Private GPs and Primary Care take off: even in one of Wales’ poorest areas…. Should we be aspiring to excellence before reducing inequalities?

Professor Sir Michael Marmot – IHE – Institute of Health is a much respected expert – but we appear to have had enough of experts in our current compartmentalised society (Mr Gove). There is not a dogs chance that politicians will take notice of Marmot’s recommendations. Indeed, the ironically named “levelling up fund” is and will fail to do anything worthwhile. My own town is not exactly a seaside one, but is on a polluted estuary and within 7 miles of many glorious beaches. More and more retirees are moving down, but not to the town centre. Most will be unaware that they are moving from a poor medical world to an absolutely desperate one, where access is terrible, investigations take ages, and standards are low because there is little competition to take jobs a town where the hospital is downgraded, and there are no plans for improvement. There are islands of quality but the arrival of West Wales first private GP in announced on the BBC 9th Jan 2024. NHS: GP says private care can help cut waiting lists. Other Wales’ private providers are listed in the BBC article, and I believe they will be very successful. I have not heard whether patients who need specialist care will need to go via their GP or can be accepted from the private GP referral. (As with Dentists) . It seems ironic that as poorer people are moving to the seaside towns, where crime rates are rising, that the medical facilities are being focussed further away. Discontent and civil unrest are in the air… Should we be aspiring to excellence before reducing inequalities? The latter does not seem to work..

In this election year, politicians must give us hope for a better future, writes Michael Marmot in his essay in the BMJ
“Hope is an orientation of the spirit … an ability to work for something because it is good…. It is not the same as optimism. It is not the conviction that something will turn out well, but certainty that something makes sense regardless of how it turns out.”1
So said Václav Havel, playwright, dissident, and President of post-communist Czechoslovakia. He had been through it all before he played a key part in his country toppling communism and emerging blinking into the light. The UK in 2024, and at the beginning of an election year, is experiencing dark days of a different sort: population health has stopped improving and health inequalities are increasing. That means that the conditions in which people are born, grow, live, work and age have stopped improving or are deteriorating.
Demoralisation and pessimism about prospects for improvement abound, with versions of: the problems are too deep-seated, politicians are all the same, the Tories don’t care, Labour is too cautious. Austerity, the covid-19 pandemic, and cost of living crisis have given little cause for hope. Against this despair, there is a great deal of evidence to suggest we can make a difference to the social conditions that will lead to better health. It is being acted on in places all across England and Wales. With an election looming, leaders of our political parties, please, get in touch with your inner Václav Havel and inspire us with a vision of a more hopeful future. The country needs hope and it needs tangible action. We have the evidence to show how to take practical steps to create a fairer, healthier society.
I want to start, though, with the issue that most urgently needs to be tackled: the dismal state of our health and health inequalities. Many of us, myself included, focus on poverty and its many effects in explaining health inequalities.2 The obverse is to focus on those least deprived. Not sympathy for the rich, but using them as a benchmark for what level of good health is possible. At the UCL Institute of Health Equity (IHE) we have shown consistently that there is not a clear divide: bad health for the poor, good health for everyone else. It is a graded picture: the greater the level of deprivation of where people live, the shorter their life expectancy. It is a social gradient that runs from the top, least deprived, to the bottom, most deprived. Even more striking is the gradient in healthy life expectancy.3
What if everyone had the good health of the least deprived 10% of the population? There would have been 1 million fewer deaths in England in the period 2012 to 2019.3 Of these, 148 000 can be linked to austerity. In 2020, the first year of the covid pandemic, there were a further 28 000 excess deaths.4
In addition to this quite extraordinary excess death rate linked to deprivation, made worse by austerity, levels of healthy life expectancy have been getting worse. Healthy life years, a measure of the length of time someone lives free of ill health, has worsened in the UK compared with the average of the 27 countries in the European Union. In 2014, men and women in the UK had a higher average number of healthy years than those in the EU 27. By 2017 this had stagnated for men and fallen for women, but had increased by two years for both sexes in the EU27.5
To any political leader who says that health is only one concern, among so many others, I have three responses. Firstly, what can be more important than one million excess deaths over fewer than 10 years? Secondly, the evidence that we have compiled in global and national reviews shows that many of the other things that should concern you—the economy, education, housing, environment, the causes of crime, inequalities—are the causes of this excess mortality.67 They are the social determinants of health. Act on these and you will have a better, fairer, healthier society.
Quoting analyses by John Burn-Murdoch in the Financial Times, Britain is a poor country with some rich people.8 Our analyses show that it is poor sick country with some rich healthy people.4 Reduce the gap in income, wealth and general social conditions, between the richest 10% and everyone else, and the 90% will have better lives and health inequalities will diminish.
Thirdly, action is already happening in cities, regions, and boroughs all around the country. Coventry was the first. They declared themselves a Marmot City in 2013. (Embarrassed disclaimer: it was not my intention or wish to call these places after me. But once Coventry did it and Greater Manchester picked it up, it had become a brand.) In our 2010 Review, Fair Society Healthy Lives, we had six domains of recommendations: give every child the best start in life; education; create fair employment and good work for all; ensure a healthy standard of living for all; create and develop healthy and sustainable places and communities; take a social determinants approach to prevention.7 Coventry made these six recommendations the basis of their planning as a city and developed a Marmot monitoring tool to assess progress.9
Greater Manchester followed, as did 40 other places, along with businesses, public sector organisations and community and voluntary sectors. The causes of health inequalities lie outside the health sector, but the NHS can be active in tackling social determinants of health. Our work with East London NHS Foundation Trust is such an approach for taking action on the social determinants of health. We have now added two more recommendations to our six: tackle racism, discrimination and their outcomes; pursue environmental sustainability and health equity together.
So, to repeat, my answer to political leaders who say that they have other things to do, is that cities and places all around the country are already doing what they can to improve the quality of people’s lives and thereby reduce health inequalities. Such local action is vital, but they need help with national policies that will make a difference. As Raymond Williams, a Welsh writer, academic and novelist said: “to be truly radical is to make hope possible rather than despair convincing.”10

