It takes a non woke, retired consultant expert to give an unofficial exit interview to change the abuse of gender reassignment after short term dysphoria (NHS on gender dysphoria). We need to be asking why so late, and why no exit interviews, and if we do them, who should undertake them. The gagging and bullying extend into the whole workforce, and the litigation anxiety of the Trust Boards means that short term issues dominate, along with bullying and denial for both patients and staff.No wonder the service has been decommissioned!We have not heard one minister yet commenting on the Cass report, and certainly my party, the Liberal Democrats have made no sensible statement as yet.. (Although LibDem voice has..) Sajid Javid: NHS let gender ideology replace children’s best interest The Times April 10th 2024. Former health secretary praises findings of the Cass report and calls on all political parties to work together to close puberty blockers loophole. When I was briefed on the NHS’s Tavistock Gender Identity Development Service (Gids) for the first time, I knew this was not just another policy area but a child protection issue and huge medical scandal in the making. As Secretary of State for Health and Social Care at the time, I instructed officials to provide all available support to Dr Hilary Cass, the chair of the Independent Review into Gids. I introduced legislation to support her investigation, and months later, backed the recommendations of the interim report. She has demonstrated exceptional courage throughout and today, her final report is published. Whilst the findings are not surprising, they are no less sickening. Quite simply, ideology replaced the best interests of children, thousands of whom have now been failed in this modern-day scandal. At every opportunity, and in each department I served in, I tried to advance the cause of child protection. In this case, the source of lessons lies within both the clinical practice, and political culture which enabled it to persist for so long. Unless each is resolved, more children will be harmed. In any other setting it is hard to imagine a patient meeting a doctor and the patient telling them what their diagnosis is. Yet the approach of self-diagnoses was the medical pathway adopted at Gids. This resulted in clinicians not showing enough interest in other potential factors, including trauma, social influence, sexual abuse or different conditions. Take the example of autism, which we know about 2 per cent of children in the UK are thought to have. At Gids, a review found that about 35 per cent had moderate or severe autistic traits. Compounding this was the widespread prescription of puberty blockers. Thankfully, that practice in the NHS is changing, but huge loopholes remain in the system. Both private clinics and prescriptions ordered from abroad remain significant problems. In the case of prescriptions, someone could simply order them online to any pharmacy in the country. The government must close this loophole without delay. But this is only one area and many more exist. Despite the specific data legislation I brought forward at Dr Cass’ request, parts of the NHS continue to block access and frustrate the express will of parliament. The common thread between all of these is an extreme gender ideology, which enables them to persist. Across political parties, we need to reassess how effective the commitment is to protecting children and keeping this militant gender lobby at bay; otherwise, this review will be wasted. Only the courage of whistleblowers and activists on this issue was able to provide the beginning of much-needed accountability. Without political support, advocates of the existing system will continue to dominate, as they have in other countries. The same theme of being afraid to tackle “uncomfortable” issues has existed in other areas before, to the detriment of children. Whether it is race, sex, gender or other identity characteristics, politicians cannot let a culture of silence prevail because of political sensitivities. As the introduction of the hate crime law in Scotland demonstrates, the consequence of compliance now risks people being forcibly silenced. party, will need to be tempered. The debate always risks descending into one where far more heat than light is offered, and one where serious policy recommendations fall by the wayside, in favour of stronger words of condemnation. That is why the NHS process was so important. It had the time and power to consider these issues and recommend meaningful change. In a changing society, where many more of these challenges will arise, only substantive processes and firm decisions will effectively manage these complex matters. I experienced first-hand that making policy in this area will never be straightforward. But as a father of four, I know how important securing a positive future on these issues is. All of us will have to navigate a changing society. But as this report today makes clear, never again should that come at the expense of our children.
In 2009 the NHS’s gender identity development service (Gids) saw fewer than 50 children a year. Since then demand has increased a hundredfold, with more than 5,000 seeking help in 2021-22. The sudden increase has gone hand in hand with the adoption of a model of “gender-affirming” care, which puts children on a life-altering path of hormone treatment. Services have been left overwhelmed, with vulnerable young people clamouring for medical interventions to help them change gender — despite a lack of evidence over the long-term effects. It was against this backdrop that Dr Hilary Cass was commissioned in 2020 to examine the state of NHS services for children identifying as trans. Her final report, published on Wednesday, delivers a damning verdict on the medical path thousands of children have been sent down. It marks a turning point in years of bitter debate over how to help this distressed group of young people, confirming a shift towards a holistic model that takes into account the wider social and mental health problems driving the rise in demand.
Gen Z and online porn
The Cass report shines a light on the biggest unanswered question over transgender healthcare: why are so many Gen Z women suddenly wanting to change gender? Cass paints an alarming picture of an anxious and distressed generation of digitally savvy young women and girls, who not only are more exposed to online pornography and the wider problems of the world than any previous generation but also consume more social media and have lower self-esteem and more body hang-ups than their male peers. When Gids opened in 1989, it treated fewer than ten people each year, mostly males with a long history of gender distress. In 2009 it treated 15 adolescent girls. By 2016 that figure had shot up to 1,071.
Cass concludes that such a sudden rise in such a short time cannot be explained alone by greater acceptance of trans identities, which “does not adequately explain” the switch in patient profiles from predominantly male to female. She also says greater investigation of the “consumption of online pornography and gender dysphoria is needed”, pointing to youngsters’ increasingly early exposure to “frequently violent” online material that can have a harmful impact on their self-esteem and body image. Gen Z is defined as those born between 1995 and 2009. Rather than focusing on the issue of gender in isolation, Cass looked at the context in which adolescents today, who have “grown up with unprecedented online access”, are experiencing such a disproportionate crisis over their gender. “Generation Z is the generation in which the numbers seeking support from the NHS around their gender identity have increased, so it is important to have some understanding of their experiences and influences,” she writes. “In terms of broader context, Generation Z and Generation Alpha (those born since 2010) have grown up through a global recession, concerns about climate change and most recently the Covid-19 pandemic. Global connectivity has meant that as well as the advantages of international peer networks, they are much more exposed to worries about global threats.” The report also focuses on 2014, when female referrals to Gids accelerated. Although this is not mentioned, 2014 was the year that CBBC, for example, broadcast I Am Leo, a video-diary-style documentary, to an audience of to 6 to 12-year-olds, showing the positive personal journey of a child who transitioned from female to male. Throughout almost 400 pages, Cass argues that the gender-related issues of young patients should be treated in the same context as the wider mental health issues facing their entire generation. “The striking increase in young people presenting with gender incongruence/dysphoria needs to be considered within the context of poor mental health and emotional distress among the broader adolescent population, particularly given their high rates of co-existing mental health problems and neurodiversity.” Cass calls for more research into the “complex interplay” between these issues and a teenager’s sudden desire to change gender.
