Category Archives: Commissioning

Chronic pain relief and Psychiatric conditions all need therapists… They have been rationed out.

Those of us in the porfession for many years know how easily a patient can transfer from acute post operative pain to chronic pain if they are not warned of the risks, educated, and “buy in” to the speedy reduction of painkillers and exercise. However, chronic pain relief and psychiatric conditions all need therapists… and these vital people have been rationed out. We should take a leaf out of the French solution, where only psychotic demented patients get drugs, and the money saved is spent on therapists. Since much of this “chronic pain” is iatrogenic, as a nation (and commissioners), we need to face up.. Without changes in the rules though, the commissioners and managers are impotent.

Sir, I note the recommendations from the National Institute for Health and Care Excellence about chronic pain (“Don’t give paracetamol to patients, doctors told”, Aug 4) but am surprised that the Nice guidance committee was chaired by a psychiatrist, given that we have a Faculty of Pain Medicine. As a retired consultant in pain medicine I developed one of the early multidisciplinary pain clinics. This included psychological and supportive therapy input emphasising the minimal medication approach with pain behaviour techniques, unless there was an underlying specific problem to target.

However, as so often is the case, the acute and surgical specialties have received the principal funding in the health service while chronic illness has had “Cinderella” recognition. On the other hand, patients continue to visit primary and secondary care on a long-term basis. It is to be hoped that this report might increase resources, but one wonders if the therapists are available.
Dr Richard Atkinson

Ret’d consultant in pain medicine, Sheffield

Katie Gibbons reports 4th August: Don’t give paracetamol to chronic pain patients, doctors told – New advice prescribes exercise for chronic pain

Sensible rationing of dementia drugs – a lead from France

Patients were left in pain for decades by health scandals

Rationing in the recent news. Obscene denial of the truth by politicians…There’s a painful list of conditions we are no longer treating on the NHS

A reversal of raioning for SE Londoners needing IVF

Jamie Bennett-Ness reports 24th Jan 2020 for Newsshopper: Discriminatory ban on single women in SE London getting NHS-funded IVF is reversed

NHS bodies in south east London have announced they are reversing a policy which denied single women from receiving funded-IVF treatment because of the burden created by single parents.

The policy, which saw single women denied funded IVF servies because of the “burden on society” caused by single-parent families, was branded “discriminatory and cruel” by one Labour MP.

NHS South East London, which includes the NHS commissioning groups for Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark, pledged to carry out a review of their IVF policy following criticism……


Ways of reducing the bill for NHS negligence – The perverse incentives and outcomes …

Every doctor and student of medical systems needs to understand the perverse incentive. I define this as a “driver within a system that works against the overall objective of the system”. Claims for medical Negligence in our tort driven system are necessary to arrest or slow down the continuing decline in standards. Unfortunately Dr Barton is correct: the 4 health services have lawyers who are salaried and paid win or lose, and 80% of claims result in success! The argument for no fault compensation has been addressed properly in NZ and several other countries, and Australia appears to have found a half way house…

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Times letters 24th Jan 2020: Ways of reducing the bill for NHS negligence

Sir, Your article “£4bn budget for legal fees in NHS negligence claims” (Jan 22) points out that the health service faces legal costs of £4.3 billion as part of a compensation bill for clinical negligence claims of £83 billion. The extent of this crisis cannot be overemphasised, as over the past three years the bill appears to have risen from £54 billion, according to the Department of Health. Apart from the usual platitudes about being careful, no one appears to be interested in addressing this parlous situation.

I previously worked for seven years in Australia, where this became a big problem and was addressed by an act of parliament transferring the liability risk away from the provider, unless it was ruled criminal negligence. This has led to a year-on-year fall of medical protection and indemnity fees for colleagues in Australia, while those in the UK have risen inexorably, providing yet another reason why doctors are giving up in droves and taking early retirement.

The start of a new government offers an ideal moment to address this festering sore on the NHS’s future.
Professor Angus Dalgleish

Foundation professor of oncology, University of London

Sir, As medical litigation costs spiral and threaten the future of the NHS, the case for a no-fault compensation system becomes overwhelming. At present, if a patient cannot prove medical negligence, they will receive no financial compensation — the decision sometimes having more to do with inadequate record-keeping than true clinical incompetence or negligence. As a result, two patients may have identical medical injuries but one will receive nothing whereas the other may be well compensated after perhaps years of litigation.

