Category Archives: Commissioning

Operation delayed? Should waiting lists be prioitised according to employment and age?

When I was in desperate need for a hip replacement, and a working self employed GP aged 52 (2001), I was under the care of a Welsh Health Service consultant. I have a locum insurance policy meant to cover this situation. I agreed to go in on a Thursday, with about 2 weeks notice. I arranged a locum, and signed an agreement with him for 6 weeks cover. 2 days later the operation was delayed due to an emergency infected hip replacement. A quick calculation revealed that it would be better to go privately (on the Friday of the same week, with the same consultant) than to accept the delay. Such delays are unknown for infections in the private sector, and all cold orthopaedic units have much fewer infections. Now that waiting lists are getting out of control, should we have logical rationing by prioritisation of the waiting queue? Perhaps readers think this is facetious, but cancers could be ranked by age (Youngest first), and cold operations such as hip replacements could be rationed according to a mixture of age, and employment: self employed being before the employed, and both before the retired and aged?

Another incentive for Private Medical Insurance / direct payment, and two tiers.

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Are you lucky enough to live in a post code where there is a cold orthopaedic option?

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Chris Smyth reports 4th Feb 2019: Wasteful NHS delays 1 in 3 operations

Almost 300,000 patients a year miss out on surgery because of delays and inefficiencies in operating theatres, an NHS watchdog report has concluded.

A third of operations start late because staff do not turn up at the same time, equipment is missing, beds cannot be found or there are other administrative problems, NHS Improvement found. Hospitals could boost the number of routine operations by 17 per cent through basic efficiencies and some surgical teams could be treating more than half as many patients again, it said.

More than four million patients are on waiting lists for non-urgent procedures such as hip replacements. The figure has been rising as hospitals struggle to keep pace with demand from an ageing population. Waiting targets have not been hit for three years and NHS leaders fear these guarantees are about to be scrapped.

The report, which looked at eight areas of surgery in 92 hospitals, said that they could carry out 291,327 more operations a year with better planning. Poor scheduling meant that 38 per cent of surgical lists finished early enough for another operation to be performed. Hospitals were urged to make staff have holiday approved six weeks in advance, and operating lists approved four weeks in advance and checked two weeks in advance, which has been shown to reduce cancellations.

Tim Briggs, national director of clinical improvement for the NHS, said: “While waiting times for surgery are lower than they have been historically, more can be done.”

Mouth and face surgery in two hospitals was found to be so inefficient that they could have boosted patient numbers by more than 80 per cent with better planning. Seven plastic surgery centres could have increased cases by more than 50 per cent, as could one urology team and two gynaecological centres.

Rachel Power, chief executive of the Patients Association, said: “Patients needing hip and knee replacements, shoulder surgery or other non-life-saving treatments should not have the uncertainty of a long wait for their pain to be alleviated. We are pleased to see new initiatives giving patients and their loved ones increased certainty over when their procedures will take place.”

Surgeons and NHS bosses protested that a serious shortage of beds was contributing to inefficiency. Ian Eardley of the Royal College of Surgeons accepted that while “every member of staff and patient can recite examples of waste”, the NHS had the second lowest number of beds per patient in the EU. “Such shortages mean time is wasted by NHS staff in freeing up beds instead of treating patients,” he said.

Amber Jabbal of the hospitals’ group NHS Providers said: “There are opportunities for efficiencies to be made. However, theatres cannot be viewed in isolation and we have to be realistic about the current resources in place. Often cancellations and down time for theatres are because of staffing levels, patient needs and the availability of beds across the system.”

Stephen Hammond, the health minister, said: “I hope to see these innovative and clinically-led proposals — many of which are based on what is already working across the country — adopted by trusts wherever possible.”

The Independent: Patients facing long delays for operations because of NHS …

Hugh Pym for BBC news 4th Feb: Could NHS have been doing more operations?

The number of patients waiting longer than 18 weeks for routine operations such as hip and knee replacements is rising year on year in England.

The total waiting list of more than 4.1 million is up more than 10% over 12 months…..

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

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Patients “hurt by hospitals that merge”…..

The Times printed a piece by Kat Lay which will stir the embers of injustice in the Welsh Valleys. On 5th Feb she writes: Patients “hurt by hospitals that merge”, but the article is not “on line”. Choice has been limited within Wales for a few years now, and different CCGs in England take differing approaches. A second opinion in Wales can be sought easily if its within ones own trust (where all specialists in a department meet regularly and think the same) but to get a genuine second opinion is not possible without private means.