Lack of evidence for medical pathway
Rather than affirming children’s gender identity with medical treatment, the report calls for a holistic approach that examines the causes of their distress. It finds that, despite being incorporated into medical guidelines around the world, the use of “gender-affirming” medical treatment such as puberty blockers is based on “wholly inadequate” evidence. Doctors are cautious when adopting new treatments, but Cass says “quite the reverse happened in the field of gender care for children”, with thousands of children put on an unproven medical pathway. Cass says gender care is “an area of remarkably weak evidence” and that results of studies “are exaggerated or misrepresented by people on all sides of the debate”. She adds: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” The report finds that treatment on the NHS since 2011 has largely been informed by two sets of international guidelines, drawn up by the Endocrine Society and the World Professional Association of Transgender Healthcare (WPATH), but that these lack scientific rigour. The WPATH has been “highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency”, Cass says.
Mental health
Mental health issues could be presenting as gender-related distress. Children and young people referred to specialist gender services have higher rates of mental health difficulties than the general population. This includes rates of depression, anxiety and eating disorders. Some research studies have suggested transgender people are three to six times more likely to be autistic than the general population, with age and educational attainment taken into account. Therefore, the report says that the striking increase in young people presenting with gender dysphoria needs to be considered within the context of rising levels of poor mental health. The increase in gender clinic patients “has to some degree paralleled” the deterioration in child and adolescent mental health, it finds. Mental distress, the report says, can present through physical manifestations, such as eating disorders or body dysmorphic disorders. Clinicians were often reluctant to explore or address co-occurring mental health issues in those presenting with gender distress, the report finds. This was because gender dysphoria was not considered to be a mental health condition. The report finds that, compared with the general population, young people referred to gender services had higher rates of neglect; physical, sexual or emotional abuse; parental mental illness or substance abuse; exposure to domestic violence; and loss of a parent through death or abandonment. The report says there was “no evidence” puberty blockers allowed young people “time to think” by delaying the onset of puberty — which was the original rationale for their use. It finds the vast majority of those who start puberty suppression continued on to cross-sex hormones, particularly if they started earlier in puberty. There was insufficient and inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health, it says, and some young females had a worsening of problems like depression and anxiety. Cass says there is “some concern” that puberty blockers may actually change “the trajectory of psychosexual and gender identity development”. Her report warns that blocking the chronological age and sex hormones released during puberty “could have a range of unintended and as yet unidentified consequences”. It describes adolescence as a time of “identity development, sexual development, sexual fluidity and experimentation”. The report says “blocking” this meant young people had to understand identity and sexuality based only on their discomfort about puberty and an early sense of their gender. Therefore, it adds, there is “no way of knowing” whether the normal trajectory of someone’s sexual and gender identity “may be permanently altered”. Brain maturation may also be “temporarily or permanently disrupted” by the use of puberty blockers, it says. This could have a significant impact on a young person’s ability to make “complex risk-laden decisions”, as well as possible long-term neuropsychological consequences. The report highlights the “concern” of young people remaining on puberty blockers into adulthood — sometimes into their mid-twenties. This is partly because some “wish to continue as non-binary” and partly because of ongoing gender indecision, the report says. Cass adds: “Puberty suppression was never intended to continue for extended periods.” The report finds young adults who had been discharged from Gids “remained on puberty blockers into their early to mid twenties”. A review of audit data suggested 177 patients were discharged while on puberty blockers. Cass says the review “raised this with NHS England and Gids”, citing the unknown impact of use over an extended period. “The detrimental impact to bone density alone makes this concerning”, the report adds.
A Dutch study originally suggested that puberty blockers might improve psychological wellbeing for a narrow group of children with gender issues. Following this, the practice “spread at pace to other countries” and in 2011 the UK trialled the use of puberty blockers in an early intervention study. The results were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes. It also found that 98 per cent of people had proceeded to take cross-sex hormones. Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice. “The rationale for this is unclear,” the report says. Puberty blockers were then given to a wider range of adolescents, it says, including patients with no history of gender issues before puberty and those with neurodiversity and complex mental health issues. Clinical practice, Cass found, appeared to have “deviated” from the parameters originally set. Overall, the report concludes there was a “very narrow indication” for the use of puberty blockers in males to stop irreversible pubertal changes, while other benefits remained unproven. It says there were “clearly lessons to be learnt by everyone”.
Social transition
The report concludes it was “possible” that social transition, including the changing of a child’s name and pronouns, may change the trajectory of their gender development. It finds “no clear evidence” social transitioning in childhood has any positive or negative mental health effects, but that children who socially transitioned at an earlier age were more likely to proceed to medical treatment. A more cautious approach to social transition needs to be taken for children than for adolescents, it concludes. The review also heard concerns from “many parents” about their child being socially transitioned and affirmed in their expressed gender without their involvement. Draft government guidance, published in December, stated that schools should not accept all requests for social transition and should involve parents in any decision that is made. Despite this, there has been evidence of schools ignoring ministers and allowing children to change gender behind their parents’ backs. The report makes clear that “parents should be actively involved in decision making” unless there are strong grounds to believe that it may put the child at risk. It also finds that social debates on trans issues led to fear among doctors and parents, with some concerned about being accused of transphobia. The interim report, from 2022, had classed social transition as “not a neutral act”. The full report explains that it is an “active intervention”, because it may have significant effects on a young person’s psychological functioning and longer-term outcomes. In a strong warning to schools, the report describes the need for “clinical involvement” in the decision-making process on social transitioning. It adds: “This is not a role that can be taken by staff without appropriate clinical training.” The report concludes that maintaining flexibility is key among those going down a social transition route and says a “partial transition”, rather than a full one, could help. In decisions about whether to transition prepubescent children, families should be seen “as early as possible by a clinical professional”.
Rogue private clinics
Long waiting lists for NHS care mean distressed children are turning to private clinics or resorting to “obtaining unregulated and potentially dangerous hormone supplies over the internet”, the report says. Some NHS GPs have then felt “pressurised to prescribe hormones after these have been initiated by private providers”, and Cass says this should not happen. The report also urges the Department of Health to consider new legislation to “prevent inappropriate overseas prescribing”. This is intended to tackle a loophole which means that, despite the NHS banning the use of puberty blockers last month, children can still access them from online clinics such as GenderGP, which is registered in Singapore.
Detransitioning
Cass says some of those who have been through medical transitions “deeply regret their earlier decisions”. Her report says the NHS should consider a new specialist service for people who wish to “detransition” and come off hormone treatments. She says people who are detransitioning may be reluctant to return to the service they had previously used.
NHS numbers
The report recommends that the NHS and Department of Health review current practice of issuing new NHS numbers to people who change gender. Cass suggests that handing out new NHS numbers to trans people means they risk getting lost in the system — making it harder to track their health histories and long-term outcomes. The review says that this has had “implications for safeguarding and clinical management of these children”, — for example, the type of screening that they are offered.
Toxic debate
Cass has called for an end to the “exceptionally toxic” debates over transgender healthcare after she was vilified online while compiling her review. In a foreword to her 388-page report, the paediatrician said that navigating a culture war over trans rights has made her task over the past four years significantly harder. She warned that the “stormy social discourse” does little to help young people, who are being let down by a lack of research and evidence. Cass added: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop. “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.” Cass said: “Finally, I am aware that this report will generate much discussion and that strongly held views will be expressed. While open and constructive debate is needed, I would urge everybody to remember the children and young people trying to live their lives and the families/ carers and clinicians doing their best to support them. All should be treated with compassion and respect.”
