Indicriminate Rationing: Cataracts are just the thin edge of the wedge

The Post Code nature of locality indiscriminate rationing means that the poorest half of the country will be asked to wait, whilst the richest half will pay. Just as they do for dentistry: patients are being levered into paying, either directly, or by insurance. The Commissioners are put in an invidious situation where life saving procedures are more important than cataracts, and they have to stay within their budgets without “rationing” officially, as this term is not allowed. So long term priorities and perverse incentives dictate that cataracts are unavailable to many people on their version of the UK’s Health Service. The result: less independence, less quality of life, more chance of falls, more depression, and possibly more chance of dementia as stimulation of all sorts helps delay. Remember there is no “N” HS, and the media and politicians are colluding to pretend there is. NHSreality feels that devolution has not helped health care, where being part of a large mutual is most important.

When will the debate on rationing overtly take place ?

March 20th 2019 in the Times. Chris Smyth reports: Cataract surgery doesn’t work, says NHS in cost‑cutting drive

Patients in half of the country are being denied cataract removal operations by NHS cost-cutting policies that wrongly suggest the surgery does not work, according to a study.

People needing hernia surgery and hip replacements are also routinely refused care by “indiscriminate rationing” policies that class common treatments as ineffective, it concluded.

Doctors and campaigners have condemned the policies as “wrong” and “shocking” but health chiefs said that they did not have the money to treat everyone. Cataract removal is the most common procedure carried out by the NHS, with 300,000 operations a year.

In 2017 the National Institute for Health and Care Excellence concluded that cataract surgery was virtually always a good use of NHS resources because patients who struggle to see are more likely to injure themselves. Its guidance demanded the health service end rationing of the 20-minute procedure that restores sight.

A study by the Medical Technology Group, a forum for patient charities and device manufacturers, found that 104 of 195 clinical commissioning groups (CCGs) that pay for care locally are classing cataracts as “procedures of low clinical value”, in defiance of the Nice guidance.

This means that they will not fund them unless doctors make an exceptional case for individual patients. The figure includes a third of groups that pay for surgery only when patients’ vision has deteriorated past a certain point.

Barbara Harpham, chairwoman of the group, said: “It’s simply not fair that patients up and down the country are being denied access to vital treatments because of where they live. This indiscriminate rationing by local NHS organisations must stop now.”

Helen Lee, of the Royal National Institute of Blind People, said: “It’s shocking that access to this life-changing surgery is being unnecessarily restricted.” Mike Burdon, president of the Royal College of Ophthalmologists, said that there was no justification for the policies: “CCGs must take notice of the Nice recommendations which reinforce the message that cataract surgery should be delivered at point of clinical need. It is one of the most efficient procedures in the health service.”

The survey also found that 78 groups class hip and knee replacements of limited clinical value and 95 limit access to hernia repair via the same method or in policies that say surgery must be delayed for more tests. Twenty-five CCGs limit all three procedures. Bedfordshire also restricts continuous glucose monitoring for diabetics.

The Royal College of Surgeons said: “It is wrong to label hip and knee replacements, and hernia surgery, as of limited value. With the NHS about to receive a cash boost in April, we need a clear message from government that restricting such treatment is wrong.”

The NHS Clinical Commissioners, which represents CCGs, said: “The NHS does not have unlimited resources and ensuring patients get the best possible care against a backdrop of spiralling demands, competing priorities and increasing financial pressures is one of the biggest issues CCGs face.

“They are forced to make difficult decisions that balance the needs of the individual against those of their entire local population. There are tough choices to be made, which we appreciate can be difficult for some patients.”

The Telegraph: More than half of NHS authorities rationing cataract operations

The Express: Outrage over NHS postcode lottery for eye and hip operations

The Express comments: That means it is wrong that the quality of care and access to treatment should be different depending on where you live. After all, we all pay the same taxes for it, so we all deserve the same access to treatment. Therefore, the latest revelations on the scourge of the so-called postcode lottery is another sad reminder of a variable quality of care.