David Byers reports in the Times 22nd Jan 2024: High rents force older tenants to move to deprived seaside towns – Relocation from wealthy to poorer areas means elderly live away from friends and family and face overstretched public services

Kat Lay in the Times monday 22nd Jan 2024: Heart disease warning as deaths hit 14-year high – British Heart Foundation says an average of 750 people a week died from cardiovascular conditions last year and calls for action on preventable causes

NHSreality posts on “Health is Wealth

Teifi Health service

Cambrian News 11th Jan: Newcastle Emlyn doctor says private GP surgeries can help ease pressure on the NHS

20th August 2023 in Teifiside advertiser: Newcastle Emlyn planning application for clinic successful

NHS: GP says private care can help cut waiting lists – BBC News …..
“But I personally think it’s impossible for the NHS to provide everything to everybody.
“The population has expanded enormously, people are living longer due to good health care, which means that there will be a role for additional services which the NHS will not be in a position to offer.”
BMA Wales said doctors leaving the NHS for the private sector was “a symptom of… the impact of chronic underinvestment in general practice over a number of years”.
It added: “Welsh government must commit to a reversal of this underfunding and restore NHS general practice to its place as the foundation of a high-quality, cost-effective health system.”

NHS dentistry crisis – and risks of population health issues that affect the poorest

The conflict between reducing inequalities and aspiring to excellence.

Be warned: its already too late for dentistry, but now the bell tolls for primary care…

Dentists in the NHS before devolution and all the changes were warning that the new contract would not work for them as self employed contractors of the service. No notice was taken. Now, its already too late for dentistry, but the bell is tolling for primary care…What would happen to GP doctor provision if the government made it VERY financilly attractive to work (say) 4 half days instead of 2 long 11/12 hour days?
The motive for trying to make such a change would be “continuity of care” …
It seems that the government wants us to be independent contractors when they want to shaft GPs, but Community Interest Companies (CICs) when they want us to “go the extra mile”. Do others feel the same?
At a recent BMA meeting with our national leader the turnout was very poor in West Wales. Was this by choice or an accident of poor timing/ communication before Christmas? I suspect disengagement and timing were part to blame, but the meeting was not “on line” either, which does not help in the Christmas buildup.

Times letters 30th December 2023: State of dentistry a warning for the NHS
Sir, your leading article on NHS dentistry (“Down in the Mouth”, Dec 29) referenced the findings of the recent Nuffield Trust report of which I was the lead author.
As you comment, urgent action and transparent choices are needed in respect of NHS dentistry which have implications for oral health and the wider NHS. We need to break out of the cycle of intermittent attention and inadequate response. Two additional points are worth emphasising.
First, oral health must become a core part of an integrated health system with a proper focus on glaring inequalities and the common factors affecting both oral and physical health. Integrated Care Boards (ICB) must lead the charge on this, working with public health colleagues in local government.
Second, and more worryingly, the story of NHS dentistry paints a picture of what might become of the wider NHS. Nobody foresaw the decline in NHS dentistry that began with the bungled 1990 reforms. The move of practitioners and patients into the private sector has been the core consequence of those changes and further efforts at piecemeal reform. GP and primary care services are already moving in this direction as access becomes more difficult — the better off are voting with their feet. Policy inaction could lead to a similar long-term decline in this field too with even greater consequences for our nation’s health.
Wilf Williams
Canterbury, Kent

Sir, As a retired dental surgeon, I take great exception to the wording in the leading article (Dec 29) that 26,000 adults were admitted to hospital “to have teeth pulled out”. Dentists don’t pull teeth out: we extract. There’s considerable technical skill required to do as little damage as possible and to promote healing. Not pull, extract.
Iain Parsons
Brampton, Cumbria

