Category Archives: Commissioning

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…

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GPs told to stop closing for half-days . Corporate bullying and breaking contracts unilaterally will not “gag” self employed GPs.

The contract between an independent GP as a self employed practitioner, and the state is a written one negotiated by the BMA. Some practices are large enough for there to be no half day closures, but some are not. This “instruction” is illegal, and should be ignored and challenged in court. (By the BMA). However, there is a problem with single handed practices, usually either in distant rural locations, or in city centres. GPs, mainly female appointments since 2000, are NOT an emergency service any longer, and their contract states this. Many GPs work part time to accommodate family commitments. The idea of the instruction is to free up appointments; I know of no GP who is not exceeding his contractual commitment, but it is very possible that corporate bullying of this nature will mean they start working to rule. It is not the professions fault that there are too few bodies at the coal face. Even today, when Medical Schools are trying to train more, there are 10 applicants for every place. Why not appoint on criteria rather than competitively…. Overcapacity might result in rather more appointments but it will take a decade. It is the perverse incentive to save money and plan for only the next four years, rather than empower good manpower planning, which has led to this situation. Government has been in denial of it’s own part in the mess that is General Practice today for at least 6 years… The corporate culture of Hospital bullying will not work in General Practice.

Exclusive: Doctors are ordered to stop halfday closing at surgeries …
Daily Mail19 Aug 2019

Anviksha Patel reports in Pulse 0n 19th August: GPs told to stop closing for half-days or risk losing £40k in funding

GP practices have been warned to stop closing for half-days or risk losing £40,000 in funding, according to new plans by NHS England.

The plans to withhold funding come as figures show over 700 practices in England regularly close for part of the working week, according to findings from the Daily Mail…..

….Figures show in 2018/19, 722 practices were shut for part of the week, 197 of which initially did not declare they were closed for a half-day. Additionally, 38 practices reported their total opening hours amounted to fewer than 45 hours per week, lower than the contracted 52.5 hours per week.

The BMA has said instead for ‘threatening’ GPs by reducing their funding, NHS England must address the GP recruitment and retention crisis as a solution to ‘lasting improvement to patient care.’

BMA GP committee chair Dr Richard Vautrey said: ‘It is disingenuous for NHS England to be so categorical in claiming they know exactly how many more appointments would be available if practices changed their opening arrangements….

Richard Ault in Stoke on Trent live 23rd August reports “North \Staffordshire GPs ordered to end half-day closing.

Orders issued to GPs to end the practice of half-day closing have been slammed as ‘political nit-picking’ by a leading North Staffordshire doctor.

NHS England says more than a quarter of a million GP appointments will be available when surgeries end the practice of shutting midway through the day…

In future, as part of the NHS Long Term plan, practices will have to seek permission from local health authorities to shut during working hours or risk losing funding worth more than £40,000 per business……

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Pulse 29th September 2017: Extended GP opening has ‘no immediate correlation’ to A&E … –

Sofia Lind in Pulse 27th October 2013: Longer opening hours needed

 

 

Hospital chief says family time would give patients a better end to life

The end of most of our lives will not be planned or expected for long. The “handover” from oncology and chemical treatment to attempt cure, and palliative and then terminal care, is not good enough. Those in charge of the former are reluctant to give up and hand over to the latter. The result is a lot of unnecessary discomfort and stress, and often in rural areas, of travelling long distances to achieve very little. The interface between these specialities would be best facilitated by a GP, preferably one with a palliative care interest. 

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Advanced directives would also be helpful, and other countries are showing us the way.

Sarah Kate Templeton on June 25th in the Times reported: Professor Marcel Levi: Dying should shun treatment and take final holiday – Hospital chief says family time would give patients a better end to life

Patients who are dying should be allowed to go on a final holiday rather than be subjected to gruelling treatment, according to the boss of one of Britain’s largest NHS trusts.

Professor Marcel Levi, a practising doctor and chief executive of University College London Hospitals, said the NHS is wasting time and money treating dying patients at the end of their lives.

He said: “I often think, ‘You would be better going on holiday with your family and you may have a little shorter but a lot better end of your life.’”

Levi, who is Dutch and was previously chairman of a leading hospital in Holland, said: “I do not find the discussion, ‘Which patients should we not treat any more at the end of their lives?’ very well developed in the UK.

“The patients do get anti-cancer treatment when the oncologist, probably the patient and his or her family know it is not going to contribute a lot and it may cause a lot of safety problems and harm.

In Holland, Levi said it is common for patients to state they have had enough treatment and do not want to go back into intensive care.

In the UK, however, he said patients are automatically continuing with treatment in the absence of an honest discussion about what is going to be achieved.

“Patients who are 85 years old do not have to expect a lot of gain from haemodialysis [kidney dialysis], but they still go there three times a week. They feel terrible on the day of dialysis, they feel terrible the day after dialysis. That is six out of seven days of the week,” he said.

“Somebody should at least discuss with them, ‘Is this useful for you? Are you really having any gain of quality of life by doing this?’

“They have a very short life expectancy and we are actually spoiling the last weeks of their lives instead of making them comfortable and them spending quality time with family and friends.”

