the NHS from people who would not have sought help in the first place.

Previous research consistently shows that new interventions intended to reduce demand on regular NHS services — such as phone consulting, walk-in clinics and NHS Direct — may be popular with patients but they tend to increase the overall workload. For those who most need the NHS (the elderly, the sick and the mentally ill) the smartphone consultation will be a poor shadow of a personal interaction with a doctor they trust. We should allow Babylon to offer this additional service but we should not imagine that it will ease the demand on NHS services or be a substitute for the type of doctor-patient relationship that people value most.
Martin Roland

Emeritus professor of health services research, University of Cambridge

Sir, “One size does not fit all” for GP care, as your report rightly says. GPs are contractually obliged to accept everyone living within their practice boundary on to their list except in very unusual circumstances. If I were allowed to cherry-pick 3,000 fit and healthy young adults and charge £50 a year I would do very nicely and at the same time improve my golf. However, I do not think I could look local colleagues in the eye who would be left struggling with the complex chronic conditions that are the core business of GPs.
Dr Andrew Holden (GP)

Petersfield, Hants

Sir, The relationship between doctor and patient is essential in clinical practice. Knowledge of clinical history and physical examination of the patient are equally important. Further, a doctor should be able to understand and share the feelings of the patient, which can only be achieved during a consultation in person. How does a smartphone app let a doctor examine a toddler with severe earache?
Dr Sam Banik, FRCPath

London N10

Sir, Providing convenient access to a GP is laudable, and the “GP at Hand” service, via a smartphone app, is something that many patients might love to have. It is worrying, however, that patients will have to transfer their NHS registration from local GP to virtual provider. This could have serious unintended consequences.

The GP at Hand service targets those with simple needs. But needs change: what happens to the person who develops a complex condition or needs in-depth investigations?

Meanwhile, local GP practices will lose the income from those relatively “well” patients, and have to manage a higher ratio of people with complex needs, putting quality in jeopardy.
Don Redding

Director of policy, National Voices, a coalition of 160 health & care charities

Sir, I assume the government will give a grant to those who cannot afford to buy a smartphone. This will be the unemployed and pensioners; the latter are among the most frequent visitors to their GP. Also, such patients will need lessons on how to use a smartphone. Perhaps the NHS will subsidise these costs from the money that it will save.
Thea Valman

London NW11

Image result for health smartphone cartoon

Legal threat to NHS for using cheap drug Avastin

Sometimes rationing can be a rational process, and the use of Avastin is such a case. My mother has it in Norwich, and so, provided it is equivalent to the other products, everyone should have it. In New Zealand the rule is that you have the cheapest product on the state, and if you choose anything different you pay for it. Commissioners need protection from this risk, and the law needs changing.

Chris Smyth reports in the Times 1st September 2017: Legal threat to NHS for using cheap drug Avastin

Pharmaceutical companies have threatened legal action against the NHS for offering patients a cheaper eye drug that could save the health service hundreds of millions of pounds.

Ministers have hit back, demanding that competition regulators investigate whether collusion between the companies is blocking doctors from prescribing the cheaper medicine, a practice the companies have previously denied.

The row centres on Avastin, a cancer drug that has proved just as effective as Lucentis and Eylea, two branded drugs, in treating wet age-related macular degeneration, a condition that affects 600,000 people in Britain.

Avastin costs a tenth of the other two drugs but, unlike them, is not licensed as an eye treatment, making doctors reluctant to prescribe it because it would put them at risk of disciplinary action.

The National Institute for Health and Care Excellence has judged that Avastin is just as safe and effective as the other drugs but said it cannot recommend an unlicensed treatment.

However, 12 health groups in the northeast have decided to offer it to patients, explaining that it would save money and avoid the need to ration other treatments, such as IVF.

“Every patient who chooses the cheaper alternative drug will help the NHS to fund important medical treatment in other areas,” David Hambleton, chief executive of South Tyneside clinical commissioning group, writes in The BMJ. “Drug companies should not dictate which treatments are available.”

However, the bodies have been threatened with a judicial review by Novartis and Bayer, which sell the licensed drugs, claiming that using unlicensed ones is against British and EU law and “runs the risk of setting a precedent that undermines the regulatory framework and NHS constitution”.

Nationwide, half a million injections of the eye drugs are given each year and according to one estimate, if all doctors switched to Avastin, the NHS would save £450 million a year. However, officials say this does not include discounts, with true savings about £100 million.

Julie Wood, the chief executive of NHS Clinical Commissioners, which represents local funding groups, said: “We cannot afford to ignore the savings of at least £100 million per annum.”

Roche, which makes Avastin, has not applied to license it for eye treatment. The Department of Health has asked the Competition and Markets Authority to look into why this is, citing financial links between Roche and Novartis, which makes Lucentis.

Novartis said in a statement that the northeast policy was misleading doctors. “Unlicensed medicines have not undergone the same regulatory scrutiny as licensed medicines,” it insisted.

Roche said it could not comment while the legal case was continuing.