Sir, Your leading article regarding the awful situation with people trying to access an NHS dentist (Dec 29) reminds me of my parents’ situation in the 1930s. Both received 21st birthday gifts of money so they could have all their teeth removed and replaced by dentures. I understand that this was quite common among the working classes in London prior to the establishment of the NHS. It looks as though we could be returning to these pre-NHS days.
Mike James
Tring, Herts

Sir, Emma Duncan is right to highlight the future problems created by a lack of access to NHS services (“NHS is even more hobbled than it seems”, Dec 29). Nowhere is this clearer than in the difficulties faced by those needing rehabilitation for a whole host of conditions. These vital services enable people to recover from an event such as stroke, or to manage longer-term conditions at home. But access to them is limited and in some instances, non-existent.
It is further hampered by a lack of space in hospitals for the rehab to take place. Worst of all is that increasing numbers of people are living with pain. The present government, and whoever wins the next election, must prioritise rehabilitation and other services that reverse the disastrous consequences of the short-term mindset.
Sara Hazzard
Assistant director
Chartered Society of Physiotherapy

“Gone to the dogs”….Respite care, along with dental care, and “fairness” is missing – absent from politicians’ mindsets. We are not “all in this together”….

There is no way the different trusts and commissioners can afford the respite care that is going to be needed in the future. Unfortunately we have a dishonest political climate where avoiding the long term is endemic. The article in comment by Emma Duncan and the leader on dental issues all point to long term failure. The idea of the health services as “safety nets” has disappeared from dentistry, from respite, and from the mindset of the young in cities. It used to be just the affluent who paid for health and dental care: now it will shortly become a majority – in a two tier system. Only one party has been in power for the last 16 years…. Voters will know who to blame, but actually, the problems began way before 2012… No wonder populism is rising, and democracy is under threat. The same short termism and dishonesty applies to water/river quality, and to the defence of the realm. It might help if it were true, but we are not “all in this together”… My grandparents used the term “gone to the dogs” for people who went drinking and betting their wages away at the greyhound tracks. Politicians have done this for us… We need to face the fact that new tech advances are further and faster than any governement can afford. So the debate shgould be on how to ration care, and what is not to be provided by the state. This might well be different for differently affluent citizens.
From the Times letters 29th December 2023: Respite from illness
Sir, The Tony Blair Institute’s proposal for an NHS illness prevention service is naive (“Blair wants NHS to stop sickness before it starts”, Dec 23; letter, Dec 27). Despite recommendations for lifestyle changes, however draconian, disease is inevitable with ageing. A much more useful expenditure of NHS funds would be on a respite and rehabilitation service run at a local level, which would do far more to help people. Daycare centres keep people out of hospital and allow them to retain a useful degree of autonomy. Combining rehabilitation with respite care leads to earlier discharge from hospital. The lack of imaginative ideas and a reliance on “experts” lacking expertise is the biggest problem in healthcare management.
Hedley Piper
Dartmouth

Emma Duncan 29th December: NHS is even more hobbled than it seems – Government tactics to suppress demand give a false picture and are storing up more problems
…… Turning people away out of hand is another method of suppressing demand. Parents whose children have a sufficiently high level of special educational needs are entitled to choose their educational provision. Councils are required to foot the bill, and since they have no money these days they tend to reject applications, whatever their merits. Appeals are rocketing and last year 98 per cent of cases were decided in the parents’ favour. Councils therefore have to fork out in the end, but by stonewalling they win themselves a bit of time. And at the end of the day, you can just leave people hanging. Children’s mental health services are in a particularly bad state, and an investigation by The House magazine discovered that children with long-term conditions such as autism are being pushed to the back of the queue by more urgent cases. In 2022 such children had been waiting a year and four months, on average, for an initial assessment — four times as long as government guidelines say they should. One child in Belfast had been waiting seven years.
While suppressing demand may relieve pressure on one public service in the short term, in the round, over the long term, it makes everything worse. The lack of social care means that old people are stuck in hospitals, so the health service deteriorates further. That makes more people sick, and therefore unable to work, which means that they don’t pay tax, so there’s less money to improve public services and they all deteriorate further.
We’re in this mess because we’ve had years of cuts, the population is older and sicker than it used to be and the economy has barely grown since the financial crisis. There’s no easy way out of it. Jacking up taxes isn’t an option. They’re already eye-wateringly high, and raising them further will shrink the economy. Instead, we need to make it easier for firms to build, to access capital and to trade with Europe. Growth is the only way out of this increasingly uncomfortable bind, but it won’t be either easy or quick.

