Category Archives: Commissioning

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

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

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

Repeat Offenders

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

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

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

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

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

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

South Wales NHS: Plan to centralise services on five sites


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

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

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

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

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

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

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

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

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

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

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

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

Squeezed to breaking point?

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


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

Navigating the system

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

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

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



Perinatal Mental Health Care: Post Code Rationing, for citizens who pay the same taxes and deserve the same services.

Perinatal Psychiatric care is disproportionately provided around the country. Mother and child units offer the best solution, keeping the family together and offering specialist support.

Numbers: It is anticipated that there will be at least 1300 admissions per year nationally. It is estimated that 0.25 In-Patient Mother and Baby beds per 1000 live births will be required (if Specialised Perinatal Community Mental Health Teams are available) or 0.5 per 1000 if no Specialised Teams are provided. There is no doubt that specialist services save lives in this very unpredictable but serious condition. Patients in Wales have no service and have to leave the Region and go to England. Since money moves with the patients, Wales hates having to pay up for its most severely psychiatrically ill, and patients from West Wales have to travel vast distances. I understand there was a unit for treatment in Cardiff but this has now closed. Is this prioritisation, restriction, reduction, limitation, or rationing? In 5 years there are not enough signatures for a debate on this issue….

Specialised Perinatal Mental Health Services (In-patient Mother and Baby Units and LinkedOutreach Teams – In England

In 2003 M Oates published Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality in the British medical bulletin

and in 2014 Samantha Meltzer-Brody and others, published Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit in Springer Link

The Maternal Mental Health Alliance publishes a map of the UK with a description of what services are available.

38 degrees started a website “No mother and baby unit in Wales” some 5y ago, and have failed to get enough signatures to their petition asking for a debate.

The Maternal Mental Health Alliance published 16th June 2018: New mums face gaps in vital specialist mental health services in Wales

and on 6th February 2019 Sophie Bennet for RadcliffesLeBrasseur reports: Perinatal mental health services: Where are we in Wales?

In January 2019, Cabinet Secretary for Health and Social Service, Vaughan Gething AM, met with the Children, Young People and Education Committee to discuss the progress of recommendations provided in the October 2017 report on perinatal mental health services.[1]

What is the perinatal period?

This extends from conception to the end of the first year of the baby’s life. This is a crucial time in a woman’s mental health and that of her baby. One in four women experience mental health difficulties during this period.[2]

Main issues identified in 2017:

  • Lack of a mother and baby psychiatric unit in Wales
  • Inconsistencies in the existing services
  • Lack of continuity in care
  • Need to de-stigmatise and normalise the mother’s experience

In a letter to the committee published in October 2018, Mr Gething outlined plans for each of the recommendations. This included a deadline for June 2019 to extend the ‘More Than Just Words’ initative to increase the presence of Welsh language options in the service.

Progress in relation to the recommendation for all Local Health Boards to have a specialist perinatal mental health midwife as five of the seven Health Boards in Wales have implemented this, while one has a specialist perinatal health visitor.

Mother and baby unit

A key focus of the meeting held in January was the fact that there is still no mother and baby psychiatric unit in Wales. Mr Gething explained that in South Wales one cause for the delay was difficulty in agreeing the location of the unit and how it is to be run. Initial interest in housing the unit has reduced to only the Abertawe Bro Morgannwg Health Board.

Meanwhile, in North Wales a lack of women who require a unit is a cause for the delay with ongoing conversations with NHS England to block book beds. Currently women in North Wales have to travel to Manchester or Birmingham to attend a unit with facilities to host them and their babies. NHS England is unwilling to create a unit closer to the border and the success in a similar scheme in England has resulted in a decrease in the number of women referred.

Committee members noted that the mother’s support network are included in the perinatal mental health initiative and removing the mother from her family and partner may be counterproductive.

Future requirements for Local Health Boards

The Assembly currently expects Health Boards to publish data concerning perinatal mental health. However this is not mandatory. This was questioned by the committee and Mr Gething explained that this was a period in the run up to mandatory publication.

Information that would be collected included time frames from referral, assessment and treatment, the experience of the mother and her improvement.

Practical take away

NHS England began a later but similar review which has been more successful. Mr Gething stated that NHS England itself is uncertain as to why its scheme has been more successful in a shorter period of time.

It could be suggested that the perinatal mental health services are another example of the differences between the devolved health care systems.

Scotland’s first Mother and Baby Unit is located at Leverndale Hospital in Glasgow#

The West Lothian Perinatal unit

And in Norther Island there are calls for a unit where there is none (as in Wales)

This is Post Code Rationing, for citizens who pay the same taxes and deserve the same services.

