Category Archives: Commissioning

Perverse outcomes abound in a Media Led society. The utilitarian imperative would be ignored by the press, and will be by shallow politicians.

The rationing of drugs by the four UK Health Services is logical. There may be post code differences but that does not mean it is wrong. It’s logical and ethical and pragmatic rationing. However, once a drug is of proven benefit and is very expensive there must be a level at which NICE disapproves. This is currently £30,000 per year. If we rationed low cost high volume medications (paracetamol etc) we could possibly afford to raise this threshold. If NHSreality was commissioning, it would spend the money on people… especially in Mental Health support care, and reduce the threshold!!

There is a large risk of another perverse outcome in a Media Led society. The utilitarian imperative would be ignored by the press, and will be by shallow politicians.

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Laura Donelly reports in the Telegraph 15th May: Political parties urged to commit to reversing NHS drug rationing plans

More than 30 charities have written to the three party leaders urging them to commit to reversing NHS measures to increase rationing of medicines.

Health officials last month brought in new thresholds which mean access to one in five treatments could be delayed or restricted.

Under the rules, all drugs expected to cost the NHS a total more than £20 million a year will be checked against new “affordability criteria”.

The cost threshold set by NHS England could affect medicines costing as little eight pence a day, if used commonly enough, as well as high cost medicines used for rare diseases.

Rationing body the National Institute for Health and Care Excellence (Nice) has said it is likely to affect around 20 per cent of drugs it assesses, with the process including changes that the head of its rationing body has previously described as “unfair”.

In an open letter to Theresa May, Jeremy Corbyn and Tim Farron, the charities – which include Parkinson’s UK, the Children’s Heart Federation and the MS Society – ask all the parties to commit to reversing the changes.

The signatories – all members of the Specialised Healthcare Alliance – said that the measures “stand to restrict and ration treatments for people with rare and complex conditions, and were implemented without the agreement of Parliament.”

The letter comes as political parties prepare to publish their manifestos for the election.

Caroline Harding, chief executive of Genetic Disorders UK said: “Under these plans, some of the most critically ill patients are being denied access to potentially life-changing treatments.

“Any decision to ration access to medicines should be taken by ministers, not unelected officials.”

Kay Boycott, chief executive, Asthma UK, said: “There is a real risk that these plans will turn the clock back on access to life transforming treatment.”

Sarah Vibert, chief executive, Neurological Alliance, said: “Politicians from all sides should pledge to rethink these damaging proposals.

“It is completely unacceptable that patients with neurological conditions risk being denied access to treatment solely on the basis of cost.

None of the parties have formally published their manifestos. But the draft Labour manifesto, leaked last week, said: “Labour will tackle the growing problem of rationing of services and medicines across England, taking action to address postcode lotteries and making sure that the quality of care you receive does not depend on which part of the country you live in. We will ensure that NHS patients get fast access to the most effective new drugs and treatments.”

Jonathan Ashworth, shadow Health Secretary, said: “There is a real and growing worry that Theresa May’s ongoing underfunding of the NHS means patients just aren’t getting access to new medicines. Patients need fast access to medicines and treatments which are recommended by Nice as being clinically and cost effective. Labour is committed removing the barriers which are being put in place and to ensuring that NHS patients get fast access to the most effective new drugs and treatments.”

A Conservative spokesman said: “NHS spending on medicines and treatments is now second only to staffing costs – in fact, the NHS in England spent more than £15 billion on medicines last year, a rise of nearly 20 per cent since Labour left office. But we can only ensure more patients than ever get outstanding care if we continue to invest in the NHS on the back of a strong economy – something Jeremy Corbyn and the other parties who’d prop him up in Downing Street simply could not do.”

Liberal Democrat Health Spokesperson Norman Lamb said:  “This is a shameful retreat from the core principle of the NHS, that treatment should be available to patients regardless of their ability to pay.

“The rationing of treatments is an inevitable consequences of this government’s chronic underfunding of the NHS. NHS England is caught between a rock and a hard place because they simply don’t have enough resources.

China’s One child policy and pension

Why is the NHS under so much pressure?