Counting the cost: NHS cuts to cataract surgery can be fatal

We were made with two eyes, and two ears for a purpose. Reducing vision to one eye means there is less visual stimulation, and the same is true for only one ear or hearing aid. Besides the falls and accidents, there is a possible dementia potential…

In the kingdom of the blind, the one-eyed man is king. - Desiderius Erasmus

Chris Smyth reporting in the Times October 26th 2017: Counting the cost: NHS cuts to cataract surgery can be fatal

If analysis of cost effectiveness is a little technical for most patients, then it does not get any starker than this: cutting back on cataract surgery could cost lives.

The latest research from the US does not prove that fixing cataracts directly cuts the risk of early death by 60 per cent — but patients whose cataracts are not treated are known to injure themselves more and generally disengage from the world. It is powerfully plausible that for some this proves fatal.

The study appears just as the National Institute for Health and Care Excellence publishes guidelines that tell the NHS that rationing is unjustified. Its calculations are unequivocal: fixing cataracts is almost always a good use of NHS money.

The problem is that the NHS’s resources are being spread ever thinner. It is striking that health officials no longer bother to dispute the evidence nor claim that their policies are not really about cost cutting. With admirable honesty, they now simply say they cannot afford to treat everyone who needs it, even for something as basic as 20-minute cataract surgery. Even if it means those patients are more likely to die early.

So far voters have tacitly accepted this. The big political question is: for how much longer?

The Telegraph: Stop rationing cataracts until patients are nearly blind, NHS warned

The Mail: End of the cataract postcode lottery: NHS are told to halt rationing

Doctors forced to plead with NHS for treatments for patients, BMJ finds …Growing healthcare rationing means GPs are having to submit exceptional requests for treatments including cataract removals and new hips and knees

Many NHS trusts ‘rationing cataract surgery’ – BBC News

Hearing loss and dementia: more research is needed. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us …


Bullying is a sign of desperation. It is caused by circumstances.. These will get worse… Dead patients don’t vote…

The temperature is rising in some parts of the country. Services are failing as doctors leave, and now patients also are “leaving” to get better treatment abroad. Polly Toynbee is correct, but although the doctors are leaving, and commissioners and those that remain know what is happening, the politicians are protected by large incomes and private options. Surgeons and administrators don’t start off as bullies. It is circumstances that drive them to desperate measures. In North Wales the GPs are at desperation level: GP surgery blasts ‘bullying’ health board over claim it’s ‘at risk’  – Betsi chiefs deny claims they want to ‘destroy independent general practice’ across North Wales (Steve Bagnall reports) 

Image result for nhs bully cartoon

In Northern Ireland BBC News reports: “NHS surgery waits run into years in Northern Ireland” and NI has never met key NHS cancer target

In Scotland the Telegraph: Bed blocking costs Scottish NHS more than £100 million a year and The Times Daniel Sanderson reports: ‘Brain drain’ as doctors abandon Scottish NHS in their thousands

And in the Telegraph more bullying, this time by Surgeons: Badly-behaved surgeons are ​putting patients’ lives in danger ​due to ‘culture of bullying’, report finds 

Tom Martin in the Express 23rd October reports: NHS crisis: SNP warned over doctor ‘brain drain’ which has seen THOUSANDS moving abroad – MINISTERS have been urged to tackle a medical “brain drain” amid warnings up to 3,000 doctors have quit Scotland’s NHS to work abroad over the past decade.

Laura Donnelly in the Telegraph reports 22nd October: Soaring numbers flying abroad for medical care as NHS lists lengthen 

The number of patients leaving Britain and flying overseas for medical treatment has trebled as NHS waiting times reach a record high, a Telegraph investigation has revealed.

Government data shows the number of people going abroad for healthcare has increased from 48,000 in 2014 to almost 144,000 last year as the health service struggles to cope with demand.

Polly Toynbee has it right when she writes in the Guardina 17th October: While all eyes look to Brexit, our NHS is about to collapse

Image result for nhs bully cartoon

Measure Cancer Mortality rather than Cancer Survival rates. Invidious differences between UK Health Systems ..

The waiting lists differential in the 4 UK health systems will become evident in mortality and morbidity. Different regions of the UK ration differently, and the results will become evident to a discontented public. We are all in the same tax system, but our life expectancies are different depending on Post Code. Waiting for 3 years for cold surgery will usually increase other risks as well as ones related to the condition.

Northern has never met key NHS cancer target reports Marie-Louise Connolly for the BBC News today 18th October. 

Previously, yesterday BBC reported: NHS surgery waits run into years in Northern Ireland

Walesonline Mark Smith reports 15th September 2017 on Avastin being unavailable in Wales.

Cancer survival rates

Closing in on cancer” (September 16th) followed the reasoning that increased survival rates mean better cures. You did not take the lead-time bias into account. This occurs when a disease is diagnosed early or by screening before it becomes apparent. Early diagnosis and screening mean that the patient lives longer with the disease and the survival rate increases, independently of any potential treatment.

In the case of prostate cancer, more screening and earlier diagnosis take place in America than in Britain and explain much of the different survival rates. Cancer mortality is a better measure for improved treatment because it indicates how many people die from a given cancer.


Check NHS cancer, A&E and operations targets in your area

Image result for cancer cartoon