The recommendations
Data collection Gender identity clinics should offer their data to NHS England for review, and more research should be conducted on the impact of psychosocial intervention — such as therapy — and the use of masculinising and feminising hormones, such as testosterone and oestrogen. Cass recommended that the NHS should also consider data from private clinics.
Puberty blockers and hormone treatment Cass recommended research to establish the long-term impact of puberty blockers, which is expected to start by December.
Assessment of other conditions Cass said that children arriving at gender identity services should be screened for conditions such as autism and other neurodevelopmental conditions.
Criteria for medical treatment When treating children with gender dysphoria, only those who have experienced “longstanding gender incongruence” will be able to get medical treatment. Even then, this will only be available — with “extreme caution” — for over 16s.
A holistic approach Before any medical intervention, Cass recommends that children should be offered fertility counselling and “preservation” by specialist services. This formed part of a more “holistic” approach to gender identity services. Cass suggested the creation and implementation of a national framework and infrastructure for gender-related care.
Growing into adulthood The review advised that follow-through services for 17 to 25-year-olds should be established to ensure a continuity of care and support when children grow into adulthood.
Detransitioners The report proposed that NHS England should “ensure there is provision for people considering detransition”, while recognising that they may not wish to attend services that assisted in their initial gender transition.
Update 12th April 2024Times letters: Cass review and the use of puberty blockers Sir, The recommendations in the report of the NHS review chaired by Dr Hilary Cass (“NHS rejects use of puberty blockers”, news, Apr 10) are excellent: I support all of them. What is missing from the report is an explanation for the unsatisfactory clinical service provided at the Tavistock Clinic. This must begin with an account of the development of gender identity, which normally occurs between two and four years. Rarely, the identity is opposite to that of the biological sex and this gives rise to gender dysphoria (discomfort). Sound research findings from the 1990s onwards suggest medical treatment (including puberty blockers) for this tiny group is indicated after in-depth assessment and counselling. From about 2005 all over the developed world, a different group — teenagers — presented to clinics with gender dysphoria. These were mainly biological girls who had a male identity. In all probability these were drawn from that minority (about 10 per cent) of adolescents who suffer from identity confusion and who were further confused by what they read on social media. These probably accounted for the bulk of referrals to the Tavistock Clinic which, sadly, sometimes failed them diagnostically. Philip Graham Emeritus professor of child psychiatry, UCL; London NW5 Sir, I wonder how history will judge the appalling use of puberty blockers in children with gender dysphoria. The lack of evidence is totally at odds with other branches of medical care, where evidence-based medicine is the gold standard. Doctors who raised concerns as long ago as 2005 were criticised, ignored or even sacked. As GPs, we can be asked to prescribe by gender clinics, including the Gender Identity Development Service. The only position to take is to follow NHS guidelines, which allow puberty- blocking hormones. To decline on personal grounds leaves one open to complaints or a claim of discrimination. The Cass report is a welcome breakthrough. Doctors must have the freedom to express doubts about unproven, experimental treatments without the risk of attracting personal criticism and bullying. This degree of mass child abuse must not be allowed to happen again. However uncomfortable or politically sensitive an issue is, to prevent a future scandal we need open debate and evidence- based medicine. Dr Fiona Cornish, GP Cambridge Sir, In light of the publication of the Cass report, I am concerned that the licensed use of puberty blockers for the treatment of precocious puberty in children — when puberty starts at an unusually early age, sometimes as young as two — may be misunderstood. These highly targeted drugs have been available for decades, have an excellent safety profile and are of huge benefit to the affected children and to their families. They revolutionised treatment and there is extensive published follow-up data. These children may have serious brain problems such as tumours or severe learning disability. After treatment, children with precocious puberty can continue into puberty at an appropriate age. It is important that we distinguish between the safety of the drugs and their unlicensed use in a situation where the long-term effect of puberty blockers and the use of transgender hormones are poorly understood. To regard this group of drugs as dangerous, as your leading article (Apr 10) appears to do, is misleading — it is the reason for using them that is the point. Dr Tony Hulse Former consultant paediatric endocrinologist, Evelina London Children’s Hospital; Hadlow, Kent Sir, In my 40 years in senior positions in secondary and comprehensive schools I was closely involved in the pastoral care of thousands of young girls and boys. Not once did I encounter a pupil who wished to change their gender. Noel Simpson Midhurst, W Sussex
Sir, The rise in children and adolescents referred to the NHS Gender Identity Development Service in the UK from 2009 to 2016 firmly aligns with the rise in popularity of smartphones and social media from 2010. With 88 per cent of those aged 16 to 24 owning a smartphone in 2014 and social media networks almost tripling their user base in the past decade, 2014 is identified by the Cass report as the point at which referrals to gender identity youth services in the UK spiked for teenage girls. In light of the Cass report, the question to ask is whether social media accessed omnipresently on smartphones by our children has been a contributory factor. Children approaching puberty and a difficult phase of adolescence may find themselves being exploited rather than supported via social media, smartphones and the network of influencers that inhabit such a space. The government should regulate such devices and content to protect children from online coercion and harm. Arabella Skinner, Safe Screens Miranda Wilson, Teched Off
Sir, This disaster has echos of the child abuse scandal of the late 1980s. Then “diagnostic signs” of abuse were used to falsely convict hundreds of innocent people. Whenever clinicians use diagnostic signs in new and radical ways they must submit to rigorous research before applying these practices on vulnerable patients. Few patients are more vulnerable than children. Those of us with years of experience have been trying to point out that a desire to be the opposite sex and to feel strongly attracted to members of the same sex are normal phases of development that children pass through. They require sympathy and reassurance, not labelling and treatment with life-changing drugs. It is the one clear obligation of parenthood that children require guidance. The present idea that every preference of the child should be indulged is nonsense. The algorithms of the internet reinforce user preference; this dangerous and perverse trait should be removed to ensure that all information is balanced. That way, misguided parents would not put pressure on clinicians (who should know better) to provide seriously harmful treatments. Just because it is possible to do something does not mean it should be done. This simple advice is normally part of medical education and needs to be clearly understood. Dr John Orchard FRCGP Retired GP and associate dean of postgraduate medical education; Youlgrave, Derbyshire
NHSreality is pleases that there is some creative change thinking but also feels that denial and inability to concieve the range & scale of the financial change needed is a continuing problem. We are still wedded to the past! Whilst most of the medical profession will endorse the 10 recommendations outlined i. NHSreality would also add: The long-term sustainability, depoliticization, the honest debate (about what is excluded ) asked for by Mr Stevens. The financing options, patient choice & autonomy v a paternalistic state, and whether a two-tier system is a necessity (as in the rest of the G7). Writing from Wales, the foundation stone of the former NHS, devolution of Health seems to have failed the nation – will we ever be given the choice of reversal? Cherishing and caring for the staff is more than merely payment and reduction of debt for loyalty. Many of those derided, and who work abroad, intended to return, but they find they appreciate the work-life balance so much more that they stay! The Times commission ( and the BMA commission ) have only touched the surface of all these issues. Whatever solutions are suggested, they need to be fair. In Enoch Powells words “The worst kind of rationing is that which is unacknowledged, for it is the essence of a good rationing system that it be intelligible and consciously accepted”. Medicine and Politics 1966. Most of my colleagues feel that a system of Proportional Representation, whereby compromises are reached without oscillating between idealistic extremes every few years, is the only way to achieve all of the above agenda. It would also be interesting to hear from the commission why they feel we have arrived at this situation, where a decade or more will be needed to reverse the decline. The Times chose to publish its commission 10 point plan for restarting the ( English ) Health Service 5th Feb 2024: The Times Health Commission’s 10 recommendations to save the NHS – Experts back patient passports, faster mental health treatment for the young and writing off student loans for doctors who stay within the health service The ten-point plan 1. Create digital health accounts for patients, called patient passports, accessed through the NHS app to book appointments, order prescriptions, view records, test results or referral letters and contact clinicians. 