An ageing population. There are one million more people over the age of 65 than five years ago

Cuts to budgets for social care. While the NHS budget has been protected, social services for home helps and other care have fallen by 11 per cent in five years

This has caused record levels of bedblocking, meaning elderly people with no medical need to be in hospital are stuck there. Latest quarterly show occupancy rates are the highest they have ever been at this stage of the year, while days lost to bedblocking are up by one third in a year

Meanwhile rising numbers of patients are turning up in A&E – around four million more in the last decade, partly fuelled by the ageing population

Shortages of GPs mean waiting times to see a doctor have got longer, and many argue that access to doctors since a 2004 contract removed responsibility for out of hours care


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Let us charge patients for extra services, GPs urge – is this “decommissioning”?

Should there be any “Extra” services in a cradle to grave health service as devised in 1948?. More and more services can be seen as “extra” depending on the political whim/philosophy of the day. Perverse incentive need to be made overt, and if minor surgery on warty lesions becomes the norm, then patients could be conned. The doctor-patient relationship has been a clean one to now…is this “decommissioning”?

Chris Smyth reports in the Times May 5th: Let us charge patients for extra services, GPs urge

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GPs are demanding to be allowed to charge patients for extra services to ease an NHS cash crisis and evade rationing.

Doctors want to offer vaccinations and minor surgery not available on the NHS, saying it will be more convenient for patients and cut down on bureaucracy.

Nine local medical committees representing GPs from Northumberland to Cornwall have asked the British Medical Association to support a change in the rules, saying they are hopelessly out of date and constitute restraint of trade. Some say the change could allow general practice to develop as a “truly commercial entity”….

Ben Molyneux, vice-chairman of the City and Hackney local medical committee in London, who will present the proposal at a conference in Edinburgh this month, said it was about “allowing patients to get the non-NHS services they want to receive from the GP they know, at a surgery near to their home”. Some patients are not covered for vaccines such as shingles or the HPV anti-cancer jab on the NHS and Dr Molyneux said it would be easier if they could pay their own GP, rather than going to another surgery. At present patients can pay other GPs, but not their own, for such procedures. The rules are said to exist to prevent distortion of the patient-doctor relationship.

Dr Molyneux said: “This adds to the pressure on short-handed GP surgeries as one patient ends up requiring multiple appointments and a new set of medical notes taking for a vaccine which is usually medically advisable.”

Prit Buttar, a GP in Oxfordshire, said allowing more private work would attract new doctors and raise money, but conceded: “It may well be more contentious when you have something like evening opening, [if] a practice could earn more opening privately in the evening than it could from the NHS.”

If the plan is backed, it will become a policy of the BMA’s GP committee, which negotiates contracts. NHS England has rejected similar requests in the past.



Doctors warn NHS is rationing best drugs to cut costs

Far better to have fairness in rationing so that all of us know what is excluded, wherever we live. Devolution and GP Commissioning have ensured inequality, and covert rationing of fearful conditions. Remember, drugs do not improve the health of populations… This is an issue for public health consultants, but are there any left?

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Jon Ungoed-Thomas in the Sunday Times 16th April reports: Doctors warn NHS is rationing best drugs to cut costs

Hospital doctors have revealed how some of the best available medicines are being rationed by the NHS in a cost-cutting drive.

Doctors including gastroenterologists, rheumatologists and dermatologists say they are being prevented from prescribing the most appropriate drugs by their local clinical commissioning groups (CCGs).

CCGs are already reducing the number of hip and knee operations by using pain thresholds to ration procedures.

Now a survey of 200 clinicians, commissioned by the drugs company UCB and conducted by ComRes, has found that seven out of 10 clinicians claim NHS funding pressures have restricted their ability to prescribe approved medications.

The Breast Cancer Now charity revealed last year that some women were missing out on a potentially life-saving drug that costs 43p a day. Bisphosphonates cut the risk of cancer spreading to the bone, but many CCGs have blocked their use.

Dr Thomas Sheeran, a consultant rheumatologist at the Royal Wolverhampton NHS Trust, said bureaucratic hurdles and financial restrictions were hampering clinicians. “It’s frustrating that the people we have to try to persuade are accountants and the CCGs,” he said.

In one case last year he said a woman at risk of going blind was turned down by her local CCG for £2,000 of drugs to save her sight. The woman was admitted as an emergency patient so the trust could pay for treatment.