Its easy to say you will fund a treatment, but much harder to say what you won’t fund. How long will the English and Welsh hold out against the media led pressures? Emergency loans for Trusts merely delays the inevitable.

In the National Institute for Health and Care Excellence (NICE) website:

One QALY is equal to 1 year of life in perfect health. QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality-of-life score (on a 0 to 1 scale).

In Wikipedia a QALY year is defined: Quality-adjusted Life Year


Quality-adjusted Life Year
The quality-adjusted life year or quality-adjusted life-year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value for money of medical interventions. One QALY equates to one year in perfect health. If an individual’s health is below this maximum, QALYs are accrued at a rate of less than 1 per year. To be dead is associated with 0 QALYs. QALYs can be used to inform personal decisions, to evaluate programs, and to set priorities for future programs.

In “Carrying NICE over the threshold” ( 19th Feb 2015 ), Professor Karl Claxton suggests that paying more than £13,000 per QALY for technologies “does more harm than good” by displacing other more effective healthcare from the NHS.

In Scotland it appears that they are taking a lead in commissioning treatment that is very expensive, but effective in prolonging life, for Cystic Fibrosis sufferers. This induces perverse behaviour in families of sufferers, and, in addition, fails to point out what services will be weakened, or not funded, since the resources are limited.  . Cystic fibrosis: Father considers Scotland move to access new drug. BBC News 20th September 2019.  In the end it has to be politicians, with public consent, who agree how to ration. We can afford the CF treatment, but only if we ration high volume low cost treatments, or other more expensive treatments, out. Decisions like that in Scotland, without equivalent saving decisions will make the Health Service (s) worse, and the differences between the haves and the have nots worse. The main expense in the health services is spent on its greatest asset: staff. These are no longer feeling valued, and those that can are making hay as locums. This is an even greater burden to their health services than expensive treatments. Add to this the cost of infections (longer stays and expensive treatments) and litigation, and it is evident that England is correct in putting its population before its CF individuals. How long will they hold out against the media I wonder? Sepsis and Litigation are much larger problems. Emergency loans for Trusts merely defers the inevitable…

A father has spoken of his agonising dilemma about whether to leave England and move to Scotland so his daughter can access life-prolonging medication.

Dave Louden’s four-year-old daughter Ayda was diagnosed with cystic fibrosis shortly after she was born.

The family live in Carlisle, 10 miles (16km) from the Scottish border, where a new drug has become available.

However, despite the position in Scotland, NHS England said the drugs were not cost-effective.

Costing £100,000 per person per year, Orkambi and Symkevi improves lung health and life expectancy for sufferers of cystic fibrosis.

Patients in Scotland can access the drugs after the Scottish government agreed a “confidential discount” with the pharmaceutical company Vertex.

Cystic fibrosis affects about 10,400 people in the UK and causes fatal lung damage, with only around half of sufferers living to the age of 40.

Mr Louden said it was “heartbreaking” that his daughter could not get the treatment…..

‘Life-changing’ cystic fibrosis drug deal for Scotland is welcomed BBC 20th September

BBC News 16th September: Review launched into Aberdeen hospital project costs

BBC News 20th September: Hospitals relying on ’emergency’ loans

Huw Pym 19th September: How much does diabetes cost the NHS?

Jonathan Ames 14th September in the Times: Locum ruling will cost NHS millions

NHS long term plan to reduce toll of NHS Long Term Plan to reduce toll of “hidden killer” sepsis

Sarah Neville in the FT 7th September 2017:  Cost of NHS negligence claims quadruples to £1.6bn in decade – Soaring bill affects quality of care and increases financial pressure on trusts

Dont ration hearing aids if you want to reduce early dementia (as well as falls and depression), and avoid Regional Disparities

Some health trusts have been reducing the number, access, and quality of hearing aids. This is particularly prevalent in Wales. The message from a large study in Michigan is that this is an important population measure: keep access to the best hearing aids available to all and avoid post code and regional discrimination. England currently offers WiFi connectivity but Wales does not. We pay the same taxes!! Hearing aid technicians often leave NHS (all 4 dispensations) to set up privately. Exit interviews would reveal why.. There is a mixture of management, resource and quality issues which drive them away after being trained at the state’s expense. Are Trusts and Commissioners suffering from selective deafness?

Image result for selective deafness cartoon

Andrew Gregory in the Sunday Times a5th September 2019 reports: Hearing aids cut risk of dementia, falls and depression

Wearing hearing aids can dramatically reduce the risk of dementia, depression and serious falls, according to the largest study of its kind.