2. Tackle waiting lists by introducing a national programme of weekend High-Intensity Theatre (HIT) lists once a month in 50 hospitals to get through a week’s worth of planned operations in a day and create seven-day surgical hubs. 3. Reform the GP contract to focus on wider health outcomes rather than box-ticking, ensure patients get prompt appointments and restore continuity of care. Encourage more super-practices and create community health centres. 4. Write off student loans for doctors, nurses and midwives who stay in the NHS to improve retention as well as recruitment. Debt should be cut by 30 per cent for those who stay three years, 70 per cent for seven years and 100 per cent for ten years. 5. Introduce no-blame compensation for medical errors with settlements determined according to need to ensure families get quick support and encourage the NHS to learn from mistakes. 6. Establish a National Care System giving everyone the right to appropriate support in a timely fashion. Equal but different from the NHS, it should be administered locally and delivered by a mixture of the public and private sectors. 7. Guarantee that all children and young people requiring mental health support can get access to treatment within four weeks and rapid follow-up appointments. Publish data on waiting times for all mental health services. 8. Tackle obesity by expanding the sugar tax, taxing salt, implementing a pre-watershed ban on junk food advertising and reducing cartoons on packaging to minimise children’s exposure to unhealthy food. 9. Incentivise NHS staff to take part in research, and put the case for research to their patients by giving 20 per cent of hospital consultants and other senior clinicians 20 per cent protected time for research. 10. Establish a Healthy Lives Committee empowered by a legally binding commitment to increase healthy life expectancy by five years in a decade and reduce health inequalities to encourage a long-term approach with cross-party agreement.
The Times letters 7th Feb 2024: Blueprint to improve the health of Britain Sir, A striking feature of the report by The Times Health Commission (Feb 5 & 6) is the recommendation of a no-fault compensation system for clinical negligence claims. The appeal is clear: a potential next step to a no-blame culture in the NHS as well as the swifter conclusion of claims. Yet regardless of the merits or otherwise of such a hypothetical scheme, there can be no doubt that this would be a complete overhaul of part of our legal system. Hence the questions and challenges will be many and complex and could last for years. For this reason the government should not lose sight of reforms that it could introduce swiftly to tackle the unsustainable cost of clinical negligence. Top of that list should be the repeal of 1940s legal provisions that pre-date the NHS and require courts to disregard the latter’s existence and instead award compensation based on the cost of private care. Action can be taken on this now, and it must. Thomas Reynolds Head of policy, Medical Defence Union
Sir, The Times Health Commission is a much-needed analysis of the NHS and the problems it faces. It was reassuring to see the challenges posed by our ageing population featured repeatedly in the report, something that we in the hospice and end-of-life sector have been warning about for some time. By 2040 it is estimated that about 800,000 people a year will die — an increase of about 150,000. The number of people who died in 2020 and 2021, during the peak of the Covid-19 pandemic, will become the norm in the coming years. This generational challenge is arguably one we are not yet reckoning with.
Britain’s hospices, which already care for more than 300,000 people a year, have the expertise for the task ahead but not yet the resources. The funding model for palliative and end-of-life care, including hospices, must be looked at urgently to ensure that the UK is prepared to meet this surge in need. Toby Porter Chief executive, Hospice UK
Sir, The proposal in the report by The Times Health Commission to write off student loans after a designated number of years of NHS service might be counter-productive unless the working environment for new entrants to the NHS is improved, as recent industrial action has demonstrated. Tying in workers for some years to a job where they are unhappy is not conducive to support for the NHS or patients. Dr Jeremy SK Phipps MRCGP Wothorpe, Lincs
Sir, The Times Health Commission recommends “a greater emphasis on teamwork and empathy” in medical training. My greatest pleasure as a junior doctor was being part of the consultant-led team, where I learnt skills from experienced seniors. These teams have been subverted by the takeover by postgraduate medical deans of the training of junior doctors. Learning teamworking, and thus improving morale, has to be by practical experience. Robin Vicary London NW7
Sir, The recommendations of The Times Health Commission all appear sensible but they do not address the fundamental economic issue, which is that if a valuable service is provided free of charge to users it is inevitable that demand will exceed supply, however large the funding may be. At present, rationing is by waiting lists but nobody seems happy with this. Better by far would be to limit what the NHS seeks to provide. Dermot Glynn London SE3
Sir, Further to your report “Public want digital pass for all their GP records” (Feb 5), I understand that the majority of those polled said they preferred convenience over the security of their health records, but given that the NHS is regularly hit by cyberattacks (typically in the form of ransomware), people should be cautious about blindly supporting the digitisation of their health information. David Lawson Dungannon, Co Tyrone
Sir, On the idea of an NHS digital pass, we have been here before. The government’s National Programme for IT project ran from 2002 to 2011 and was an attempt to digitise NHS records. It was a spectacular failure, with the final cost estimated at more than £11 billion. Eric Leach London W7
The Times letters 8th Feb 2024: Rescue plan for health and NHS dentistry ir, The Times Health Commission has produced an excellent ten-point plan for health; a similar approach is needed for dentistry. Having worked in dental teaching hospitals for more than 40 years I have witnessed the declining availability of NHS dentistry in primary care. The NHS dental recovery plan, which includes a bonus for dentists, will not solve the problem of universal access, and the promise of 2.5 million extra appointments is unlikely to be met (“Dental vans will tour country under plan to boost access”, Feb 7). The dental contract needs radical reform, particularly as remuneration for NHS dentists often does not cover the cost of providing treatment. Newly qualified dentists do not want to work in a broken NHS system: some opt to go directly into private dentistry. An NHS service that provides appropriate remuneration, job satisfaction and continuing professional development will attract recent dental graduates. Increasing the number of dental student places is not the answer until NHS primary-care dentistry is reformed. Moreover, the lack of dental emergency treatment is unacceptable in a civilised society: the government must provide immediate funding for many more emergency dental hubs, which can be accessed by all and not simply those in rural areas. A national water fluoridation programme is welcome and long overdue but will not solve the crisis of dental access. Professor Anne Field, FDSRCS Liverpool
Sir, When I was a child, a dentist came to school every year to check our teeth — I don’t remember anyone needing treatment in hospital. Surely the diagnostic work could be done by final-year dental students, who would gain experience and some pay. Lynn Jones Cardiff
Sir, The ten recommendations of The Times Health Commission are timely, necessary and sensible. Your ninth point makes the case for NHS staff to take part in research, proposing that 20 per cent of hospital consultants and other senior clinicians have 20 per cent of their time protected for research. The same should apply to nursing research, which is happening at the professional and technical universities we represent. I know of one research nurse who undertook a study of why patients were often malnourished while in hospital. Another nurse’s research project explored the normalisation of assaults on mental health nurses working in in-patient settings (many cite this as a reason for leaving their roles or the profession altogether). The report is right to say “thought should be given to how other NHS staff could be given protected time for research”. Nurses’ research time needs to be protected too. Vanessa Wilson CEO, University Alliance