The drug in question, infliximab, is approved for use by the National Institute for Health and Care Excellence (Nice) for some conditions, but the treatment for this patient was considered experimental.

Sheeran said another drug used to treat arthritis and approved by Nice, abatacept, was not being permitted by Wolverhampton CCG for some patients.

He said there were concerns that patients who were not given the most suitable drug were more likely to be readmitted to hospital, so the drive to cut the drugs budget was in fact not cost effective.

Patients are entitled to drugs approved by Nice for specific conditions, but there is often no national guidance and CCGs make their own funding decisions.

A spokesman for NHS England said: “As the NHS goes into the most financially challenging few years in its history, it is right that we strive to ensure maximum value for patients from every penny available, but ultimately these are legally decisions for clinical commissioning groups, informed by best evidence and national guidance where appropriate.”

A spokesman for Wolverhampton CCG said that although it could not comment on individual cases, “a number of individual funding requests have been approved for the prescribing of abatacept”.

Drugs Bust – Opportunistic companies take advantage of a hole in the regulations.

On the surface this looks like a typical South African legal loophole arbitrage opportunity taken by a smart businessman and the manipulated are the British public whose administrators left a loophole in the law. the loophole has been there for years, only recently abused, and has not been closed as yet.
A deeper analysis might suggest that Glaxo was complicit in this immoral action, and that they took advantage by owning a share of the new company. Politicians need to get their act together and block this in future.

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Bill Kember in The Times 14th April reports: Drug giant’s secret plan to destroy cancer medicine – Company staff discussed dumping life-saving stock unless 4,000% price rise agreed

Staff at one of the world’s leading drug companies discussed destroying supplies of life-saving cancer medicines in a battle to impose massive price rises across Europe, The Times can reveal.

The proposal was raised at Aspen Pharmacare during a dispute with the Spanish health service in 2014 over attempts to increase the price of the medicines by up to 4,000 per cent.

The company, which runs its European operations from Dublin, began a continent-wide effort to drive up the price of five cancer medicines after buying the rights from the British company GlaxoSmithKline (GSK).

The price rises meant that the cost of busulfan, used by leukaemia patients, rose from £5.20 to £65.22 a pack in England and Wales during 2013, an increase of more than 1,100 per cent. The price of chlorambucil, also used to treat blood cancer, rose from £8.36 to £40.51 a pack in the same year.

Aspen, a South African pharmaceutical company……

Drugs Bust – Times leader 14th April 2017

Let’s celebrate!” This sign-off to an internal email at Aspen Pharmacare followed the conclusion of a deal, but not the sort of deal any business should be proud of. The South African company had agreed increases of up to 1,500 per cent in the cost of life-saving cancer drugs aimed mainly at children and the elderly after months of threats to withhold them or destroy supplies.

This agreement was struck with the Italian health service but the company was emboldened by its earlier experience with the NHS: Aspen had raised the prices of these drugs in England and Wales by up to 1,200 per cent. This is the latest in a series of scandalous abuses of a drug pricing loophole brought to the attention of the public not by regulators, the health service, police or civil servants, but by The Times.

As a direct result of this newspaper’s public interest reporting, which is under sustained threat from both the government and the courts, a bill is now before parliament that will close the loophole in question and save the NHS and taxpayers hundreds of millions of pounds a year.

There are more practical steps that can be taken to halt the extortionate practices of companies that exploit the marketing rights to out-of-patent drugs. There is also a question to be answered by both the maverick firms that buy up these rights and the giants that sell them. How can any business be a party to withholding or forcing up the prices of cutting-edge medicines, knowing that desperately ill children need them? That the question even arises is a moral outrage.

Aspen is controlled by Stephen Saad, one of Africa’s richest men. In 2009 he oversaw the acquisition from GlaxoSmithKline (GSK) of a portfolio of cancer drugs known as Cosmos, which until then had been sold at a modest profit. As branded drugs their pricing was strictly regulated. Being out of patent, under rules then in force, these prices could be reset at whatever level the market would bear provided they were renamed and recategorised as “unbranded generics”.

We all pay the same tax…. but “Scotland gets cancer drug that is too expensive for England”. The Times advocates rationing ..