New Zealand has had a successful no-fault compensation scheme since 1974, with changes in 2005 ironing out some of its early anomalies, resulting in most claims being resolved in weeks rather than years. Litigation lawyers are the only people benefiting from the system in the UK.
Dr Andrew Quayle

Retired GP, Martock, Somerset

Sir, The cost of medical negligence (or accidents) is indeed high, but the possibility that the size of a giant claim might be reduced means that many cases end up in court because the legal fees justify an expensive defence. However, with court and legal costs of about £2,800 per day on top of barristers’ and solicitors’ fees it is often cheaper for an NHS Trust to settle a little case for a small sum than to defend it. While this is often done without an admission of liability it is open to abuse, because once word gets around it may generate frivolous or spurious “me too” claims that result in a payment of a few hundred pounds without many questions being asked. The system needs to address this as well as the top-end settlements.
Dr Andrew Bamji

Rye, E Sussex

Sir, NHS legal costs are inflated partly because of perverse incentives. NHS lawyers are paid win or lose, which encourages “deny, delay, defend” behaviour and promotes speculative defences. By contrast, claimant lawyers are generally paid “no win, no fee”; payment is by result, which imposes commercial prudence. This is amply borne out by NHS Resolution figures which show that compensation is paid in 80 per cent of cases where proceedings are issued. NHS lawyers should be paid by result and not rewarded for failure.
Dr Anthony Barton
Solicitor, Medical Negligence Team

Professional Liability Insurance : Market Global Report Jan 2020 – Fusion Science Academy

New York Telecast: Global Liability Insurance Market Status (2015-2019) and Forecast (2020-2024)

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Lexicology: Wright Hassall LLP The most notable medical liability case in 2019

United Kingdom August 27 2019

The NHS is facing an existential crisis. The negotiations over junior doctors’ pay and conditions and widespread dissatisfaction among GPs, combined with a £2.45bn overspend by NHS Trusts, is impacting on patient care. The NHS is treating more patients than ever before, including a rapidly growing number of elderly people whose care, in many cases, is caught in a Mexican stand-off between the NHS and social services.

The NHS announced it has paid out more than £1.63 billion in damages for medical negligence in 2017/18; this is an increase from £1.08 billion in 2016/17 with the highest number of claims coming from emergency medicine. The number of claims made as a whole has decreased slightly (0.12%), but the cost to the NHS continues to increase.

The cases outlined below are some of our most notable and an indication of what can go wrong when the caring services come under pressure – and these are just the tip of the iceberg……

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Update 29th Jan Times letters 2020:

Sir, I would be delighted to accept the challenge from Dr Anthony Barton that NHS lawyers should be paid by results (letter, Jan 24) so long as in return he accepts that claimant lawyers should pay NHS costs when they lose. This should include the more than 80 per cent of cases that never reach court, often because they were frivolous claims which were pursued regardless of commercial prudence. These nevertheless incur NHS legal costs and waste vast amounts of NHS staff time, which often leaves them inadequate time to care for their patients.
Martin Sheppard

Retired NHS consultant
Haverfordwest, Pembrokeshire


Sensible rationing of dementia drugs – a lead from France

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

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

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

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

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

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

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

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

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

Little benefit

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

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

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

Change of emphasis

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

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

Medworm: Re: France removes state funding for dementia drugs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


20190746 thedoctor January issue 17

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

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

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

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

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

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

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

Read the BMA report

A&E is a National Accident waiting to be repeated over and over again… Northern Ireland is worse, but there are two tier waits in parts of Wales as well.

Not only is the standard variable, and post coded so that the outcome is rather random, but its getting worse. No amount of money can replace staff who are no longer available. A&E is a National Accident waiting to be repeated over and over again… This is for England. There are no comparable figures for the other dispensations where figures are far worse. Even the 4 hour waiting standard does not imply seeing a responsible diagnostician, but a triage nurse! Northern Ireland is worst of all… There are “two tier” waiting lists in Wales as well, particularly at Oswestry. Because money moves with the patient, and NI cannot pay, choice of going elsewhere is being denied…

Carol Hylton on 3rd December 2019 wrote to the BBC asking “Election 2019: What will you do about A&E provision in West Hertfordshire?”.

Nick Triggle revealed 13th December on BBC News Website: Every major A&E misses wait target for first time

Every major A&E unit in England has failed to hit its four-hour waiting time target for the first time, NHS figures show.

All 118 units fell below the 95% threshold in November as the NHS posted its worst performance since targets were introduced more than a decade ago.

Alongside the growing waits in A&E, the data showed there were record delays finding beds for the sickest patients.

The numbers on waiting lists for routine care also hit an all-time high.

NHS England medical director Prof Stephen Powis said the NHS was facing a “very tough few months”.

He said staff were “pulling out all the stops” but added that increasing demand, particularly among patients with complex illnesses, and a shortage of staff were making it difficult.

Nigel Edwards, of the Nuffield Trust think tank, said the figures were “very worrying” as the coldest months were still to come.