Sir, The report by The Times Health Commission omits to address the ludicrous pay structure in the NHS. At present consultants are paid the same regardless of workload, speciality or expertise. This is totally dispiriting to those in the front line. How can it be right that a specialist in adult cognitive behaviour is paid the same as a consultant cardiac surgeon? Worse is the fact that the bright and best able doctors are going to work abroad, because they feel that their skills are undervalued and so not rewarded. Dr JRD Laycock Consultant anaesthetist (ret’d); Southampton
Originally in the printed edition by Rachel Mortimer under “Not all seriously ill citizens are entitled to free NHS care… So why aren’t they getting it?” the title is changed on line to “Why don’t the seriously ill get the free care they’re entitled to?” This disengenious change in the english language is important. Most of the care of the elderly is NOT medical. Most of it has been defined, and re-defined as “Social” and differently in each County Council , commisisioning group or funding authority. This is deliberate. It allows admittedly post code rationing, but at the same time it allows funders to ration covertly and approprately to their means. The idea that the elderly infirm should have the same quality of care in every part of the country has never been acknowledged. Ever since the state contracted out elderly, disabled, nursing and mental health care. This problem exemplifies why those with most capital should fund their own care whenever possible, and then the redistribution could be done nationally. By redistributing locally we have created a very unfair system. It reinforces NHSresality request for ID cards and means tested co-payments and rationing. The “only” difficulty is media led denial, short term thinking and honesty of politicians, and the use of “Trust funds” by the very wealthy who can end up officially without any capital, but with plenty of draw down resources if needed. Just as Palliative and Terminal care is only derisorily state funded, but is usually shorter term, the longer term care of citizens is unaffordable. It is back to business as usual this weekend after the festive season. But while many of us will have spent the past couple of weeks having a joyous time with their loved ones, this may have sown the seeds of new worries. . When families come together at the end of the year it can become acutely apparent how older members or those struggling with ill health have deteriorated — and how other relatives are finding it hard to cope as carers. Some unpaid carers do not feel comfortable asking for help, but many others do not know what support is available to them. The understanding of care in this country is murky, and few know what they are entitled to. Too many assume that they will get no support from the state if they fall ill and require care, or mistakenly believe that they will need to forfeit their home to qualify. • Dad died before he got his NHS care funding Seriously ill adults with complex health needs should be entitled to free care, at home or in a care or nursing home. This is called NHS continuing healthcare in England, Wales and Northern Ireland — it was available in Scotland until 2015 but has since evolved into hospital-based complex clinical care, which can be offered only in a hospital setting. Crucially, NHS continuing healthcare is not means-tested and a person’s assets are not taken into consideration when it is decided whether they qualify for funding. You could have £5 or £500,000 in the bank, your entitlement to free care is the same. The funding can be life changing. The average weekly cost of a nursing home was £1,241 in November, according to the Office for National Statistics. A year in a typical nursing home is likely to cost more than £64,000, a sum that would make short work of the most diligently saved nest eggs. Eligibility depends on having a “primary health need” because of illness — those who require social care because of old age and frailty will not qualify. • The £61,000-a-year care cost crisis NHS continuing healthcare is hard to secure, however. Almost 49,000 people in England were assessed for it in its standard form in 2022-23 but only 22 per cent were deemed eligible, according to NHS England statistics. In England, applications are assessed by local integrated care boards rather than by a central NHS body, and each interprets eligibility differently, creating a postcode lottery. What qualifies as a primary health need in Surrey may not get you funding next door in Hampshire. Those who have cognitive conditions such as dementia are at particular risk of falling through the cracks and the complexity of their needs can be missed during funding assessments. Perhaps it is because of this ambiguity and the strikingly low success rate of applicants that NHS continuing healthcare is so little known among those who need it most. I spoke with one reader this year who hadn’t heard of the funding despite her father having been in and out of hospital for six months before having dementia diagnosed last year. He had worked until he was 79 and paid taxes for decades, only to be kept in the dark about crucial support in his hour of need. Something has gone very wrong when patients who could be entitled to life-changing care funding are not given the opportunity to apply for it. And if they do apply and are rejected too many assume that the NHS must be right, when this is often not the case. The NHS has been forced to pay back millions of pounds after patients — or someone acting on their behalf, such as a relative, charity or lawyer — have appealed against an unsuccessful care application. You have six months to lodge an appeal, and you can secure retrospective funding dating back years. ‘How we got £90,000 back in care home fees’ I spoke with one man who won back £250,000 in wrongly paid care fees for his mother. But his fight for NHS continuing healthcare took the best part of a decade, and the refund came six years after his mother’s death. This is a sad reality. There are too many cases where relatives have spent the final years of their loved one’s life appealing against incorrect funding decisions — taking up precious time and energy that could be spent with family — only for the NHS to finally admit it got the decision wrong after the patient has died. So many people who should get help with their care will be incredibly vulnerable and without a relative or friend to fight their corner. They face raiding their savings and selling their home to pay for care that they should be getting free. Applying for NHS continuing healthcare and appealing against rejections are gruelling and time-consuming. You need to navigate a labyrinth of red tape. But regardless of whether you decide to apply, it is your right to know that this funding is available. If you know someone who is severely ill and might need care now or in the future, put NHS continuing healthcare on their radar. It could transform their quality of life.
But will commissioners and trusts be willing and able to afford all the potential noew treatments, without rationing out xome of the cheap treatments which could be delegaterd to autonomous citizens? In dispensations with “free prescriptions” the dilemma will be even more acute. The pace of tech advance is faster than any governement can afford. Some of the new cancer and strange disease treatments are so expensive that no responsible governement should fully fund them for everyone whatever their means.
Genetic Medicine – Tom Whipple, Science Editor They call them “pain crises”. For hours, days, or even weeks, people with sickle cell anaemia suffer intense, debilitating, agony, when the blood vessels to part of the body become blocked. These crises become part of their lives — something that they know could strike them down at any time. This is also the first treatment to be approved that uses Crispr, a technique for editing the genome. Sickle cell anaemia is caused by faulty genes, this treatment cures it by changing those genes. It is hard to believe it has been only a decade since the development of Crispr — molecular scissors that enable the editing of the genome. The tool has since become integral to plant science, animal science and bacteriology. Its creators have won the Nobel Prize. In 2023, the UK became the first country in the world to approve a particular treatment for the condition called Casgevy. This is great news for sufferers. The implications go far further than stopping their pain crises, though. But its great promise was always medicine: that it offered a way to hack the human body itself to cure disease. It is not surprising that sickle cell anaemia is the first condition to be treated with Crispr. It is a simple genetic condition, learnt about by generations of schoolchildren as a classic example of evolutionary trade-offs. It is also in a part of the body — the blood-making cells in bone marrow — that can be removed, tweaked, and put back in. This means there is no need to use the treatment in humans, with the risks that it might snip and replace the wrong bit. But this will not be the first Crispr treatment, and nor will those that follow be so restricted. This is the year the world gained a new branch of medicine.