Merging hospitals will improve standards, but it should not exclude choice and second opinions in a liberal society. You might argue that our 4 Health Services are in such a parlous state that the restriction to individual liberty is justified by the gain to the population as a whole. John Stuart Mill argues that this is the only justification for such restriction of liberty. Hence taxation is justified, health and education are mutualised, and social safety net has moved on from the poor house or the workhouse.

In areas where travelling time is significant, transport systems are relevant to quality of care.  There is a big difference between A&E attendance (speed, access) and cold referrals  (quality, choice). A government that put its money into prevention should then focus more on cold referrals if you are unlucky enough to get a “black swan” condition, or need A&E. 

I happen to live in a rural area, with a soon to be closed teaching hospital. I live in an area with poor and slow transport. The road east can be blocked by dozens of agricultural or industrial HGVs. My chances of a stent to save my heart attack, or clot busting treatment for a stroke, of killing me, will be much greater that those who live within 20 minutes of a merged facility….  depending on where it is located. Air ambulance is a charity, and we cannot depend on helicopters as the numbers are too large.

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Patients “hurt by hospitals that merge”. 5th Feb 2019, Kat Lay in the Times.

Hospital managers harm patients because they reduce competition, according to a watchdog report.

A typical merger plan costs the NHS more than £2.5m a year as a result, the Competition and Markets Authority found.

The report said that falls, pressure ulcers, blood clots and Urinary Tract Infections could almost treble if a merger created a local monopoly. It also estimated that deaths could increase by almost 500%.

Health policy experts said that the findings were interesting but questioned the watchdog’s conclusions. Nigel Edwards (Formerly policy director of the NHS England), chief executive of the Nuffield Trust, told the Health Service Journal: “The conclusion that a merger will increase death rates is completely illegitimate and an over-extension of the analysis because there are other factors driving this”. They included whether a hospital was in a rural area or used for teaching, he said.

The study used NHS statistics from 2013-15 across eight hospital specialities that covered about two thirds of admissions. Since 2006 patients ( In NHS England, not Wales or Scotland) have had the right to choose the hospital where they receive treatment.

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Rationing in CF and Cancer

We could afford all the drugs for all “rare” and “minority” conditions if we rationed health care overtly. We could start with exclusions (eg paracetamol) and co-payments.  The ability to alter genetic information may, in future make disease such as Cystic Fibrosis limited to those generated by two new mutations. In a dominant genetic condition this has to be accepted, but in a recessive condition, where two carriers have to breed to get the recessive trait, we may be able to abolish the condition. 

Is there is a perverse outcome in a universal health care system. Why are nearly half those living with CF in the UK?

More than 30,000 people are living with cystic fibrosis (in the UK) (more than 70,000 worldwide). Approximately 1,000 new cases of CF are diagnosed each year. More than 75 percent of people with CF are diagnosed by age 2.

It is clear that the pace of technological advance is faster than any state’s ability to pay, unless they ration overtly. Same for Cancer. If the state won’t pay, a two tier system happens by default. 

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Chris Smyth reports 5th Feb in the Times: ‘Hundreds die’ after being denied cystic fibrosis drug

Hundreds of patients have died during a three-year wrangle over a cystic fibrosis drug, say campaigners who want action to break the deadlock.

Parents of children with the genetic disorder have criticised the makers of Orkambi, accusing it of holding out for a price it knows the NHS cannot pay.

Vertex, the manufacturer, says it would go out of business if every country paid what the NHS is offering, and had to recoup billions spent on research.

Christina Walker of the CF Support Group said: “There has been a catastrophic failure over a prolonged period of time. We can’t say how many of those patients would be alive but a proportion, if they had been treated, would be.”

Orkambi would improve lung function for about half of England’s 8,200 patients with cystic fibrosis. It would also slow patients’ decline and, it is hoped, extend lives. However, its £104,000 per patient per year cost was rejected.

Matt Hancock, the health secretary, accused Vertex of attempting to “hold the NHS to ransom” and “rip off the taxpayer”. Yesterday the Conservative MP Bill Wiggin used an adjournment debate to demand that ministers activate a rarely used legal provision called crown use, allowing the government to make generic versions of the drug for about £5,000 per patient per year.