The thin edge of the wedge. Is private A&E going to thrive and become the shape of the future? Aneurin Bevan, what would you do?

Chris Smyth of The Times reports on the first Private A&E in London, (The private A&E will see you right now) and the leading article on the 15th derides the change. This development has been predicted by NHSreality for some time now, and the two tier unofficial health service is here. Politicians and the Media seem to conspire in a collusion of impotence. Is health just too toxic a subject for UK citizens to address? Nobody copies us now, and those that did have realised their error and changed the funding basis to be founded in reality rather than in the clouds.….”

Is Primary care to follow dentistry? Rather than Denplan, will GPplan to be marketed soon? The whole aspect of removing fear has been denied. We are bringing back fear… Those interested might like to read Bevans chapter 5 at the end of this post.

The Times view on private medical care: expansion signals a health service in trouble – It is the failures of NHS provision that are generating demand for private treatment

We report today that patients are increasingly turning to private provision for this care.

This is not only a rational decision for those patients who can afford private treatment for accident and emergency. It also has public benefits by easing pressures on the health service. Though it will be tempting for policymakers to rail against the emergence of a “two-tier” system, it would be more constructive if they focused on the failures of NHS provision that are generating the demand for private treatment.

The market for private provision of non-urgent operations is established. But demand for these services, generally known as casualty, emergency and urgent care units, suffered in the early years of this decade after the financial crisis of 2007-09. Even so, about 11 per cent of Britain’s population has some form of private medical insurance. The principal gap in these policies is that they do not provide cover for accident and emergency.

This is not because emergency treatment in the health service is so good that no one would want to go elsewhere. On the contrary, waiting times in hospitals are too long and getting longer.

We just cannot have Everything for everyone for ever. 

The Times article and leader are below:

Private A&E London Private AandE London

In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

Surgery waiting lists at ten-year high. The perverse outcome is a two tier society…

 

 

The rising trend in fraud in the UK health services.

My calculation for a population of 70 million is that this “fraud” costs us all around £16 each. The known parts are £5 loss to staff, £1 loss to patients, and £10 the professionals.  How can an organisation be run by administrators and leaders so much in the dark? We know purchasing power is reduced in smaller Health Services (Wales, Scotland and N Ireland), and now we know more about what they have been unable to correct due to the perverse incentives in the system. How many families have crutches, walking sticks and other accessories no longer needed? A small co-payment, is needed, with partial refund when returned undamaged. The managers need a breakdown at the touch of a button, of all missing items. Can you imagine a company like Screwfix or Argos not knowing what was where? Whilst the figures are not high, the rising trend shows it might become a real problem in future. 

Fraud is also a concern in other countries, especially the USA. Some comfort…

Kat Lay reports 8th October 2018 in the Times: Fraud in the NHS could have paid for 40,000 nurses

Fraud costs the NHS £1.29 billion every year, according to the health service’s anti-corruption watchdog.

The money would be enough to pay for more than 40,000 staff nurses or buy more than 5,000 frontline ambulances, the NHS Counter Fraud Authority said in its annual report.

The organisation was established on November 1 last year. The new figure is higher than the £1.25 billion identified at its launch. The estimated total loss includes £341.7 million from fraud by patients and £94.2 million by staff.

Fraud by dentists adds up to about £126.1 million, the watchdog said, and opticians £79 million. Fraud in community pharmacies is estimated at about £111 million and in GP surgeries it is worth £88 million. People accessing NHS care in England to which they are not entitled is thought to cost the health service £35 million. The rest included fraud involving NHS pensions, bursaries and legal claims.

Simon Hughes, the authority’s interim chairman, said: “Ensuring public money pays for services the public needs and doesn’t line the pockets of criminals means we all benefit from securing NHS resources.”