This podcast from Second Opinion makes it clear that having Hep C is both prohibitively expensive and only available to the well insured and the very rich. Insurance companies will fight not to have to fund the new expensive treatments. The cost of improving technology is greater than any state can afford, unless the state waits for patents to expire, or increases the treatments excluded, (for some people, ideally in a means tested and graded system ) . The UK has always tried to exclude new treatments until the political pressure is too high, the cost is vastly reduced or the patent has expired. It was 2014 that the new treatment was announced (now 10 years later) , but it has transferred companies, been modified, and patented differently in the USA. Hepatitis C treatment advice from NHS England. The rationing of the treatment differently in different trust is unethical in any form of universal comprehensive system. The British Liver Trust says: Hepatitis C is a virus. If it is not treated it can cause serious liver damage, making you feel very unwell. Over many years, hepatitis C damage can lead to cirrhosis or liver cancer. More than 9 in 10 people with hepatitis C can now get rid of the virus by taking tablets. Most people have no side effects from treatment. Hepatitis C is currently funded by most trusts (Note not all!) , and all UK citizens have the potential for a cure.
The new rearrangement of the ministers sitting in their deckchairs on “NHS Titanic” is likely to achieve little for health care. The government does not know who to give health to – so we have another short lived minister for an organisation with a short prognosis. No waiting list reductions are likely in my lifetime…. With the highest sickness and absenteeism record in the western world, along with losing staff, increasing efficiency will be a right challenge. Like managers in the 4 health services, ministers are learning to move on before theiy can be accountable.. Managers and commissioners are stuck in the provider procurer split, where the money moves with the patient. So Wales is bust and cannot afford good care, and its citizens wait longer with the outcomes you might expect.Mr Barclay is replaced by Ms Atkins…. so?With strikes, social care void, and no meaningful manpower plan, on top of the waits….I remember putting “ergophobia” and “plumboscillosis” on sickness certificates way back….
The Times leader 14th November opines: Careless Inefficiency – Fixing low productivity should drive radical improvements Attempts to examine the NHS’s ills often alight on simple and superficially plausible diagnoses: that the health service is chronically short of funding, understaffed, or both. But it is worth seeking a second opinion. What these rote explanations cannot account for is the puzzling productivity crisis at the heart of the service. Despite a larger budget and higher staff numbers, the NHS is treating fewer patients than it did before the pandemic. To its credit, NHS England has woken up to this productivity problem; as reported in the Times, the service has contracted the consultancy firm McKinsey to carry out a ten-week review into the causes of its poor performance. Once recommendations are ready, they must be ambitiously implemented: doing so is the only way to put taxpayers’ money to its most effective use and turn around a sclerotic service. Though disputes over staffing levels and funding are often the most noticeable symptoms of disorder in the NHS, evidence suggests that neither is at the root of the service’s productivity slump. The NHS employs 16 per cent more doctors than it did four years ago, and 37 per cent more than it did in 2010. Even adjusting for increased staff absence due to sickness, manpower has increased. Real-terms funding is up by £20 billion. The mystery is why greater resources are being put to worse use. Elective surgery has slumped, as have the number of incidents recorded by ambulance services. Against the backdrop of a growing workforce, it is not obvious that throwing more staff or money at the service would do much good. Given such dismal figures, it is hardly surprising that the prime minister’s ambition to slash waiting lists looks doomed to fail. The list stands at a record 7.78 million; but this figure may well play down the scale of the crisis. More than 11 million patients are in need of follow-up care — including those waiting for referrals and cancer check-ups, or needing treatment for post-operative complications. Taking these cases into account brings the total waiting list to more than 18 million. None of this induces confidence in the NHS’s ability to weather what could be a tougher winter than last year’s, which left patients stalled in queues of ambulances outside A&E departments. Surveys of hospital leaders show that eight in ten fear this winter will be worse; only 27 per cent expect the quality of health care to be “high” next year. Just what underlies the chronic lack of productivity in the NHS is uncertain. One explanation is that though staff numbers are up, they have not risen in the right places. While there are more hospital doctors than ever, there are 2 per cent fewer family doctors than in 2019. Only one in four GPs now work full time. The knock-on effect is to increase pressure on hospital services. A higher standard of community care would also help to shift the NHS’s emphasis away from acute treatment and towards much-needed preventative initiatives. Another likely source of inefficiency is the long-term underinvestment in capital assets — buildings and equipment — within the health service. Over the same period that its workforce increased by 26 per cent, the value of its capital assets rose by 4 per cent. This looks like a particularly inefficient use of funds at a time when technological breakthroughs in the management of data and diagnostics could dramatically improve patient outcomes. Taking such innovation seriously could put a fragile health service on the mend.
Times letters 15th November: NHS productivity Sir, reports that management consultants have been brought in to boost productivity in the NHS, despite higher budgets and more staff, highlight deep-rooted management challenges (news, Nov 13; leading article & letters, Nov 14). While managers are often portrayed as a burden, the truth is that good managers run organisations effectively. Research from the Chartered Management Institute and the Social Market Foundation found that, on average, 43 per cent of NHS hospitals scoring above average in management practices achieved “high quality” outcomes — better patient care — compared with 14 per cent of those below average. Embedding a pipeline of skilled managers into the NHS, through proven routes such as degree level and senior leader management apprenticeships to upskill existing, knowledgeable and hardworking staff, is crucial if we are serious about finding a longer-term fix to the productivity problem. Anthony Painter Policy director, Chartered Management Institute Sir, A management consultancy can surely only address management. This approach may have relevance to business, but only where healthcare itself is a business can measures of productivity be easily defined and become an arbiter of good function. The NHS is not a business. It is a public service, and while the number of services it produces is one measure, the quality, accessibility, and reach of those services is at least as important and may not be captured in a business-focused review. Professor Tony Redmond Stockport
Letter follow up on NHS productivity Letters 16th November: Curing NHS ills and Letters 17th November on Productivity: Sir, A good start to improving NHS productivity would be to recognise that the NHS is over-administered and undermanaged (news, Nov 13 & 15; letters, Nov 14 & 15). Clinical teams need the support of experienced managers to reduce unwarranted variations in performance in all areas of care and freedom from overbearing bureaucratic oversight. The NHS relies on the discretionary effort of its staff and this has been eroded by the pandemic, staff sickness and chronic staff shortages. Political leaders must show they value staff and find a way of resolving industrial disputes. Investment in new buildings and technologies must be prioritised to support the adoption of innovations in care. This means not raiding capital budgets to cover gaps in running costs, as is happening yet again. The effects of endemic short termism by successive governments are now in plain sight. Professor Sir Chris Ham Solihull, West Mids
Sir, The root of poor NHS productivity is widespread unexplained variability in performance. Every NHS activity is done to world-class standards in some places but appallingly badly in others. Bringing the poor performers up to and beyond the average, as McKinsey will recommend, would improve overall productivity by 20 per cent or more. However, since there are few mechanisms for transferring best practice and extraordinarily poor understanding of what resources each activity consumes at the local level, this will be rather difficult to achieve. David Hulbert Ex-NHS trust non-executive director and McKinsey consultant, London N1
Sir, As a consultant paediatric radiologist I am all too aware of the limitations of human visual perception and remain hopeful that artificial intelligence algorithms will deliver genuine benefits to patient care (“AI tool could help prevent one in five heart attacks”, news, Nov 14). However, the direction of this research is, in my view, misguided. As technology becomes more advanced, we will doubtless be able to identify ever more individuals at risk of cardiovascular disease, but epidemiology already tells us most of the adult population is at risk. Promotion of a healthy lifestyle across the board would be a better use of resources as 80 per cent of heart attacks and strokes are preventable. I appreciate the headline “Common sense could help prevent four in five heart attacks” is unlikely to make your front page, but now we have a minister for common sense, who knows what is possible. Dr Michael Jackson Edinburgh
Sir, The management consultancy McKinsey has been brought in by NHS England to examine why it is not performing more operations than before the pandemic (“NHS failing to improve despite rise in budget and staff”, Nov 13). Perhaps they could save money by instead asking their own consultant surgeons.