Times leader on dentistry: Down in the mouth (not on line)
….The blight has been caused by the wholly inadequate arrangements by the NHS to employ, support and pay dentists……Rural dental deserts in Norfolk, Lincoln and Devon (Thats only England) ……..What has gone wrong? Dentists blame the governement for forcing through a new contract that the Nuffield Trust says are “unfit for purpose”. There are also too few dentists being trained. Last year there were nearly 6m fewer courses of NHS dental treatment than the year before the pandemic. ….The Nuffield trust says that the government must faxce the unpalatable choice of spending millions more on resporing a full NHS dental service or accepting that this is no longer affordable and mandating state-funded dentistry to provide only a “core” service for emergencies. It is a choice that should never have to be made. Healthy teeth are as much a sign of a nation’s health as any other indicator. Failure is all too visible, as Americans and Dentists well know.

The pace of advance of technology is beyond the ability of any government to pay

wE MUST NOT follow the USA: If you have Hepatitis C be grateful you are not living uninsured in America. But according to the Liver Trust some UK dispensations will still not fund it!

imes letters 30th December 2023: State of dentistry a warning for the NHS
Sir, your leading article on NHS dentistry (“Down in the Mouth”, Dec 29) referenced the findings of the recent Nuffield Trust report of which I was the lead author.
As you comment, urgent action and transparent choices are needed in respect of NHS dentistry which have implications for oral health and the wider NHS. We need to break out of the cycle of intermittent attention and inadequate response. Two additional points are worth emphasising.
First, oral health must become a core part of an integrated health system with a proper focus on glaring inequalities and the common factors affecting both oral and physical health. Integrated Care Boards (ICB) must lead the charge on this, working with public health colleagues in local government.
Second, and more worryingly, the story of NHS dentistry paints a picture of what might become of the wider NHS. Nobody foresaw the decline in NHS dentistry that began with the bungled 1990 reforms. The move of practitioners and patients into the private sector has been the core consequence of those changes and further efforts at piecemeal reform. GP and primary care services are already moving in this direction as access becomes more difficult — the better off are voting with their feet. Policy inaction could lead to a similar long-term decline in this field too with even greater consequences for our nation’s health.
Wilf Williams
Canterbury, Kent

Sir, As a retired dental surgeon, I take great exception to the wording in the leading article (Dec 29) that 26,000 adults were admitted to hospital “to have teeth pulled out”. Dentists don’t pull teeth out: we extract. There’s considerable technical skill required to do as little damage as possible and to promote healing. Not pull, extract.
Iain Parsons
Brampton, Cumbria

Sir, Your leading article regarding the awful situation with people trying to access an NHS dentist (Dec 29) reminds me of my parents’ situation in the 1930s. Both received 21st birthday gifts of money so they could have all their teeth removed and replaced by dentures. I understand that this was quite common among the working classes in London prior to the establishment of the NHS. It looks as though we could be returning to these pre-NHS days.
Mike James
Tring, Herts

Is dentistry still part of each health service in the UK? “..how far (does) the NHS aspires to offer a comprehensive and universal service”? ….

The incompetent politicians need to al least provide free dental care for all children. This alone will pay back in the health budget in later years.. NHSreality has warned about heart valve disease and the risks from not having sufficient state dental provision for 12 years now...

Kat Lay 19th December 2023: Universal access to an NHS dentist is ‘gone for good’ – Nuffield Trust warning comes as eight in ten dentists refuse to accept new adult NHS patients
Universal access to dentists on the NHS has probably “gone for good”, according to an expert review of the service. The survival of NHS dentistry will require “politically unpalatable” choices, such as limiting provision to things like emergency treatment, pain management and check-ups, with harsher means-testing for any wider services, the Nuffield Trust think tank said. Its warning comes as analysis suggests eight in ten dental surgeries in England are not taking on any new adult NHS patients, while seven in ten are not accepting new child patients.

Those figures, from the Labour Party, are based on data from surgeries that have recently published updated information on the NHS website. The Nuffield Trust review identified a series of “serious problems with dentistry in this country”, including growing difficulties with access and persistent inequalities in both access and outcomes. 
The contract between dentists and the health service was “unfit for purpose”, the review found, with much of the need for dental care unfulfilled. Tooth decay was the most common reason for a child aged between six and ten to be admitted to hospital. Last year nearly six million fewer courses of NHS dental treatment were provided than in the last year before the Covid-19 pandemic, the analysis revealed. Funding in 2021/22 was more than £500 million lower in real terms than in 2014/15.