Ms Walker, who backs the plan, has organised a letter from dozens of doctors to Vertex, estimating that 220 British patients eligible for Orkambi had died since the drug was licensed in late 2015. She said it was “heartbreaking” to see her eight-year-old son, Luis, getting sicker, estimating he had lost a quarter of his lung function during the impasse.

Rebecca Hunt, of Vertex, said: “We are determined to find a solution that allows the NHS to provide patient access to our precision medicines across the UK with budget certainty and also allows Vertex to continue its research and focus on a cure for cystic fibrosis and

other serious diseases.” She said invoking crown use would undermine Vertex’s “ability to achieve these goals”.

The Department of Health said: “We’re aware there may be other avenues open to resolve this issue, but our approach remains urging Vertex to accept NHS England’s generous offer.”

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Kat Lay on 2nd Feb: Mother of four is denied cancer drug that could save her life

A British nurse with four children is being denied potentially life-saving cancer treatment that was approved in the United States more than a year ago.

Health experts have criticised how slowly innovative cancer drugs are approved by the European Medicines Agency and UK regulators.

Heather Bellamy, 48, from Downham Market, Norfolk, had acute myeloid leukaemia (AML) diagnosed in 2014 after a routine blood test at the GP surgery where she worked.

Despite several rounds of chemotherapy and donor stem cell transplants the cancer keeps recurring and she has reached the limits of treatment available on the NHS…..

Indirect consulting: wrigling on the hook of rationing health care

GPs manage more and more chronic conditions by remote control. The telephone is a boon in this respect, and since the patients are known to them, visual contact is not necessary. But when it comes to new patients, who need a new diagnosis “every patient deserves  and examination”, especially if this is reassuringly negative. Hospital consultants can follow up simple post operative patients over the phone, and this can be done by nurses. Just as follow ups in GP practices can be done by nurses. But the total percentage potential for indirect consulting is limited. In an age where many patients are elderly, with multiple pathologies, we have to accept that a face to face consultation is best, and an examination is usually appropriate. NHSreality has been warning that there would be much “wriggling on the hook of rationing health care”, and this is just another wriggle.

Times Letters: The doctor will see you now — by Skype – Times letters 9th Jan 2019:

Sir, Skype consultations will mostly work in general practice because the majority of patients present with self-limiting illnesses (“Millions of patients to see doctor by Skype”, Jan 8). However, I predict some disasters when patients are presenting with an evolving serious condition.

A few years ago, a very ill patient was admitted to my hospital, septic from a large abdominal abscess. This (and more) was treated successfully by an emergency operation. Four days before admission, the patient could only be offered a telephone conversation with her GP, who diagnosed a peptic ulcer. If that patient had been seen in consultation by the same GP it is likely that the rapid pulse rate, the fever and the patient’s reluctance to move freely (a sign of developing peritonitis) would have been recognised.

Telephone and Skype consultations are a compromise solution and are not without risk. This policy is a panic response by technocrats at the Department of Health and NHS England, who may never have worked at the bedside.
J Meirion Thomas, FRCP, FRCS

Consultant surgeon. London SW1

The Times followed this up 10th Jan 2019:

Chris Smyth reports: Seeing Doctor by Skype dismissed as highly unlikely

As little as 2 per cent of hospital appointments could end up being conducted over Skype, according to experts who have cast doubt on plans for a digital revolution of the NHS.

Making online appointments work is “really, really hard”, would take decades and was unlikely to save the NHS any money, according to academics from Oxford University who have studied attempts to digitise care.

On Monday the NHS pledged to move a third of outpatient appointments online, which it said would save billions of pounds and avoid the need for 30 million hospital visits a year. Simon Stevens, head of NHS England, promised that patients would be able to “access advice at the touch of a button”.

One youth diabetes clinic has moved 20 per cent of its consultations online. However, the authors of the most detailed research into Skype consultations in the NHS, published in the Journal of Medical Internet Research, said that it often failed because of problems retro-fitting existing systems and getting staff to change working habits.

In a letter to The Times, Professor Trish Greenhalgh and Dr Sara Shaw wrote: “A national survey from Norway, an early adopter of remote consultations, suggests that overall (incorporating specialties such as elderly care, for example), the fraction of all hospital outpatient consultations that can be conducted remotely is closer to 2 per cent.”

While patients save time on travel, doctors would not gain any time by avoiding face-to-face meetings, they added.