Whilst it will not mean a disaster in differential outcomes for the population, this post-code differential highlights the anomalies of our 4 regional health services. It reinforces the WHO opinion that there is no longer an NHS. It brings back fear when we should be reducing it, and it makes it clear that rationing overtly is the pragmatic answer. I too would exclude Kadcyla for terminal patients. The main beneficiaries of the Scottish decision are Roche shareholders.. The Times leader advocates rationing, but not necessarily “overtly”.

 Chris Smyth reports 12th April 2017 in the Times: Scotland gets cancer drug that is too expensive for England

A life-extending breast cancer drug rejected as too expensive for England and Wales is to be made available to Scottish patients.

Scotland has also become the first part of the United Kingdom to offer a pill that cuts the risk of HIV infection by 90 per cent after NHS England fought a court battle to avoid paying for it. Campaigners warned that English taxpayers would not put up with subsidising treatments in Scotland that they could not get themselves.

Scottish public spending is £10,500 a head against £8,800 in England, with the NHS getting £2,100 and £1,900 per person respectively. English and Welsh taxpayers contribute more to Scottish health spending through the Barnett formula.

The drug Kadcyla can offer an extra nine months of life to patients…

We should all care about the UKs unequal health services. “Who Cares: the play that puts the NHS under the knife”

All the Health Services are sinking – who will be bold enough to re-design their replacements, before its too late to take to the lifeboats?

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

The Times leader encourages rationing – a policy denied by all politicians. “Drug Frontier” – It is wrong that a cancer drug is available in Scotland and not in England or Wales – 11th April 2017:

adcyla is an advanced breast cancer drug that prolongs the life of patients for an average of nine months and in some cases for much longer. It is also, at £60,000 to £90,000 a patient, one of the most expensive cancer treatments ever brought to market. Despite this the drug is readily available to women in 18 European countries, including Germany, Austria, France and Scotland. But it is not available in England or Wales.

An important cause of this disparity is health spending per head that is significantly higher in Scotland than in England, thanks largely to the generosity of the Barnett formula by which block grants from Westminster to Holyrood for public service subsidies are calculated. For the 1,200 women in England and Wales who could benefit from Kadcyla, and who help to fund both their own and Scotland’s health services through their taxes, this is not merely back luck. It is an unconscionable injustice.

These women and their families may ask what can be done to fix such blatant unfairness. Experience suggests an answer, but not a satisfactory one. Recent pricing battles between pharmaceutical companies and the National Institute for Health and Care Excellence (Nice) involving other cancer drugs have shown that when Nice and the NHS bring to bear the full force of their leverage as one of the world’s biggest drugs buyers even the biggest companies can be persuaded to lower their prices.

“The system is working,” Sir Andrew Dillon, Nice’s chief executive, claimed last month. If so, it is working in a way that leaves patients in limbo and desperately anxious while the regulator and the drugmakers bargain with each other. In the case of Kadcyla, it has so far not worked at all. Roche Pharmaceuticals, the drug’s Swiss manufacturer, has been under pressure to lower its cost for three years and has not budged. There is still hope, since the company may decide that discounted sales to such a big customer are better than none, but as the two sides haggle, patients die.

The gap in per-capita health spending between England and Scotland is narrowing but still conspicuous. It roughly halved from £213 a person a year in 2010-11 to £103 a person four years later. The difference is not funded by any underlying strength of the Scottish economy, which has contracted as world oil prices have fallen by more than half in the past six years. It is funded chiefly by Westminster, as shown by the overall gap in per-capita public spending between the two countries. Even as Scotland’s national income has fallen with its oil revenues, its total spending per head has remained at least 18 per cent higher than in England.

The two countries’ health services are independent of each other and can set their own priorities. Simon Stevens, chief executive of NHS England, has admitted that certain costly cancer drugs once available either as a matter of course or through the Cancer Drugs Fund will no longer be because he has prioritised GP surgeries and mental health. The fund is in any case overspent and being wound up. The list of drugs not available on the health service will lengthen.

This newspaper accepts that as people live longer and treatments get costlier the NHS must ration its services or find more sources of funds. The case for a new funding model is only strengthened by the fact that a world-class treatment is available in Scotland but not in England. The case for Roche to cut its prices is even stronger.


Creeping closer and closer to overt rationing – but without the debate needed.