The think tank criticised decades of neglect from politicians that had left NHS dentistry extremely vulnerable to the impacts of the pandemic, austerity and the cost of living crisis. Thea Stein, chief executive of the Nuffield Trust, said: “We need to see immediate action taken to slow the decay of NHS dentistry, but it is increasingly clear that we can no longer muddle through with an endless series of tweaks to the contract.
“Difficult and frankly unpalatable policy choices will need to be made, including how far the NHS aspires to offer a comprehensive and universal service, given that it does not do so at present. If, as seems, that the original model of NHS dentistry is gone for good then surely the imperative is to provide enough access for a basic core service for those most in need.”
Any future government must consider swift action to shore up the service, the report urged; for example, by increasing the intervals between long-term check-ups, boosting the recruitment of dental therapists from the private sector and investing in preventive care for children.
In the longer term, politicians faced a choice between adjusting the NHS offer by expanding it with a huge injection of funding, or scaling back to a “minimum offer”. Providing enough access for a basic core service for children, older people and those who cannot afford private care would mean “removing some of the rights to NHS services which people currently enjoy in theory, but usually go without in reality”, the authors added. Stein said: “Whichever way we go, I’m afraid that NHS dentistry cannot continue without some kind of evaluation of the offer even if there are some major improvements to the way services are contracted and commissioned.”
Wilf Williams, the lead author, said: “This report illustrates that continued neglect of dental policy is not a viable strategy. The result is a widening gulf between the government’s stated aim that everyone who needs one should be able to access an NHS dentist and the dire reality of elusive and increasingly unaffordable care.
“For the wider health system, the lessons are troubling: without political honesty and a clear strategy, the same long-term slide from aspiration to reality could happen in other areas of primary care too.” The Department of Health and Social Care has promised a “dental recovery plan” for months, issuing statements in August indicating it was due shortly, although none has been published.
Labour has promised a dentistry rescue plan, including funding for 700,000 more urgent appointments a year, incentives for new dentists to work in “dental deserts” with the worst provision and supervised toothbrushing in schools. It said its plans would cost £111 million a year and be funded by abolishing the non-dom tax status.
Wes Streeting, the shadow health secretary, said: “The Conservatives have left NHS dentistry to wither and now the service is barely worthy of the name. Patients are told to go without or do it themselves, with DIY dentistry now shockingly common.”
An NHS spokeswoman said: “The NHS has implemented the first reforms to dentistry in 16 years, which are helping dental teams address the inevitable backlogs that built up during the pandemic and the most recent stats show that this is working with dental activity up by more than a fifth on last year. “The NHS long-term workforce plan is committed to transforming dental services, by increasing dentist training places by two fifths [by 2031/32].”

Letters in the Times 20th December 2023: Dentistry warning
Sir, Dr Gerard Bulger is absolutely right when he says that the system of payment for GPs is responsible for exacerbating the crisis in NHS general practice (letter, Dec 18). This is borne out by the experience in dentistry, where the collapse of NHS services was prompted by the introduction of a new dental contract in 2006. It ended the system of paying dentists directly for the amount of work they did and replaced it with an anomalous contract with punitive targets, coupled with a ceiling on the amount of work a dentist could do and be paid for. Successive leaders of the dental profession have failed to persuade the government to rethink this misguided policy. One can only hope that GPs’ representatives are more successful.
John Grossman
Northwood, Middx

Sir, NHS Trusts work hard to boost productivity (report, leading article, Dec 16; letters, Dec 18 & 19), including conducting more operations, discharging patients more quickly and using artificial intelligence for faster referrals. Improving public health, increasing public investment and reforming social care are also vital to help reduce pressure on the NHS. But it is hard for trusts feeling the pinch from tight budgets and asked to find unprecedented savings to improve productivity when there are more than 121,000 vacancies in the NHS in England alone. Employees are already overstretched in the face of relentless demand and many more patients with complex conditions.
Saffron Cordery
Deputy chief executive NHS Providers

The Guardian 20th December 2023:
Four out of five dentists in England not taking on new NHS patients, research shows

Theres no better sign of an imploding health system than increasing child death rate – and an increasing health divide. Read Martin McKee, professor of European public health opinion below….