The NHS has employed more surgeons, but many senior ones have gone part-time as they have become disillusioned, so the actual number of full-time equivalents has gone down. The number of operating theatres and lists is the same, so new surgeons have taken lists from older and more experienced ones, reducing the number of operations. The punitive tax regulations, which are finally being addressed, led to premature retirements and a huge loss of morale. The CPI-adjusted pay of consultants has fallen by 30 per cent in 12 years.
Did Covid influence this? Yes. Surgeons had no option but to continue to operate, unacknowledged and often without effective PPE, knowing many in China and Italy had died in similar circumstances. Why is the government deaf to all of this? Twenty-five years ago, most senior doctors were faithful Conservative voters. The systematic devaluation we have experienced has reversed that, so the government no longer sees us as worth investing in. Almost without exception, doctors used to shore up the NHS by working far beyond their contracted hours, but no work force that feels undervalued will work to its full potential. Alistair Jenkins, Hugh Gallagher, Bruce Jaffray, Joe O’Donohue, consultant surgeons; James Graham, consultant radiologist, Royal Victoria Infirmary, Newcastle
NHSreality contends that the health services are for treating fairly and equally, all the sudden and unprecedented (for an individual) diseases that are sprung upon us all at some time, and which lead to fear. The fear is that treatments are possible, but not available to all. There can be post coded differentials, or national differentials in provision, and in the latter case at least they need to be fair. Choose and book, available in England is an advantage to those with the ability, determination and funding to take advantage. It is not available in the other dispensations. A new drug for advanced Prostate cancer is not available immediately in England, but is available in the other areas. A new use for an old cancer breast treatment drug has been found: prevention. Now it is off licence. But it may not be approved equally in all the UKs 4 dispensations. Physiotherapy advice from the minister is in a dream world. 15 hours a week after a stroke! Not one area of the UK can offer this, and although relatives might be trained, what about those without advocate / relatives? If the health services are to be cradle to grave, why is palliative and terminan care only part funded? (and birth is fully funded). If it is really to cover everything for everyone for ever everywhere and for free why do we have pharmacy charges, eye charges, dental charges etc? Although health education, including about fitness is a duty of the state, use of media is relatively cheap. Dr Whitty is correct, but it is a distraction from the insurance based systematic safety net we were meant to have.As things get worse we need to ensure horizontal and vertical equity equity should be seen and accepted… Commissioners have no role in this – only politicians.Without GPs(see downloadable pdf below) , access will be inefficient, there will be too many referrals, and too many investigations by “physician assistants”. The system will clog up and be even more expensive. Those with the means will go privately – more and more. The Chartered Society of Physiotherapists: 10th November 2023: Chris Whitty’s annual report highlights vital role of physiotherapy amid ageing population in England – The Chief Medical Officer (CMO) for England, Chris Whitty, has published his annual report, highlighting the health challenges posed by the country’s ageing population. The CSP has welcomed the report, which focuses on areas such as falls prevention, physical activity and maintaining independence into old age. Responding to the annual report, Karen Middleton, chief executive of the CSP said: ‘We welcome the publication of the CMO’s annual report, with its clear focus on the country’s ageing population and prevention. To echo the CMO’s sentiment on living well in old age, physiotherapy has a vital role in adding life to years and, where possible, years to life. ‘There is a clear message to the medical profession in this report that growing multi-morbidity requires more generalists than specialists. This is something that the physiotherapy profession has recognised and is adapting our training to. It is also encouraging to see physio specifically mentioned in the report, particularly around falls prevention, with independence and physical activity also key themes where physio plays a pivotal role, running throughout the report. ‘The geographical challenges highlighted speak to the need for investment in community rehabilitation, and for it to be accessible closer to where people live, not just in acute hospitals or major population centres. This aligns with the CSP’s belief that everyone has a right to rehab, no matter where you are in the country. ‘Any investment in rehab services, however, must include the workforce to deliver them. By highlighting AHPs throughout the report, it sends a clear message that investment in these essential roles must not be overlooked.’
I contend we need to give “hard truths” on many issues, including health We need to redefine what the 4 health services are for, and where/ for what services patient autonomy is more important than state paternalism . We can reinvent the wheel or we can copy a service that works already. NZ, Australia and Canadian states are relevant models, as is most of the EU . Liberal conference has always ducked “hard truths” but the nation is ready for them. ID cards will follow seat belts as essential..and reluctantly accepted ID cards (virtual and physical) will allow means tested copayments for all healthcare whilst standards rise from the current nadir . During this period the two tier system has to be reluctantly accepted, until we choose our model(s). John Britnell was unable to mention “rationing” and unable to choose between systems as various had some parts that were better than others. In John Bretnall’s book, “in search of the perfect healthcare system” he acknowledged that some bits could be taken from different systems (mental health from Holland?) But he fails to use the honesty of ” rationing”. There is no government that can keep up with the cost of all new technologies, treatments, advances, and therefore rationing is essential. The shape of my former job as a GP has changed beyond recognition since 1976 when I began. (see graphic below) . The young doctors in GP training realise that their reality will be very different from the taught theory implying long term relationships and advocacy with a varied day. So they have the options of a different UK medical career, going to another country with their well respected degree, or changing to a different career. For someone used to handleing complexity and multi tasking there are many more attractive opportunities. ( see second graphic below). Yes the waiting lists may be long in Southend, but they are longer in Wales!