He said: “Returning to Downing Street, Boris Johnson has been met by an immediate reminder of the grim winter his government faces in the English NHS.”

Worst ever month for A&E

Overall just 81.4% of A&E patients were seen within four hours last month – that is the worst performance since the target was introduced in 2004.

The figures include those seen in major A&E units, as well as minor-injury units and walk-in centres….

BBC NI reports today 16th December: Stormont stalemate: Medical leaders call for end to deadlock

Tomáš Tengely-Evans reports in the Socialist WOrker today 16th December: Historic Strike in Northern Ireland NHS  as waiting lists for all surgery beat all records. Allan Preston for the Belfast Telegraph November 23rd reports on “Waiting times that would not be tolerated elsewhere : Steve Aitken, Ulster Unionist Leader.

November 20th: Northern Ireland’s healthcare system is broken

and Waiting lists ‘two-tier health system leaves poor behind’

The Belfast Telegraph Today: Block on Northern Ireland patient transfers to GB to help tackle …

and the staff are demoralised: Northern Ireland hospitals cancel operations due to staff shortage…


Privatisation? Disclosures declaring an interest are not restricted to research or organisations; they also apply to individauls.

Aside from the fact that there is no NHS any longer, the question of how many services should be privatised is important. We know that more efficiency results from private provision, as profit has to be made. However, there may be a conflict between the short and long term, with privatisation simply helping to meet budget constraints, rather than raise longer term standards. Should Health Boards and Trusts be honest about this? Commissioners will always be tempted to ration by privatisation. 

In General Practice the meeting of reps is becoming rarer, but it does happen, and meetings are still subsidised. The reward for this is access to busy professionals, and influencing them.

In normal daily practice a GP, Consultant or a Physiotherapist may be restricted in the service provision that they deliver. If they know what they provide is inferior to what they would like, and if they are putting the patient at the centre of their concern, should they not come clean and declare the deficit? This is a disclusure that might not be so popular as it would expose the shortfalls and enhance private practice.

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The Nuffield Trust asks the rhetorical question “Is the NHS being privatised”? in its recent report. The BMJ reflects this in its own report; Is the NHS being privatised?

The LibDem approach was that the question was wrong….

In the BMJ Carl Henegan and Margaret McCartney argue in commentary that we need to record and manage conflicts of interest across healthcare. Decaring interests and restoring trust in medicine. BMJ 2019;367:l6236

A retrospective study , using data from the French Transparency in Healthcare and National Health Insurance databases, reports that GPs who received no gifts prescribed cheaper generic drugs and had better drug prescribing efficiency indicators than those in receipt of gifts….

the value of the Transparency in Healthcare database. Without it, gifts to French GPs from pharmaceutical companies would not be readily accessible for analysis.

….The French “Sunshine Act” (The Loi Bertrand) established the Transparency in Healthcare database that became publicly accessible in 2018. The law requires health products companies to disclose agreements with healthcare providers publicly within 15 days. Any benefit to the healthcare provider exceeding a value of €10.00 (£8.60) in cash or in kind must be disclosed within six months.15 Although no direct causal link was found between the gifts received and GP prescribing, Goupil and colleagues’ study shows the importance of disclosure legislation: gifts to French GPs are common (36 232/41 257 GPs (87.8%) listed in the database had received gifts) and are associated with poorer prescribing practices and increased costs to the healthcare system.

The influence of organisational or individual conflicts on clinical practice demands a system-wide strategy to manage and mitigate such conflicts.

Gareth Iacobucci in the BMJ asks the same question and gives a graphic answer: Is the NHS being privatised? BMJ 2019;367:l6376

The NHS is shaping up to be a key battleground in the upcoming UK general election….

How much has private provision in the NHS increased since 2012?

In 2014 The BMJ found evidence of a big increase in the number of contracts being awarded to private firms after the 2012 act (fig 1).6 But this didn’t translate into significantly increased spending on private providers, as many contracts were small in value.

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The best and worst places to have your hip operation (In England. No global comparisons)

All hail the honesty of the Health Services Journal. Unfortunately they are not allowed to advocate rationing and freedom of speech is limited. But the stories they expose and the issues they address are relevant to  us all. There are many problems, which include poor staff hygiene, poor hospital cleaning, inadequate training, and above all, the failure to separate cold orthopaedics from “dirty” hospital cases where infected wounds and guts are operated on in the same building. The old fashioned DGH has served its time for hips and knees. But why are there no comparable figures for the Scottish, Welsh and Irish Hospitals? Because there is no “National” health service, I as a taxpaying citizen in Wales cannot find out how my service performs compared to England. Indeed, I would like to know comparisons with other countries, and with the private sector. Only with such data can patients be properly advised, and of course they also need to be “led” ask the right questions! Rationing by lack of choice, restriction to a local DGH, and long waiting lists, can only lead to more infections and complications (increased obesity and heart attacks from immobility). Should your GP air these issues when you choose to be referred? Of course he should even if it means telling the truth about your local services.