About 43% of NHS spending goes on the over-65s, according to the Nuffield Trust healthcare charity. This age group also occupies about two-thirds of hospital beds, National Audit Office figures show. Between 10% and 20% of the NHS budget is spent on people in the last year of life, a government-commissioned palliative care funding review found.

Dr Gordon Caldwell, a consultant physician at Worthing Hospital, West Sussex, agrees that British doctors — himself included — often avoid frank discussions about letting patients die.

He said: “Often, as doctors, we hold on to hopes of marginal benefits — ‘You could live 30 days longer, perhaps to three months’ — but omit, ‘This will involve 60 days attending hospital, so you could not go to see Snowdon and Anglesey with your grandchildren.’

“We have relatives demanding, ‘Do everything, doctor.’ Those same relatives, when the patient dies, ask, ‘He didn’t suffer, did he?’ Well, if we were honest [we would say], ‘Yes, he did because you asked us to do everything.’

“I strongly suspect many patients would want less medical interference, such as tests, treatments, last-ditch attempts at chemotherapy.

“Doctors must learn to be honest about the true likely effects of their tests and treatment — a marginal benefit in a few patients at a lot of opportunity loss. A day spent having chemotherapy is a day not with the family.”

Levi said it is up to physicians to broach the subject and it is often welcomed by patients and their families.

“It is the doctors who start the discussion. It was a bit tricky when we did this [in Holland] but it actually turned out that many, many patients and their families were extremely supportive,” he said.

“There were many families of patients who died of cancer who said, ‘If I knew before this was going to happen, we would not have done this operation or this chemotherapy.’”

Professor Karol Sikora, former chief of the World Health Organisation’s cancer programme and chief medical officer of Proton Partners International, a private cancer and healthcare specialist, said there are now more than 25 cancer drugs available that cost more than £50,000 for one year’s treatment and in most cases these would prolong life for only an extra three months.

He added: “There is so much pressure to be active, driven by the pharmaceutical industry and the breakthrough mentality. Giving patients permission to let go has got a lot harder over the last decade.”

However, Baroness Finlay, a crossbench peer and palliative care consultant, believes patients must be given the options of treatments that could help them live longer.

“Sweeping judgments about a person’s quality of life are dangerous,” she said. “Anyone can refuse or cease treatment and that wish must be respected but it becomes dangerous when people are not given the options that might help them live longer and live well.”

Judith Kerr, 94, the children’s author and illustrator who wrote The Tiger Who Came to Tea, has already made her preparations. Last year she told The Sunday Times she keeps “a little piece of pink paper signed by the doctor, saying ‘Do not resuscitate’.”

She added: “Having had a good life, to go through this misery, and at great expense to everybody else — expense not only in money but in emotion.”

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions.

Selecting doctors, and portfolio careers crossing from primary care to Hospital.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

The Canadians shame us with their plans for end of life care

Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

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Bradford staff: government breaking its promises….. This needs to be a nationwide rather than a local solution.

If we look at pensions as a promise of  future payment, and we assume that the English Health Service, along with the other 3 dispensations, has a “ponzi” scheme type of pension fund, then it is not surprising that Trusts and their boards of directors try to escape future commitments that they cannot fulfil. The whole of the former NHS (when we had one mutual) is funded on this basis, but by denial of the long term problems, politicians are forcing locally based solutions, inequity, and poverty in their workers old age. In effect they are breaking their promise… just as the Greeks had to …. The problem needs a nationwide solution so that the pain if felt equally. The earliest Trust sare those most likely to get away with it, and some already have. The result is post-code rationing by ethically and legally dubious means….  In any event, the whole state as well as health worker pension situation needs review….

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Unison website reports 8th July: Bradford hospital staff strike to stay in the NHS and picket lines will begin

BBC reported 14th August: Bradford Teaching Hospitals staff to strike over outsource plan

and Susie Beever of the Yorkshire Evening Post reported 1st August that there would be a two week strike over jobs 

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The History: Bradford Hospital has a track record. Simon Freemna in the Times 27th November 2004: Hospital’s rescuers charge £160,000 for the privilege

Sarah Kate-Templeton in the Times 2016: Safer births campaign: Shamed hospitals blame high stillbirth rate on the mothers

Rhys Blakeley in the Times 19th August 2019: Plea for state pension age of 75

 

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care? 

The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.

Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…

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BBC News reports 4th July: Social care: Hunt and Johnson urged to consider NHS-style free service

Public Service Executive reports: Peers call for NHS-style free social care system and an extra £8bn to tackle funding crisis

and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”. 

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

New and higher taxes will never solve the problems of health and social care…

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”…

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Nov 2016 NHSreality: NHS funding and rationing: The debate (and the denial) intensifies… It’s going to get worse..

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..

A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)

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The “Economist” acknowledges health rationing, but does not recognise that it is covert…. More and more anger to come.

How long will the UK citizens put up with untruths? How long will it take for the proper debate to begin? The Economist recognises rationing, Enoch Powell in “A new look at Medicine and Politics” recognised rationing in 1966. We cannot go on without knowing what (for us) will be unavailable. It is surely a human right to be able to plan for your own health, your family’s health, your death, and illnesses. No wonder citizens are getting more and more angry..