BBC reported Child death rates on the rise in England. In Wales a rise in Measles reflects the anti vax population who just dont believe the experts (or the graveyards). Walesonline 20th November 2023: Scientists concerned by ‘staggering’ 43% rise in deaths from contagious Victorian disease. The OECD iLibrary contains Health at a Glance, and migrants and refugees might account for some of the increase. (see below) There are a number of other more important drivers causing the current regressive child deaths: the banking crisis (after which bankers got richer), the vote for Brexit, (everyone got poorer) the covid epidemic, (those who cant work from home got poorer) and the populist movement led by the Sun and the Mail whereby vaccination rates are falling in poorer less informed families. Health is directly correlated to wealth, and our tax system needs to address this more directly if we are to reverse the current regressive and divided society. Child deaths are not due significantly to a shortage of drugs, but a shortage of staff: the deeper reasons are due to a shortage of political altruism and planning, a collusion of denial, disinformation, and an exhausted and expired tax system. This is the first time child deaths have increased in my lifetime. Its going to get worse before the trend is stopped.. In the future we could have heart valve diseases due to lack of access to dentistry added to all the increasing other causes.
Elisabeth Mahase opines: “Unforgivable” rise in deaths in children must prompt action, health leader warns 10th November 2023 BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2651 
The number of child deaths in England has increased by 8% in the past year, from 29.3 to 31.8 deaths per 100 000 children (3743)—the highest since data collection started in 2019.1
Deaths in children aged between 1 and 17 years increased by 16% in the year to 31 March 2023 compared with the previous year, while deaths in children under 1 year old increased by 4%, showed data from the National Child Mortality Database. December 2022 saw 391 deaths altogether—the highest number in any single month since 2019.
Of the deaths reviewed (3271), the most common likely causes were a perinatal or neonatal event for children under 1, malignancy for children aged between 1 and 9, and suicide or deliberate self-inflicted harm for children aged between 10 and 17.
Mortality rates for children of black or black British ethnicity saw the biggest rise from 42.2 per 100 000 in 2022 to 56.6 in 2023 and also increased substantially among Asian or Asian British children from 43.1 to 50.8. By comparison the rate dropped from 25.6 to 25.3 among white children.
The estimated infant death rate is nearly three times higher for babies of black or black British ethnicity (8.7 per 1000 live births) and two times higher for those of Asian or Asian British ethnicity (6.2), when compared with white infants (3.0).
Deprivation was a significant indicator or risk, the data showed, with deaths in children in the most deprived neighbourhoods of England twice as common as those among children living in the least deprived neighbourhoods—48.1 per 100 000 v 18.7. And while the death rate in the least deprived neighbourhoods had decreased in the past year (19.1 to 18.7), it continued to rise in the most deprived areas (41.5 to 48.1), “demonstrating widening inequalities,” said the report.
Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, called the figures “devastating” and “unforgivable,” saying that they must serve as a “wake up call” for political leaders. “Infants and children living in deprived areas are more than twice as likely to die than those in less deprived areas. This is a harrowing but avoidable statistic,” Kingdon said. “Behind this awful data published today is a whole raft of deteriorating child health outcomes and the clear driver is rising child poverty in the UK. Poverty, health inequalities, and the associated loss of life is not inevitable.”
She said that poverty was a political choice and that governments had ample opportunity to tackle it. “If our government wants to get serious about health, then it must also get serious about poverty and inequality,” she said. “Reducing child poverty must finally become a national priority. We need to see a clear strategy, with measurable targets across national and local levels, and a strong emphasis on preventative health measures.”
The college has previously published warnings over the worsening health of children living in poverty in the UK. It highlighted data suggesting nearly a third (29%) of all children in the UK—or 4.2 million children—are in poverty, while 800 000 children live in households that needed to get food from a food bank in the past year.2
The number of child deaths in England has increased by 8% in the past year, from 29.3 to 31.8 deaths per 100 000 children (3743)—the highest since data collection started in 2019

Health at a Glance 2023: OECD Indicators

Health at a Glance provides a comprehensive set of indicators on population health and health system performance across OECD members and key emerging economies. These cover health status, risk factors for health, access to and quality of healthcare, and health system resources. Analysis draws from the latest comparable official national statistics and other sources. Alongside indicator-by-indicator analysis, an overview chapter summarises the comparative performance of countries and major trends. This edition also has a special focus on digital health, which measures the digital readiness of OECD countries’ health systems, and outlines what countries need to do accelerate the digital health transformation.