The analysis found the risk of developing dementia within three years of being diagnosed with hearing loss fell by 18% for those who used hearing aids, compared to non users. The risk of falls fell by 13% and of depression by 11%.

In July, a study of 25,000 adults found aids improved memory and attention.

Elham Mahmoudi, a health economist at Michigan University who led the study based on 115,000 adults, said: “We already know that people with hearing loss have more adverse health events . . . but this study allows us to see the effects of an intervention and look for associations between hearing aids and health outcomes.

“Though hearing aids can’t be said to prevent these conditions, a delay in the onset of dementia, depression and the risk of serious falls, could be significant. We hope our research will help clinicians and people with hearing loss understand the potential association between getting a hearing aid and other aspects of their health.”

Beth Hartley, 29, a food manager for Sainsbury’s, said hearing aids changed her life after she was found to have hearing loss at the age of five. Hartley, of Wheathampstead, Hertfordshire, whose grandfather had hearing loss in later life and had dementia when he died, said: “I consider wearing hearing aids incredibly empowering — both in the short term for integrating socially and in the long term for my mental and physical health.”

Rebecca Dewey, a research fellow in neuroimaging at the University of Nottingham, described the new study as “compelling”, adding: “Too much of the time, hearing aids sit in a drawer to the direct cognitive disadvantage of the person.” Around 7m Britons could benefit from aids but only about 2m use them, research suggests.

Roger Wicks, of Action on Hearing Loss, said: “With the number of people with hearing loss predicted to rise to one in five by 2035, and with the link to dementia increasingly clear, more must be done to encourage greater take up of hearing aids.

“Some areas of the country already have restrictive policies on hearing aid provision — going against all clinical guidelines — in a misguided effort to make short-term savings.”

James Connell, of Alzheimer’s Research UK, said the key advice to ward off developing the disease was not smoking, drinking within recommended guidelines, staying mentally and physically active, eating a balanced diet and keeping blood pressure in check.

The Mirror: Hearing aids can reduce the risk of dementia and depression …

Rob Andrews for Stoke on Trent live reports 5th September 2019:  Will you be affected? Thousands of Stoke-on-Trent patients …




Don’t believe we are rationing? Do you believe in transparency and honesty? Why not use the correct word?

Just in the last few days these news items reveal the truth. Despite this the “R” word can never be acknowledged by politicians. None since Enoch Powell has embraced the truth. (Described by Richard Smith, former BMJ editor as “the best book written on the NHS”. A new look at medicine and politics: 1975 and after. Pitman Medical 1976. 2nd edition. ) 

Link to his book published by the Socialist Health Association

Why do you think we had no PET scanners until 20 years late! Why are there waiting lists longer than any other G7 country (and the results to match)? Why have the two countries that emulated the original NHS reconsidered? (NZ and Scandinavia). Why are we only appointing 1 doctor for every 10 who apply and have been encouraged to do so by their careers officers? Why are botched operations so commonplace?  Why does the NHS Ombudsman produce reports which have no notice taken? Do the politicians read these reports?

If you believe in honesty and transparency why not use the correct word? We will never win the hearts and minds of the health service staff if politicians and media and public collude in the language of denial.

Henry Bodkin in the Telegraph 14th September 2019: NHS bosses tried to “gag” father of boy whose life was ruined in botched operation

In The Guardian 30th August 2019 Dennis Campbell: ‘Crumbling’ hospitals putting lives at risk, say NHS chiefs  –  Four in five NHS trust bosses in England fear Tory squeeze on capital funding poses safety threat

Why cannot Cheshire recruit enough GPs? Pulse reported by Lea Legraien 14th September

Why do we still get fraudulent managers promoted (The Independent 19th December 2018)

Why are half of the 4 health services’ trusts using out of date radiotherapy equipment? ( Andrew Gregory in The Sunday times 15th September 2019 )

This is particularly important for Pembrokeshire and West Wales as we have a long distance over difficult roads to travel to Swansea at present. Our planned new Hospital, wherever it is, needs Radiotherapy, Radio Isotope Investigations, and STENT treatment for Coronary Heart Disease if our options are to be the same as those in more favoured areas. I reproduce the article at the bottom of this post.

Adam Shaw for the Harrow Times reports 13th September 2019: North-West London CCGs dismiss claims of “rationing” services.

Kat Hopps September 13th in the Express reports: IVF: How NHS IVF treatment is unfair postcode lottery and keeps couples childless

A disgrace and a shame on politicians: “Surge in patients raising own cash for amputations”. Rationig by waiting and by incompetence.