If we want to win the cooperation and hearts and minds of medical staff we need to find out the truth about what they think. BMA conferences full of retired and burnt out doctors may reject the “long term plan” but there is no link with the doctors at the coal face.

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Not only is devolution a failure (certainly in Wales) but the 4 different systems allow different language of obfuscation, different methods of rationing, and outcomes. The anger will be the same.

The East Anglian daily Times shows how angry and dissatisfied the citizens are becoming. If you multiply the figures up over 200 health staff are attacked daily in the UK.

NHS GPs Economist 0619 Whats up Doc June 2019

Enoch Powell 4 Supply and Demand – Rationing  Minister of health for 3 years 2nd Edition 1974

Toni Hazell 28th June in GP mag: Here are two potential problems with primary care networks.  Huge hurry, and who takes responsibility?

Andrew Papworth reports 30th June 2019 in the East ANglian Times : “NHS staff aren’t punchbags”: Shock as six workers a day attacked in Suffolk by patients.

BMA ARM: Doctors spurn NHS long term plan

NHS patients ‘face more treatment rationing since coalition restructuring’

Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

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Endgame for the NHS? Warrington and Horton Trust are bust – same as Wales. Two waiting lists, one for Wales, and one for England.

Just as Wales cannot afford (without central intervention from Westminster treatment for North Wales patients in CHester.  ( Solved by Loan or grant we wonder?) the services their patients need, Warrington and Horton are trying alternative methods to ration by encouraging purchase schemes. They forget that the average DGH has more complications than a private hospital, and if you are paying you might as well ensure safety, quality and a consultant of your choice. (The default operation consent allows any of the team to do your operation). Quite rightly, Helen Salisbury questions whether there us anything that can be done to stop the financial decline. If the 4 health services are to remain free at the point of need, (as opposed to want) we need to ensure that need is not defined by the patients themselves! Now it would be interesting if Chester patients were to demand care in Wrexham, but with longer waits and lower standards this wont happen. Wrexham would be delighted as the money moves with the patient. Chester and Oswestry will have two waiting lists, one for Wales, and one for England.

Helen Salisbury opines: Endgame for the NHS? (BMJ 2019;365:l4375 )

Since its foundation, the NHS has been committed to providing treatment according to clinical need. The distinction between want and need is important—there may be treatments that patients want but don’t need, such as cosmetic surgery. In these cases, they have to go to the private sector and pay up front or through insurance. This is set out in the first two points of the NHS constitution,1 which state that the NHS provides a comprehensive service, available to all, and that access is based on clinical need, not a patient’s ability to pay.

This week Warrington and Halton Hospitals NHS Trust was in the news for its published list of charges for 71 procedures.2 This is not entirely new: starting with an initial offer of varicose vein surgery in 2013,3 the scheme was relaunched in September 2018 with a hugely expanded list of procedures and has only now hit the headlines. This list appeared under the banner “My Choice—by the NHS, for the NHS,” next to the NHS logo. This is very confusing and would leave many people asking, “Is this an NHS service or not?” The list included prices for cataract surgery (from £2251 (€2523; $2872)), knee replacement (from £7179), and hip replacement (from £7060), all of which are beyond the means of most people served by these hospitals, given Warrington’s high deprivation.4

The justification given by the trust is that these procedures have been limited by NHS commissioners.5 Operations on this nationally generated list were initially referred to as “procedures of limited clinical value” and are now “criteria based clinical treatments.” If patients don’t meet the criteria but still want the surgery, they will have to pay.

This makes a mockery of the NHS constitution: either patients have a clinical need, in which case they should receive timely NHS care, or they don’t need the surgery, in which case it’s not in their interests to have it, and it shouldn’t be done by the NHS.

What this programme reveals is that access to procedures with a proven track record of safety and efficacy, which patients need in order to see clearly or move comfortably, is being denied. The “criteria” for many patients are increasingly stringent: the Royal College of Surgeons raised the alarm in 2017 about restricting hip and knee surgery on the basis of arbitrary pain and disability thresholds rather than clinical assessment.6 And cataract guidelines from the National Institute for Health and Care Excellence explicitly state that commissioners should not restrict access to surgery on the basis of visual acuity,7 yet that’s what happens to patients covered by over a third of clinical commissioning groups.8 These decisions are not about optimising outcomes for patients but are a reaction to inadequate funding, requiring patients to be significantly visually impaired or disabled before they’re treated.

Even more worrying is that an NHS trust is explicitly offering a two tier service, with earlier treatment if you can pay. We should resist this transformation from a single, comprehensive system, where all are treated equally, to one where rich patients have rapid access and poor patients struggle to be referred and then languish on waiting lists. Bevan must be turning in his grave.

Methods of rationing in 1966. Warrington shows that we have since invented many more….

Wrexham.com suggests the problem of Welsh patients being seen in Chester is resolved. What nonsense. The financial solution is opaque indeed… and will be so for the foreseeable future.

Manchester, Liverpool, Hartlepool: Death rates in your local DGH are too high..