Martin McKee, professor of European public health, in the BMJ: Brexit three years on: Health and the NHS are still suffering BMJ 2023;380:p232
Three years ago, on 31 January 2020, the British flags that had flown outside European Union buildings for over 40 years were lowered. The then prime minister Boris Johnson had “got Brexit done.” Except he hadn’t. As we now know, he had agreed to a withdrawal agreement, covering the rights of EU citizens in the UK, the UK’s financial obligations, and arrangements on the island of Ireland. He did so in the knowledge that, at least with respect to Ireland, he had no intention of adhering to the agreement and the quest for an alternative solution remains as elusive as ever.1
Meanwhile, there is growing recognition among those who voted for Brexit that they were lied to and the promised “sunlit uplands” are nowhere to be seen.2 The “opportunities,” such as trade deals with other parts of the world, have revealed just how powerless the UK now is.3 A clear majority of the British public, 62% as of January 2023, now think that Brexit was a mistake.4 And this is before many of the provisions of the Trade and Cooperation Agreement, such as incoming border checks, have even been implemented by the UK; some arrangements, such as on financial services, that have been given a few years grace period, will eventually expire.5 New provisions that will create new trade barriers, including those related to energy intensive industries, will be introduced.6
Those most impacted by these problems, such as researchers working on European projects7 or small businesses that once exported to the EU, are well aware of them. The scale of the damage inflicted by Brexit is less widely appreciated. British politicians, bolstered by large sections of the media, have consistently blamed global events for the UK’s woes. But the pandemic and the Russian invasion of Ukraine have affected all countries—in some cases, such as those adjacent to Ukraine, to a much greater extent—yet the UK has fared much worse on almost all measures than its European neighbours.8
What does this mean for health and the NHS? We can look to two new reports that analyse the situation in detail. One report, from the Centre for European Reform, asks how much Brexit has damaged the economy.9 It used a technique that creates a “synthetic UK” as a model, based on a weighted average of similar countries pre-Brexit and compares its subsequent performance with what actually happened. This isolates the effect of Brexit from all the global factors. The findings are stark. In the final quarter of 2021, the UK’s gross domestic product was 5.2%, or £3bn, smaller than it would have been if the UK had remained in the EU. Clearly this limits the financial headroom that the government has to increase NHS funding, even if it wished to, constraining its capacity to respond to the current crisis. This also exacerbates the financial pressures of the cost of living crisis on many people who are already facing hard choices between heating and eating that will inevitably worsen their health, placing added pressure on the NHS. By the end of 2021 it was estimated that Brexit had added £210 to the average annual food bill.10
The second report is from the Nuffield Trust.11 It looks specifically at the impact of Brexit on the NHS. From the outset, one of the greatest concerns was about the UK’s dependence on health workers from abroad—especially the European Economic Area (EEA). We can now see that this concern was justified. Numbers of nurses coming from the EEA fell dramatically after the referendum and have not recovered. The report also notes how growing hostility to foreigners drove some to leave. The effect was a 28% reduction in nurses and health visitors on the UK register who qualified in the EEA, a net loss of over 10,000. This was compensated for by a marked increase in recruitment from the rest of the world, although this raises questions about the ethics of recruiting from countries that are themselves facing often critical shortages of health workers. Importantly, the increase was nowhere near enough to meet the NHS’s needs.
The problems are greater when we look beyond the overall figures, as some specialties were especially dependent on EEA staff. This is adding to already severe shortages in specialist staff including dentists, anaesthetists, and cardiothoracic surgeons. In these cases, the fall in recruitment from the EEA has not been compensated by increases from elsewhere. These shortages have knock on effects, placing greater pressure on remaining staff and exacerbating problems with morale and retention.
There have also been shortages of drugs, illustrated by a rapid rise in waivers that allow pharmacists to pay more when they cannot find a drug at the usual price. The authors attribute this in part to the decreased value of the pound and the falling value of imports of drugs since 2016, in marked contrast with the increases in every other G7 country.
These problems were obvious from the outset to those who understood the EU but were dismissed by Brexit supporters as “Project Fear.”12 There is some scope for mitigation by a future government that can show the EU that it can be trusted, but there is no escape from the fact that Brexit will continue to damage health and the NHS for the foreseeable future. The tragedy is that neither of the two main English political parties is willing to do anything about it.

NHSreality on The health divide and Health is Wealth

BMJ letters 2021: The impact of Brexit on health is only just beginning

Punch MSN newspaper reports Pharmacists fear rise in child deaths over drug scarcity

Child deaths are always worse in the poorest populations

Up to now: since 1981: (Published in the Yorksire Press feb 2022)

HPV vaccination programme will deliver more than reductions in cervical cancer. It will also reduce orofacial cancer, but in 40 years time.

NHSreality is always looking for good news, and the anti-vaxers will be hard put to decry the benefits of the HPV. It has already delivered for Cancer Cervix, and numbers are falling fast. It will also help reduce oro-facial cancers, which are also largely sexually related. The real issue for ministers is just how to discuss the disinvestment of the money spent on cervical screening, perhaps introducing means tested co-payments from all taxpayers to subsidise those most at risk. (The same might happen for Breast Cancers at a future date) . The press release from UCL (see below) is a red herring for population health, but not for individuals…. Adam Laver is right to indicate that there are more oropharyngeal cancers, and the outcomes for those unlucky to have a late diagnosis, but the vaccination of both sexes will reduce the risk, although a cancer in “coffin corner” which is the rear lower rear sulcus is still a poor prognosis. Good news for patients and dentists. But like with cervical cancer, new drug regimes are very much better… If only we can afford them.

NHS sets ambition to eliminate cervical cancer by 2040

Maryam Zakir-Hussain for The Independent on MSN: Cervical cancer will be eliminated in England by 2040, the head of the NHS has pledged thanks to new strategies to increase the uptake of vaccines and screenings.

UCL announced (coincidentally) that: Better use of existing drugs increases cervical cancer survival and reduces recurrence

Adam Laver for Yorkshire post reports 16th June 2023: National shortage of dentists in UK causing rise in oral cancers – Oral cancers in York are on the up as the UK faces a national shortage of dentists.

5th Jan 2023: Children’s oral health in England is ‘national disgrace’, says head of royal college

The last thing GPs want is to strike. ..