Sue Frith, its interim chief executive, said: “Fraud always undermines the NHS, with every penny lost to fraud impacting on the delivery of vital patient services. If fraud is left unchecked, we believe losses will increase.”

The report said there was “no such thing as a ‘typical’ NHS fraudster”. It noted that there were barriers to tackling the issue, including a lack of understanding of the problem in many NHS services. It added: “There is also sometimes a mistaken assumption that reporting fraud casts the organisation involved in an unfavourable light.”

At the end of March there were 45 criminal investigations in progress, the report said. In July a neurology nurse from London was jailed for 16 months for fraud by false representation. Vivian Coker, 53, from Camberwell, took sick leave from August 2014 to May 2016. During this time she received pay of £32,000 from St George’s University Hospitals NHS Foundation Trust, but had also registered with two agencies and worked shifts. Coker initially denied the charges but changed her plea at Kingston crown court.

In March the authority helped to jail Andrew Taylor, a locksmith employed by Guy’s and St Thomas’ NHS Foundation Trust. He was sentenced to six years for defrauding his employer of £598,000. He had charged the NHS mark-ups of up to 1,200 per cent.

Taylor, 55, from Dulwich, was found guilty at Inner London crown court of fraud by abuse of position. Financial investigators “established that Taylor was leading a cash-rich lifestyle beyond his legitimate means, which included paying for his son to attend a private school whose fees were £1,340 a month and purchasing a brand new Mitsubishi L200 vehicle at a cost of £27,400”, the report said.

It also described the case of Paula Vasco-Knight, 53, chief executive of South Devon NHS Trust, who made fraudulent payments of more than £11,000 to her husband, Stephen. She admitted fraud by abuse of position in March 2017 and was given a 16-month prison sentence, suspended for two years, and ordered to do 250 hours of unpaid work by Exeter crown court.

The couple said that they did not have sufficient assets to repay the money but investigators found that they had access to personal pensions that could be surrendered.

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

We need more co-payments – not less. But “Stealth dentistry charges bring in millions for NHS”

Co-payments are an important principle in Insurance. They reduce claims. There is no incentive to reduce claiming on the 4 medical health services, except waiting lists/times and in England, prescription charges. In ophthalmology, and in dentistry there are big co-payments. Dental care is riddled with worrying incentives, and the contract with dental surgeons needs changing. But before it is changed we need to re-examine the whole ideology of the health services. With the poorest getting more obesity, and more sugar related dental decay, many in the professions are expecting a rise in streptococcal heart disease. Does the recent rise in scarlet fever (The Mirror) and scarletina reflect this risk increase? Rationing (restricting, prioritising, excluding)is usually reasonable, but it should not be covert. or unequal, or subject to a lottery of where one lives.

Chris Smyth reports for the Times 4th April 2018: Stealth dentistry charges bring in millions for NHS (Be sure to read his analysis at the end

Hundreds of thousands of patients are paying a “stealth tax” when they have an NHS dental checkup, making the government millions of pounds a year.

Within five years NHS patients at a third of surgeries will be paying more than their treatment costs as dental fees continue to rise, an analysis has shown. This will raise £20 million for the government, leading to claims of a “rip-off” tax on treatment.

Just over half of NHS patients pay for their dentistry, with children, pregnant women and those receiving low-income benefits exempt from the charges, which are considerably lower than private treatments.

After charges rose at the weekend, a checkup costs £21.60, fillings and teeth extractions cost £59.10 and complex work such as crowns and bridges costs £256.50. These fees go to the government. Dentists are paid through an arcane system for each “unit of dental activity” (UDA) that they perform.

An analysis of NHS payment data by The Times and the British Dental Association found 331 surgeries that are paid less than £21.60 for each UDA. This means that patients are paying subsidies to the NHS of up to £10 at each checkup, making the government £1.3 million over the next year.

Henrik Overgaard-Nielsen, the association’s chairman of dental practice, said: “When patients put in more towards their care than the government pays to provide it, NHS charges cease to be a ‘fair contribution’.”