It is a “hard truth” that very few child graves are evident in graveyards after 1952, When did vaccination start? It is evident that good dental care has reduced the incidence of Heart Valve Disease and untreatable oral cancer. Both these are likely to increase in the years ahead as access to NHS dentists becomes harder and harder. It is evident that cancer survival has increased, for most common and some rarer cancers. It is probable that Cancer Cervix will kill far fewer people, but this will be due to the HPV vaccine more than to cervical screening. The same may be true in 10 years time for Cancer Breast. How to we tell the “hard truth” that its time to disinvest from, or charge for, some screening services? How do we address the lack of progress on sepsis over a decade? How do we reinstate the Public Health system that would have helped prpare and deal with a pandemic better? How do we reinstate post mortems: the truth is out there but we wont find it out. How will we make junior doctors feel valued and stay in the UK, and how will we make oldies feel they want to work on in the interim? How can we manage a service divided into 4 with different rules and it be fair? How can we reduce the cost of the last year of life? How can we bring back choice? How can we reduce gagging and increase whistleblowing, and be honest about near misses and significant events? How can we bring back teams and improve training standards back to whatb they were before EU working time directive was so aggressively implemented? How can we reduce tribalism in maternity care, ensuring consultant led care for all mothers in an ageing demographic with high risk? How do we make young people feel their vote counts? How do we depoliticise health so that its not an issue at each election? How do we manage waiting lists fairly and avoid a two tier system which does not have the consent of the people? How do we get honest politificans to debate the above issues? How do we get fewer jokers and chancer/gamblers putting themselves forwards as politicians? How do we stop the abuse and trainign degradation of trainee doctors? How do we get meaningful exit interviews and feedback, from all employees and patients, including commissioners and board members? nd Am I in Wales still part of a National Health Service?
The Sunday Times leader 12th November 2023: As the NHS waiting list keeps growing, our leaders keep quiet -No one is addressing that millions are waiting for operations Thursday’s news that the NHS waiting list had hit yet another record high, with 6.5 million patients needing 7.8 million operations, was the latest data point on the road to a dystopian reality. But, as we have noted before, it was barely acknowledged by a political class that has long since switched off when the subject of healthcare reform is raised. Our data editor, Tom Calver, visited Southend, the conurbation in England with the highest number of operations needed per capita. His report includes comments from a 64-year-old man who could barely walk by the time he got a hip operation on the NHS. “I think they delay saying you need the op,” he said. “I had a scan, and was told they would ring me in six weeks. I waited — delay, delay, delay — until I rang them and they said, ‘Oh no, you were supposed to call us!’” The degradation of trust in the NHS, which consumes almost 40p in every pound spent on public services, is dangerous. We are tacitly moving towards a system in which the wealthy pay to go private for scans or surgery while the less well-off are left to suffer in silence. Steve Barclay, the health secretary, has been preoccupied with procuring more beds in care homes to ease the strain on hospitals, setting out a much-delayed NHS workforce plan and holding the line in pay disputes with striking doctors. Wes Streeting, his opposite number, speaks sense about boosting primary care, preventing illness instead of simply treating it and reform rather than blank cheques. But both parties are falling well short of providing the detailed answers Britain needs. Another data point arrived on Friday, showing the economy was flat in the quarter to September. With little growth and the tax burden already so high, the pips are squeaking. Creative thinking will be needed.
The ageing demographic and a universal non-means-tested benefit are recipes for covert rationing. Educated, patient and informed families will have more success in the quagmire of fighting with their local Health Commissioners: after all there is a £53k-a-year care timebomb we can’t afford to ignore. The rationing, deceipt and delay of continuing health care – which is not meant to be means tested. Posthumous success is no consolation.. The Times 28th October 2023: Dad died before he got his NHS care funding – NHS approval rates for some types of long-term care are as low as 20 per cent — with dementia suffers such as Annette Chidgey’s father particularly likely to be turned down Six months after Annette Chidgey’s father, David, was diagnosed with vascular dementia in 2019 she applied to the NHS for help with care costs. David was in the late stages of the disease with serious complications and his wife, Shirley, was in her eighties and struggling as his full-time carer. David should have received funding under NHS Continuing Healthcare (CHC), which covers the cost of care for seriously ill adults, but his application was refused twice. In 2022 the NHS reversed its decision and admitted he had been entitled to free care, but it came too late — David died in May 2021.
Chidgey and her family are one of thousands who are denied NHS CHC every year. The funding is notoriously hard to secure. Almost 49,000 people in England were assessed for standard NHS CHC in 2022-23, but only 22 per cent were deemed eligible, according to NHS England statistics. The funding is not means-tested, meaning that a person’s assets are not taken into consideration when deciding whether they are eligible. For those who do qualify, the funding can be life-changing — the average weekly cost of a nursing home was £1,228 in September, having jumped by 10 per cent in a year, according to the Office for National Statistics. But families, charities and lawyers have warned that the application and assessment process for funding is slow and draining, and that decisions vary greatly across the country. Applications are assessed by local integrated care boards, rather than a central NHS body, and each can interpret eligibility differently, creating a postcode lottery. Chidgey fought for more than two years for the funding her family was owed. She is a retired litigation solicitor, having given up work to help to care for her father in his final years, but not even her legal training could have prepared her for the ordeal. “I felt angry, frustrated and stressed throughout the entire process and didn’t feel I could fairly participate in a process which was so flawed,” she said. “The form completed by assessors is inherently prejudicial against people living with dementia. Assessors were focused on finding reasons why my dad was not eligible rather than taking a balanced approach. His needs were minimised, and my views were discounted and ignored.” David was also registered blind and had a diagnosis of depression and type 2 diabetes. When he was assessed for NHS CHC for a second time in March 2021 he was living in full-time care because the family could no longer safely look after him at home. Chidgey said that assessors in the case did not meet her father and did not discuss his care with the nursing home, instead relying on care home records. She eventually successfully appealed against the funding decision last year, but says the process has left her shaken. “Families are physically and emotionally exhausted from providing care. It is totally draining. My dad is no longer here but the CHC process has left a huge scar on me, and I feel incredibly angry about the way he was treated,” she said. Dementia and other cognitive conditions frequently fall through the cracks during funding assessments. Andrew Pike from the charity Dementia UK said: “NHS CHC can be a lifeline for many families living with dementia. However, the system is flawed and is causing huge distress. “The national framework used for the process fails to recognise that dementia is a complex, challenging and progressive condition. The needs of people with dementia are often misunderstood, underestimated, and incorrectly assessed.” In a survey of more than 1,770 people who knew someone with the condition, carried out by Dementia UK, 5 per cent said they had been successful in completing a full CHC assessment. Last week the charity launched its “Fix the Funding” campaign, calling on the government to review the CHC process to meet the needs of patients with dementia. Families who are refused free care for seriously ill relatives are instead selling homes and raiding savings that had been set aside for inheritances to pay the bills, said Jemma Garside from the law firm Kingsley Napley. “I have a client who has put a charge on his property to pay for his wife’s care because he can’t do it on his own, but has been turned down for NHS CHC. He feels like they’ve been abandoned,” Garside said. But a rejection for funding does not necessarily mean the NHS is in the right. You have six months to appeal a decision and can also secure retrospective funding, although often the support is granted long after the patient has died. Dan Harbour from Beacon, an organisation which helps people to appeal against NHS funding decisions, said: “So few people are found to be eligible at the initial assessment stage. But over the past 18 months we have been winning most of our appeals — this has shifted, because at one point there felt like there was just no accountability from integrated care boards when challenged,” Harbour said. “But it’s hard to navigate the appeal process without support. Families are often exhausted and emotional.” When an integrated care board writes to a patient or family to notify them of a failed application, they are required to tell them about the six month appeal window, though Harbour said this does not always happen. The Department of Health and Social Care was approached for comment.
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