Professor Greenhalgh said: “I don’t want to be the killjoy that says ‘this is impossible’ — I would like more appointments remotely [but] 33 per cent is a high ambition and if it is going to happen, it will be in 20 years.”

She said that the most optimistic scenario was that the NHS “can probably get to 10 per cent but I don’t think it’s going to save any money”. She added: “The argument is it will make the NHS more efficient and I don’t think it will. If you build another lane on the M25, more people will start travelling. If you make doctors and nurses more available by Skype, patients will want more appointments.”

Although many GP surgeries offer video consultations on smartphone, Professor Greenhalgh said that hospitals are way behind: “One of the reasons is sheer scale; buying a laptop is easy, getting 100 people on to a network is hard.”

Existing Skype clinics had failed from lack of administrative support, but Professor Greenhalgh said that too vigorous a national push risked repeating the mistakes of the chaotic £10 billion NHS IT scheme set up under Tony Blair that failed to link up hospital records. “A target of 33 per cent over Skype in ten years sounds like a top-down policy that hasn’t learnt the lessons of history,” she said.

She advised the NHS to reform rules that meant hospitals did not get paid for online appointments, suggesting: “Don’t start with the technology. Start with transforming the service.”

Professor Stephen Powis, NHS England medical director, said: “There are often better alternatives to the traditional outpatient visit. Many areas are already doing this, with practical benefits for patients and staff . . . [the] plan is clear that while digital services will not be everyone’s choice, they will be provided for those who want them, helping to avoid an extra £1 billion in newoutpatient costs over the next five years.”

Doctors to see groups of patients – is probably madness. The fox is waiting..

Any GP you want: so long as you’re healthy



In a celestial world as outlined by the old NHS, there was universal, cradle to grave cover, with no barriers to access, free at the point of delivery, and without reference to means. Funny that we have so many medical charities then. And the greatest number of these charities is in the Hospice (Palliative and Terminal care) sector. These charities are mostly run from physical buildings, and hospices, but in the poorer areas of the country they are “Hospices at Home”. The idea to help elderly at home is a good one, BUT it overlaps so much with charitable providers. The perverse incentive for Trusts and Commissioners to offload as much as possible to these charities will inevitable mean there are large post code voids in cover. NHS reality does not object to this IF it is honestly discussed. The solution is a means based insurance based system, and since most of the assets in the UK are held by the elderly this would be more progressive.

Chris Smyth reports November 22nd in the Times: Rapid response teams will help elderly at home

NHS “rapid response teams” will be on call 24 hours a day, seven days a week to help frail and elderly patients who fall or suffer infections, Theresa May will say today as she promises to use extra health service cash to keep people out of hospital.

GPs will also get to know care home residents personally in an effort to keep them well at home. Such services will get an extra £3.5 billion a year by 2024 as part of a £20 billion boost promised to the NHS in the summer

Experts welcomed the ambition but questioned whether the NHS would have the staff to provide the services, and warned that such top-down initiatives often backfired…..

…Simon Stevens, chief executive of NHS England, said that guaranteeing the money for local services would help to make the plans a reality.

“Everyone can see that to future-proof the NHS we need to radically redesign how primary and community health services work together,” he said. “For community health services this means quick response to help people who don’t need to be in hospital.”

Sally Gainsbury, of the Nuffield Trust think tank, said: “This money will simply allow GPs and community services to keep up with demand over the next five years. That’s important but it means the new money announced today is not going to lead to a significant change.”

She added that there were “serious questions about whether the NHS has the right staff in the right places to carry this out”. She warned: “We would agree the NHS needs to focus on helping people more outside hospital and getting them home more quickly. But the idea of telling every local area to do the exact same thing has often backfired in the NHS, as it is bound to be less well-suited to certain places.”

NHS in Scotland is “not financially sustainable,” auditors warn. Do the Scots expect a bail out?

Is the Scottish Government expecting England to bail them out? Financial responsibility comes at a price, and it looks as if Scotland is not willing to pay that price – yet. Reality has not yet hit our politicians. Health has to be rationed…. Individuals can declare bankruptcy, but not state hospitals.

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In BMA news Bryan Christie on 25th October reports: NHS in Scotland is “not financially sustainable,” auditors warn (BMJ 2018;363:k4520 )

A stark warning has been issued about the future of the health service in Scotland in a critical report that says it is not financially sustainable in its current form.