The government pays most of the cost for fee-payers at 68 practices. Last year The Times revealed that half of dentists with data available were not taking on new NHS patients.

Charges have been rising by 5 per cent a year. If this continues until 2022, and payments to dentists increase at the previous rate of 1.5 per cent a year, then 2,128 of 6,300 high street practices will be charging patients more than their treatment costs, raising £20 million for the NHS.

Neel Kothari, a Cambridgeshire dentist, said: “For many patients, NHS dentistry has become a fixed price service largely funded by themselves. It raises the bigger question: how much should the government be contributing towards NHS dentistry?”

Dentists say that a fifth of patients have delayed treatments because of their cost, while the UDA system has led to concerns that dentists are incentivised to rush appointments to maximise their pay.

A Department of Health spokesman said that access to services was increasing. “Dental charges remain an important contribution to the overall costs of services and this increase will ensure there is no shortfall in the costs paid by users and those met by the NHS.”

Analysis
Dentists rarely kill patients. While this is good, the low risk of toothache puts it way down the NHS priority list (Chris Smyth writes).

Ministers have delayed fixing the NHS payment system that rewards dentists for seeing more patients. The system as it is creates worrying incentives: Desmond D’Mello caused the largest recall in NHS history after secret filming showed him not changing gloves and equipment between patients. D’Mello, who earned £500,000 a year from the NHS, was struck off but not before five patients turned out to have hepatitis C.

For almost a decade the government has been saying that it wants to shift to a system that rewards dentists for preventing illness, but little has been done. At a time when the NHS needs money, increasing charges is an easy way of raising it. But the government profiting from this looks wrong. Ministers may claim that this is the least-worst option, but they should own up to what they are doing.

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

The freedom of movement which is inherent in our society may be threatened for doctors…. Coercion has no place in a modern society. We must train more, (long term) or buy in more from other countries (short term)…

The European Convention of Human Rights insists on ones ability as an individual to move ones labour across borders. We may well be abandoning this element of our legislature when we Brexit. However, why should only one group be punished in this way? What about teachers, architects, dentists, lawyers and surveyors? What about plumbers and electricians who emigrate after training  for that matter? And what about the Welsh trained doctors who move to England or other parts of the UK. We have a net 20% loss of graduates annually in Wales. Should they be punished for leaving Matthew Paris’ “dustbin” to work elsewhere in the UK as well? 

Social mobility is to be encouraged. We regret parochialism, and we usually reject any form of racial discrimination. Coercion is not a good thing.. Despite having the lowest proportion of overseas immigrants we voted for Brexit – first time that is. Brexit, if implemented “hard” will cause more expense, not less, in training doctors, and more shortages of staff.

The perverse incentive for every government to train too few doctors needs to be removed. If we aim at an excess of 10%, use modern methods of education in the community,  we can solve the problem in 10 years’ time. Meanwhile, it looks as if it’s going to get worse, as is student debt.

Laura Donelly reports in the Telegraph 20th January 2018: NHS “should consider forcing doctors to pay back training costs if they quit”.

Junior doctors who go abroad to work after benefiting from £220,000 worth of world class training should be forced to pay back some of their costs to the NHS, healthcare leaders say.

Niall Dickson, the head of the NHS Confederation, which represents senior managers, said shortages of staff were now the most pressing concern facing the health service, as he called for major changes to retain more medics.

The former head of the General Medical Council said the NHS should consider forcing doctors to remain loyal to the NHS, by making them commit to at least four years’ service, as happens in the military.

Jeremy Hunt, the health and social care secretary, floated similar ideas at the Conservative Party conference in Autumn 2016, when he set out plans to train an extra 1,500 doctors a year.