In the Times Monday 14th October a short report ( not in the on line edition) reads:

Repeat Offenders

The hospitals with the worst records for having to repeat knee and hip surgery on patients are revealed in a report in the Health Services Journal. The sick/ Six NHS hospitals are Southampton General, Milton Keynes, Chichester, Wansbeck, (Northumbria), Weston General, Somerset, and Ormskirk DGH Lancashire. Overweight patients, high infection levels and shortcomings in supervising trainees are blamed for poor performance.

In the Telegraph they report: “Revealed: the best and the worst places to have your hip operation”.

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites


Incremental neglect tips over into significant and costly malfunction, as rationing is denied but extended..

The damning statements from the finance officers show how neglect and denial have built up to a point where it will take 15 years, and the importing of many overseas nurses and doctors to even start to put our 4 health services right. Since devolution has failed in Wales it will be even harder here, where I am based. “…..Incremental neglect tips over into significant and costly malfunction, and opportunities for strategic renewal and improvement are being squandered. Many interviewees identified ways that their trusts could better manage their capital investment programme, but these were eclipsed by the near-universal call for increased funding and a relaxation of central controls. 

Iestin Williams reports for the Health Foundation 8th March 2019: Views of NHS finance officers on limited capital.  see below…

Laura Donelly on 28th May 2019 in the Telegraph reports: A doubling in rationing of cataract surgery

BMJ 2017; 358 doi: (Published 04 July 2017) Cite this as: BMJ 2017;358:j3190

Laura Donelly in the Telegraph 11th August 2018: Numbers “going private” for surgery soaring as NHS rationing deepens.

Nick Triggle for BBC News 4th July 2017: NHS ‘rationing leaves patients in pain’

Pressure on NHS finances drives new wave of postcode rationing
(Published 04 July 2017)  BMJ 2017;358:j3190

[PDF] NHS Rationing and the Law. Warwick Heale. MA Medical Ethics. Interest in legal and ethical issues in treatment funding decisions.

Iestin Williams reports for the Health Foundation 8th March 2019: Views of NHS finance officers on limited capital.

Fixing leaky roofs, servicing ageing scanners and updating antique IT systems – the maintenance of capital infrastructure in the NHS isn’t the most enthralling of topics, and it’s generally only talked about when things start to go wrong. However, recent warnings about the lack of NHS capital investment and controls on capital spending by trusts have put this issue very much in the spotlight.

At a national level, we know that for some time now, money has been diverted towards the day-to-day costs of health care and away from capital budgets, leaving them severely squeezed. However, less is known about what this means for the trusts affected and the services they provide. We tried to find out more by speaking to finance directors at NHS trusts across England.

Squeezed to breaking point?

The trusts involved in our study were clearly feeling the financial pinch. In itself, this is nothing new. For example, taking out loans to pay for new IT systems or delaying the overhaul of outdated estates are commonplace. However, when basic maintenance work starts to be repeatedly postponed, the concerns voiced become a little more insistent. This was the tone of many of our interviews. We were struck by the prominence of the word ‘crisis’ – one not used lightly by seasoned finance personnel.


The squeeze on budgets has necessitated tough decisions about what to fund and what not to fund, and in what order. As a result, all but the most urgent of capital plans were frequently being abandoned or at least put on hold. In many cases, considerations around efficiency and improvement have been crowded out by more immediate concerns over safety and service viability. However, while this has mitigated the short-term impacts on patients and services, finance directors frequently lamented the potential long-term harm. In short, organisations were engaged in reactive rationing, rather than proactive priority setting.

Navigating the system

Interviewees described a much-changed environment in which sources of funding they had previously used for major capital projects were increasingly unavailable. Many trusts have found themselves unable to generate revenues to pay for capital projects, and were frustrated by the central financial controls imposed upon them. Others argued that the process for applying for centrally held NHS funds, including through partnerships arrangements such as STPs, was increasingly complex and inaccessible. Opportunism – for example, in the form of asset sales and charitable fund raising – offered only a partial solution to those trusts with access to these options.

All these factors are building towards something of a ‘perfect storm’, in which incremental neglect tips over into significant and costly malfunction, and opportunities for strategic renewal and improvement are being squandered. Many interviewees identified ways that their trusts could better manage their capital investment programme, but these were eclipsed by the near-universal call for increased funding and a relaxation of central controls.

Dr Iestyn Williams (@IestynPWilliams) is a Reader in Health Policy and Management and Director of Research at the Health Services Management Centre at the University of Birmingham