It’s not really the blood sugar which need monitoring, except in an emergency when most patients will know if they are at risk of high or low (more dangerous) sugar levels. The real testing that is helpful is the Hba1c levels, and these Glycated Haemoglobin levels are not available to patients as yet. Hba1c averages out the sugar levels over months. Rationing strips is rational.. but it should be universally and equally applied to all citizens. We have known about this since 2013 – it is not new news.If it becomes overt, and recognised by politicians then that IS news. We are creeping closer and closer to overt rationing, but without the debate needed to win hearts and minds. Nearing Easter and egg time Diabetics may need more monitoring…

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The Belfast telegraph on April 6th reports: NHS rationing ‘restricts access to diabetes testing strips’

People with diabetes are being refused blood glucose testing strips due to NHS rationing, according to a new report.

The Diabetes UK study found that people with the condition – who need to test their blood glucose levels several times a day – are having restrictions placed on how many strips they can have, sometimes by GP receptionists.

Many Clinical Commissioning Groups (CCGs), which have come under fire for rationing other NHS services, have guidance on how often people should test their blood glucose and how many boxes of strips should be issued per month.

They have also urged GPs to switch patients to cheaper blood glucose meters and cheaper strips (less than £10 for 50) – sometimes against the patient’s will.

Diabetes UK said the rationing was a “false economy” because the cost of dealing with complications caused by poorly-managed diabetes, including stroke, heart disease, amputations and blindness, is far higher.

A Diabetes UK survey of more than 6,000 people found 25% had not been prescribed enough test strips for their needs.

A separate poll of over 1,000 people found 27% of patients had either experienced restrictions or been refused test strips, compared to one in five four years ago.

More than half (52%) of these had Type 1 diabetes, which is controlled by insulin.

The National Institute for Health and Care Excellence (Nice) recommends that all Type 1 patients self-monitor blood glucose levels, testing at least four times a day.

People who are frequent drivers, take regular exercise or who are at high risk of suffering low blood sugar may need to test up to 10 times a day. Illness such as flu can also cause erratic blood sugar levels and more testing.

The charity said it was also concerned that people with Type 2 have been told they do not need to test their blood sugar, despite those on insulin and some medications needing to.

The report said: ” Budget constraints or ‘excessive testing’ were often the reasons given to people to explain why the restriction was occurring. People with diabetes found these restrictions stressful and had to make difficult decisions about when to test or not.”

One patient said: ” I was told they were expensive and we should test less. Only need to test four times a day. We use an (insulin) pump so need to test every two hours.”

Another said: “They said I had my allowance for the month. There is a blanket limit on the number of test strips available to diabetics across the CCG.”

Another patient said: ” Doctor’s receptionist told us we test too often “, while another said: ” I had to get my diabetes specialist nurse to ring my GP receptionist who was the one who questioned my use of strips on several occasions.”

One said: “I feel annoyed that every week or so I need to keep ordering and that I need to justify myself to a surgery person that knows nothing about what we go through. ‘

The report said people were being forced into testing less, or were trying to buy strips online or via eBay, despite concerns about quality.

It also said some patients may not meet requirements set down by the Driver and Vehicle Licensing Agency (DVLA), which says some patients must test every two hours.

In the survey, 66% of people were also given no choice of blood glucose meter and had been switched to a different, cheaper meter, without any discussion with them.

Of these, 25% were not happy with the meter provided, including that it was was too large to carry around or did not upload the data to a computer.

Some patients were forced on to cheaper meters when their test strip prescription ran out, leaving them no choice but to accept a different meter.

Diabetes UK policy manager Nikki Joule said: “These short-sighted cost savings cause people real anguish and potential financial distress.

“It also means people are struggling to manage their diabetes, which can lead to serious consequences for their health, so we urge people to challenge restrictions and refusals.

“Local policies should allow sufficient choice and flexibility for individual circumstances to be taken into account when prescribing test strips and meters for people with Type 1 or Type 2 diabetes.”

Professor Jonathan Valabhji, NHS England’s national clinical director for diabetes and obesity, said: “Ultimately these are decisions for CCGs, but should be informed by best evidence and national guidance where appropriate.

“We need to ensure adequate provision and that clinicians take into account widely recognised Nice guidelines, which are clear about the need for test strips to support people in particular with Type 1 diabetes.”