However, the idea of penalties for those who leave Britain soon after completing medical school was put…

 Young doctors must repay debt to taxpayers before moving abroad …

Doctors could be forced to work at least five years in NHS under plans …

Jeremy Hunt unveils plan to fine doctors who move abroad after … The Independent 2016

NHS CRISIS: Make doctors leaving UK pay back training fees, says … The Express 2017

Newly trained doctors to be tied to NHS for four years, announces … Pulse 2016

The Social Mobility Dustbin – Matthew Paris in the Times 20th Jan 2018

extract:

…Might an unintended consequence of the loss of manufacturing and mining coupled with the decline of the class system and increases in the mobility of labour — all those cultural changes we call “upward social mobility” — be a corresponding increase in downward social mobility? I’m hardly warning of an influx of Old Etonians into “sink” estates, but of the possibility that “ladders out” of deprivation, if climbed, have consequences for those who do not take them as well as those who do. I would never use a word like “residue” for an individual human being — every human being has the possibility of defying the odds — but I wonder whether we have accidentally created self-reinforcing pockets of deprivation that have something of the residual about them? What has the sale of council houses done to the status of those who didn’t buy?….

Private Medical Insurance options… Going to get more popular? Our leaders show us the way.

PMI or Private Medical Insurance is going to get more and more popular in the next few years. There are several choices to be made, especially regarding the company, the excess and whether to go for full cover, family cover or even “group” cover. It is not inconceivable that groups of professionals or trade unions might club together to get a group policy. These are much cheaper than individual cover.

As the standards fall, and complication rates rise, infections will get more common, and the risk reduction by going private will be the greater. Don’t forget that Private Medicine escapes from complications either by prevention (No shit in this theatre) or by transferring to the UK’s 4 health services when things go wrong.

Private Medicine does take away from health services’ waiting lists, and as such the gain to the 4 health services is much greater than the loss of £250 million annually. However, as the percentage of citizens who choose PMI or just to pay outright increases, there is a more obvious health divide. Those who can afford it have operations at a time they choose, from a consultant and not a junior, and have less complications and get back to full function more quickly. The morbidity of waiting for 160 weeks as in N Ireland cannot be measured, but we know that heart complaints and obesity are likely.

Choosing a high excess means a lower premium, but the reason you take out this option is for disasters. These might include an exclusion from a NICE approved cancer treatment in your particular post code. I have not been able to research helicopter transport options to Tertiary Cardiac Surgical centres. In remote areas of the country citizens are too far from such centres to reach them in time for a stent in the event of a heart attack……

Casualty (A&E) services are degenerating as well as planned care. It may not be long before ambulances ask if you might like to go to a private A&E ….. These are NOT covered by most policies.

40% of what a GP sees has a psychiatric element to it, and 40% of GPs in training do not get psychiatry in their rotations. PMI can be perverse in its application, especially in Mental Illness. In Australia the actuaries have commented: “Insurers offer perverse incentives on mental health claims”. (Banking and Finance in Australia) Mental Illness can be long, and making a claim is laborious. Once claiming successfully there is less incentive to get back to work quickly than there is with physical conditions, according to actuaries.

Whether you decide to pay directly or insure, remember that premiums rise as you get older, and are higher still for those with pre-existing conditions, Even if your cancer is cured and 5 years old, you may well be loaded or even rejected.

NHSreality predicts PMI will get more popular, and that there may be differentially higher rates in regions whose services are worst, as more claims will be made. Our “leaders” will show us the way…

Chris Smyth reports October 20th in the Times: NHS spends £250 million patching up private care

Paul Gallagher for Inews reports: Junior doctors in private hospitals ‘left in charge of up to 96 beds each’

MoneySupermarket offers a comparison website. as do many others.

The big UK players are: AXA PPP,         Aviva,        Western Provident,         BUPA

and of course there is the Benenden low cost option (Mutual) which excludes cancers, and only operates when waiting lists are longer than their policy (always these days)

23rd August 2017: Best private health insurers revealed by Which?