Pembrokeshire Oncology cancer services in crisis

There is a “need to put doctors in charge and force them to take account of patients’ views. Cancer survival rates are (just) one of the prime examples of NHS mediocrity.”

Desperate NHS needs a desperate remedy – care is already rationed

The 3 myths of the NHS…..& …No learning from other countries – no co-payments, and more scandals..

Britain ranked last (out of 20 rich countries) by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.

Why are half of the 4 health services’ trusts using out of date radiotherapy equipment? ( Andrew Gregory in The Sunday times 15th September 2019 )

Almost half of NHS trusts are using outdated radiotherapy machines that are far less effective at killing cancer cells to treat patients.

The revelation comes days after the UK came bottom of an international league for cancer survival rates in The Lancet Oncology journal.

In 2016 the NHS said it was investing £130m in upgrading radiotherapy equipment but the figures, revealed via freedom of information requests, found 46% of trusts are still using outdated linear accelerator (Linac) machines beyond their recommended 10-year lifespan.

Dr Jeanette Dickson, president of the Royal College of Radiologists, said more advanced radiotherapy techniques enable “greater precision when targeting specific tumours and have been shown to be less harmful to surrounding tissue than older types of radiotherapy, depending on the complexities of the cancer being treated”.

Rose Gray, policy manager of Cancer Research UK, said it was “deeply concerning” to hear outdated radiotherapy machines were being used.

She said: “The NHS has grappled with the question of how best to replace outdated equipment for many years, and the government has repeatedly been urged to put a long-term plan in place.

“But . . . that still hasn’t happened. These investigation findings prove the urgent need for a solution to this persistent problem.”

In total, 57 of the 272 Linac machines used this year are 10 or more years old. One of them that is still in operation has been used for 17 years.

Dr Peter Kirkbride, the former chairman of the government’s radiotherapy clinical reference group and spokesman for the Radiotherapy4Life campaign, said: “That radiotherapy has been put on a lower footing than other cancer treatments — such as chemotherapy — by successive governments is an open secret within the NHS.”

The Liberal Democrat MP Tim Farron, chairman of the all-party parliamentary group on radiotherapy, described the figures as “shocking”.

He said they proved the investment in 2016 had been a “drop in the ocean” when compared with what is required to meet soaring demand.

Saffron Cordery, deputy chief executive of NHS Providers, which represents hospitals, added: “What we do know is that for year after year, money earmarked for capital investment has been siphoned off just to keep services running.”

An NHS spokeswoman said 80 radiotherapy machines had been upgraded since 2016 and patients were benefiting from “a range of improvements” to cancer services.

Enoch Powell 4 Supply and Demand – Rationing


Hip and IVF rationing – the thin edge of a web of denial

The rationing around hip replacements not only causes pain and depression, and lack of mobility, but it accelerates ischaemic heart disease, obesity from inactivity, and diabetes. This means more hart attacks and strokes than we need to have as a nation. The profession knows all this and when we are in need we may be in a post code with well managed waiting, but we may be in a poorly managed or funded trust, perhaps with a shortage of long term staff. Manned by a succession of locums the result is more infections and complications. No wonder many people vote with their feet and go privately. They can choose their consultant, when they are operated on, and reduce risk greatly to avoid complications.

What is so silly is that the government does not admit to rationing at all. If it did we would rightly wish to know the how, why, where, when and what was not available to us all… it is only when this type of honest discussion is possible that things will change. 

In the last week I have heard first hand of different rules regarding wheelchairs for paraplegic and legless patients, hearing aids (In England they have WiFi compatibility but not in Wales) and expensive drugs for rare conditions. We have to ration overtly…

Meanwhile they will get worse, and the unofficial, unintended (presumably) two tier system will extend…Just wait until it affects YOU, or your nearest and dearest.

Max Pemburton in the Daily Mail 24th August 2019 waxes lyrical about his gran’s waiting for her Hip replacement.

On the same day in the Telegraph Dev Chakravarty asks: Why shouldn’t single women be able to have IVF on the NHS

Aside from the fact that there is no NHS, the rules in Wales and England, and from Trust to Trust and Post Code to Post Code are different.

Since it is funded by the taxpayer, there will always be a degree of rationing in the services the NHS offers patients for free at the point of use. The debate over which services it provides, based on which criteria, is therefore a constant in our public discourse. There are few areas more sensitive than the provision of IVF.

The NHS limits access to IVF in all sorts of ways in different parts of the country, but the reports that NHS South East London is to bar all single women from receiving funding for such treatment were startling. In justifying its decision, which is now under review, the authority controversially cited a document which declared: “A sole woman is unable to bring out the…

Image result for web of denial cartoon