Audit Scotland has performed its annual health check on the service and found a continuing decline in performance, longer waiting times for patients, major workforce challenges, and increasing difficulty among health boards to deliver services within existing budgets.1

Only one of the eight key national performance targets was met in Scotland in 2017-18 (for patients with drug and alcohol issues to be seen within three weeks), while only three of 14 NHS boards met the 62 day target for cancer referrals. And there has been a 26% rise since 2016-17 in the number of patients waiting more than 12 weeks for inpatient or day case surgery, to a total of 16 772 in 2017-18.

Total spending came to £13.1bn in 2017-18, a fall of 0.2% in real terms on the previous year, forcing NHS boards to use one-off savings or extra support from the Scottish government to break even. In the coming years projected increases in healthcare costs are expected to outstrip any additional funding for the service.

“The NHS in Scotland is not in a financially sustainable position,” said the report. “The scale of the challenges means decisive action is required, with an urgent focus on the elements critical to ensuring the NHS is fit to meet people’s needs in the future.”

The steps the report recommends include:

  • Moving away from short term firefighting to long term fundamental change

  • Ensuring effective leadership

  • Creating a more open system to encourage an honest debate about the future of the NHS

  • Carrying out detailed workforce planning, and

  • Improving governance and the scrutiny of decision making.

Caroline Gardner, auditor general for Scotland, said, “The performance of the NHS continues to decline, while demands on the service from Scotland’s ageing population are growing. The solutions lie in changing how healthcare is accessed and delivered, but progress is too slow.”

The day before Audit Scotland’s report was released the Scottish government announced an £850m initiative over the next 30 months to shorten patients’ waiting times across Scotland. It seeks to achieve the 12 week treatment time guarantee for all inpatient or day surgery patients, which was introduced in 2012 but has never been met.

But Lewis Morrison, chair of BMA Scotland, said that this was the wrong approach. “We need to adopt a more mature, wide ranging way to assess our NHS and the care it delivers. Simply piling more political pressure on the meeting of existing targets that tell us little about the overall quality of care will do nothing to put the NHS on a sustainable footing for the long term.”

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I’ll pay later, and possibly with my life.. NHS trusts face a record £6bn backlog of repairs…

If there are 60 million souls in the UK (I know its more) the £6,000,000,000 bill equates at £100 each man woman and child. And you can be guaranteed its an under estimate. The trouble is that I don’t have the option to pay now, and prevent deterioration. I’ll pay later, and possibly with my life.. while successive governments think, and deny. Capital projects are decreed by devolved government in Wales, Scotland, and N Ireland, but centrally in England. 

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The Times reports 23rd October 2018: NHS trusts face a record £6bn backlog of repairs

NHS trusts are sitting on a record-high backlog of almost £6 billion worth of repairs or replacements that need carrying out, official figures show.

About £1 billion of the outstanding repairs are “high risk”, meaning that they could result in “catastrophic failure, major disruption to clinical services” and are “liable to cause serious injury and prosecution” if they are not addressed immediately. Examples of maintenance required could include upgrading software on medical equipment, maintaining generators and boilers and ensuring the structural integrity of buildings.

In the year to March there were 17,900 incidents across England in which patients were harmed or put at risk of harm because of infrastructure problems, according to the data from NHS Digital. This is an increase of 800 in a year. Clinical services were delayed, cancelled or otherwise affected because of problems with buildings or facilities on 3,835 occasions, an increase of 1,500.

Chaand Nagpaul, chairman of the council of the British Medical Association, said that there was an urgent need for extra funding to address the NHS’s “impoverished infrastructure”.

The repair bill has risen every year since 2011-12, when it stood at £4 billion, while costs for outstanding high-risk works have more than tripled over the same period. NHS trusts spent a combined £404.5 million trying to reduce the backlog last year but the bill rose by more than £400 million.

Siva Anandaciva, chief analyst at the King’s Fund, a health think tank, said: “Deteriorating facilities and unreliable equipment can expose staff and patients to increasing safety risks, and make NHS services less productive as operations and appointments may be cancelled at short notice.”

For the past four years the Department of Health and Social Care has transferred money from the capital budget to use on day-to-day spending. A spokesman said: “Investment to tackle this maintenance work has increased by 25 per cent from £324 million in 2016-17 to £404 million in 2017-18. We are also investing £3.9 billion into the NHS to help transform and modernise buildings.”

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