In Dentistry the same players offerings can be compared, as well as Denplan

Drivers for more PMI: (Our leaders show us the way) Waiting times, Choice, Standards, Risk reduction….

Government officials, former Chairmen and CEOs of Health Trusts, and Politicians all choose PMI. Why? (The Express 18th October 2017: Anger as new NHS watchdog chief REFUSES to give up private …)

As the UK disintegrates there will be competition for professions in shortage. GPs are the gatekeepers and the single reason the system has been “efficient” in the past. Now there are Concerns Cornwall could lose GPs to Devon over pay

NHS problems and Waiting Lists are unacceptable : NHS Health Check: Hunt says NHS problems ‘unacceptable’ reports Nick Triggle for the BBC on 10th February.

NHS Health Check: Which part of the UK is doing the best/ (worst)?

Faye Kirkland and Phillipa Roxby report: NHS Health Check: A&E waits for January ‘worst ever’

Full article The 10 ‘longest’ hospital delays exposed

l article How one GP practice tackled waiting times: 

Jeremy Hunt: We must do better on NHS waiting times

Full article UK’s short GP consultations ‘crazy’

Full article Nine in 10 hospitals ‘overcrowded’

Full article Upfront charges for foreign patients

MPs urge action on lengthy wait for autism diagnosis

Children waiting up to 18 months for mental health treatment – CQC

NHS ‘sleepwalking into winter crisis’ as waiting times soar to nine …

NHS surgery waits run into years in Northern Ireland

There is no substitute for experience in medicine, especially General Practice and Surgery, but all specialities. The experience Doctor/Surgeon knows when NOT to take action as well as when to interfere.

After failing to tax sugar – Doctors want warnings on sweets and chocolate to scare children off sugar…

Lets face it, it’s the same ignored and disenfranchised families in the Grenfell tower as the people who don’t get to the dentist. They are an important sub-group. The dental contract needs renewal, and dentists are altruistic enough to want a service that prevents both long term and short term complications. If the BDAs approaches have failed to make caries important (short term) then perhaps the emphasis on preventable heart valve disease (long term) will make government see sense. NHSreality still feels there are too many perverse incentives in a system where the surgeon is the same person as the assessor…

Chris Smyth of The Times reports 30th June 2017 on the BMA ARM conference: Doctors want warnings on sweets and chocolate to scare children off sugar

Warnings on sweets and chocolates are needed to scare children off sugar and help to fight tooth decay and obesity, the British Medical Association has said. The labels could include pictures of rotten teeth and overweight children, although milder “traffic light” warnings may also be considered.
The BMA also wants free toothbrushes for children under five, and for schools to teach children about brushing their teeth to help cut the “shocking” number who need surgery.
A third of children are overweight or obese when they leave primary school and tooth decay is the most common reason for children to be admitted to hospital. The BMA said tougher action was needed after Theresa May dropped plans to curb promotion of junk food in a government obesity strategy last year.

Iain Kennedy of the BMA said 18,000 children under five had been admitted to hospitals in the past two years to have teeth removed, often under general anaesthetic. He said: “Doctors are calling on the government to help prevent further children from needing these operations by regulating food manufacturers to place warnings on sugary foods.”
Mick Armstrong, chairman of the British Dental Association, backed the plans, saying: “These simple steps could ease a huge burden being felt across the NHS. Political indifference has allowed a preventable disease to become the number one reason for hospital admissions among children.”

Graham MacGregor of Action on Sugar said: “We should have warning labels and they should show rotten teeth, people who are obese and amputated legs, because that’s the reality.”

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Five million children failed to see a dentist in past year..

How do politicians of all parties maintain that the NHS is free at the point of delivery? Dental care is certainly not..

Open Wide – The system for dental care is letting patients down. Regulatory gaps need filling and dentists seem to agree..

Patients at risk as GPs face forced shutdown – will Primary Medical Care follow Dental Care into being covertly rationed?

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…