Rationing in the NHS – Analysis From Nuffield Trust –‎

Rationing ‘already widespread in the NHS for a … – Belfast Telegraph September 2016

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NHS confusing public by using ‘gobbledygook’

In keeping with the BMA in Wales, Nick Triggle reports that “NHS confusing public by using ‘gobbledygook'” in the Times 28th March 2017.

The BMA Wales response to the Welsh Government was that we wanted “a clearer and more honest language” to be used in health. Needless to say this has not happened, and indeed NHSreality does not blame the Welsh politicians. The recommendation for “honest language”, along with “Exit Interviews” was buried deep within the BMA response ( Our health, our health service BMA response) to that part of the Green Paper , and did not appear in any bullet point summary. The rules of the game, for Commissioners (de-commissioners) will ensure that the language barrier remains. Therefore we need to change the rules. Both language and outcomes are going to get worse.. until we agree there has to be a cost.

Imagine the scene. Up and down the country, local NHS leaders are crowded into meeting rooms discussing information transfers and ambulatory care, when someone jumps up and shouts “I’ve had enough of sticky toffee puddings”.

Confused? You’re not the only one. The language being used by the health service is simply gobbledygook, says the Plain English Campaign (PEC).

Steve Jenner, the campaign’s spokesman, said the health service was riddled with “jargon” when it comes to explaining anything from the closure of hospital services to major incidents.d he even believes the NHS may be doing this on purpose.

“If you use impenetrable language it means the public has no clue what is going on. I can’t help thinking that suits the NHS sometimes,” he said.

“What this jargon is describing is very important. It should be articulated very clearly.

“We expect doctors to clearly explain themselves. It should be the same for the NHS management,” he added.

Sticky toffee puddings or important NHS plans?

STPs – dubbed sticky toffee puddings by some in the health service – are among one of the most important developments in the health service in recent years.

But you would never guess from the official name – sustainability and transformation plans.

However, the jargon goes further than that, according to the PEC. Look through most plans – there are 44 of them – and you will find some strange phrases.

Cambridgeshire and Peterborough’s documents, for example, talk about investing in “system-wide quality improvements” and developing a “shared understanding of all the interrelated issues”, while being able to learn “what it means to us as individuals and as organisations”.

Meanwhile, documents from North Central London shared the experience of one patient’s care that went wrong.

It says due to “hand-offs, inefficiencies and suboptimal advice and information transfers” the “patient’s pathway” went on for too long.

Another popular “pathway” is the ambulatory patient pathway. What does that mean? The patient can go home after being seen in hospital.

Is the NHS involved in a medieval battle?

Vanguards are a term used to describe the formation of a medieval army. But the NHS has also – ahem – deployed the term.

There are 50 vanguards that have been set up to test new ways of running services. They were created in 2015 and include schemes to get hospital doctors working in community clinics and to provide advice via video link-ups as well as the creation of super hubs in the community bringing together GPs, district nurses and council care teams.

You should not be surprised to hear evidence of what works best in the vanguard programmes will then be fed into the STP process.

But it’s not just in England where jargon can be found. Northern Ireland’s 10-year health strategy, published last autumn, promised to shift the focus from “treatment of periods of acute illness and reactive crisis approaches, towards a model underpinned by a more holistic approach to health and social care”.

Or, more simply, try to get people to live more healthily and give them better support to stop them needing hospital care.

Running hot or just busy?

Taps run hot, but so too, it seems, does the NHS. Commentators and health service managers have been using the phrase to describe just how busy hospitals and, in particular, A&Es were this winter.

It may be a bit of an odd phrase, but it is at least easier to understand than Operational Pressures Escalation Level Four.

That is the new name for a black alert – when hospitals get so busy they have to cancel non-emergency operations, divert ambulances and call in extra staff.

And guess what red alerts – the level down from black – were renamed? Yes, that’s right, Operational Pressures Escalation Level Three.

Guidance issued by NHS England last year ordered hospitals to use the new terminology when communicating with the public and media.

Not everyone obeyed. Newspaper coverage this winter was littered with reports of black and red alerts.

And what did NHS England make of this? They were unable to provide the BBC with a response.

The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

In Search of the Perfect Health System ( a new book reviewed )

The BMA response ( Our health, our health service BMA response) to that part of the Green Paper