The GPs in England are voting on whether to take strike action for the first time since the 1966 contract ( GPs will be asked to consider all options in response to the Government’s imposition of an ‘insulting’ and ‘inadequate’ contract, the BMA has warned.  ). As contractors they have negotiated their self employed working conditions with the governement of the day for decades. Over the last 3 years, despite warnings that the profession was unhappy and burnout was commonplace, the contract has been “imposed” without the consent of the profession. Is it any wonder that GPs feel uncared for and given the demand increase at nearly 2500 patients per full time GP, they are feeling militant. Like the RAAB concrete issues, GP and doctor recruitment has been coming on us for decades. Political inactivity, mainly from the current team in office, but also from the other parties, has led to a situation where “it’s too late”. Headline reporting as below does not help: although Ms Lay corrects herself in the article, most people read and listen soundbites. Its Midwives nurses, physios, as well as doctors who are in short supply. “NHS pays agency £2,000 for a midwife shift“.
Kat Lay reports: GP average salaries rise by a quarter in a decade – The record high is due to extra work during the pandemic, the doctors’ union says

GPs’ average earnings have risen 23 per cent in a decade to a record £118,100, according to figures published today by the NHS.

It comes as family doctors threaten industrial action over high workloads and what the British Medical Association calls a “disastrous” GP contract.

Public satisfaction with GP services is at record lows, with only seven in ten patients describing their overall experience with their local surgery as “good”. Rising numbers of patients report going to A&E because they cannot get appointments.

The average GP’s income before tax in England was £118,100 in the 2021/22 financial year, up from £95,700 a decade ago in 2011/12.

The record high is likely to have been affected by extra work taken on during the pandemic, the doctors’ union said.

Male GPs earned an average of £146,000, while female GPs earned an average £97,500.

Unlike most doctors, GPs are not directly employed by the NHS but operate as contractors. GP partners own a share of their practice and employ other staff, including salaried GPs.

The data shows an average pre-tax income of £68,000 for salaried GPs and £153,400 for GP contractors.

“The data released today does not reflect the current reality of GPs struggling with the continually escalating costs of running a practice,” said Dr David Wrigley, deputy chairman of the England GP committee at the BMA.

“Although these figures for average earnings are more than 18 months old, they reflect not only the temporary emergency funding that was made available to general practices to support their teams to give millions of vaccines, but in addition, payment for countless hours of additional work GPs did throughout the pandemic to try and keep up with routine patient demand on top of the vaccination programme.”

He said that since 2015 there were more than 2,000 fewer full-time, qualified GPs and each was now responsible for 2,305 patients.

Wrigley said spiralling inflation had not kicked in during the time period covered by the data, and “gives no indication of the yet-to-be-seen impact of the huge cost and staffing expenses rises GP practices have been experiencing in the current and preceding financial year”.

He said: “GPs who run their practices are responsible for all costs and risks, so they plan 12-18 months ahead to ensure they can continue to pay the bills, pay their staff and pay themselves an income at the end of the year. When their running costs rise, as they will have done in the period since today’s data was published, their income inevitably falls.”

Separate figures showed GPs and their staff had provided 1.36 million appointments per day in July this year, up from 1.24 million in July 2022. Just over two fifths were delivered on the same day they were requested.

Ruth Rankine, director of primary care at the NHS Confederation, said: “These figures once again reflect the significant efforts of GPs and their staff, who are continuing to quietly deliver for patients.

“We should not underestimate the challenges ahead with general practice playing, yet again, a key role in the delivery of the Covid vaccination programme while practice and workforce numbers continue to decline. It is imperative that the needs of primary care are considered as part of wider system planning and funding for winter.”

Dental disaster

The plight of poor patients with toothache is akin to that of 2 centuries ago when there was no affording treatment and most rotten teeth were removed. The long term effects of poor dental hygiene will lead to future expenses related to Subacute bacterial endocarditis (SBE) – a disease that a truly civilised society would have no truck with. But short term FPTP politics means no politician cares. The current dental contract has been a disaster and we could do a lot worse than to return to its predecessor. Eleanor Hayward on April 24th in the \times: One in four avoid dentist because of cost – Revelation comes as a 8.5% price rise for NHS charges comes into force today. Part of the problem is that the item of service systems in all forms of healthcare provide the same perverse incentives to overtreat and over-investigate. Separation of diagnosis from treatment provision helps, but even then there are conspiratorial distortions.

DENTAL DISARRAY Times letters 27th April 2023
Sir, Further to your report “One in four avoid dentist because of cost” (Apr 24; letter, Apr 25), I worked as a dentist in a market town from 1965 to 1996. Almost all my work was for the NHS, with only a tiny proportion being private work. The system of remuneration was based on “piece work” and we were paid for what we did, with set charges for each item of work. To ensure that the work claimed for had actually been done, two or three times a year a patient would be called back in to be seen by the regional dental officer. If the work was queried by the RDO then the dentist would be put under greater surveillance but most people in most professions are honest and do their best, and the system worked well. Not only did it work well but it was fair, unlike the present system, where payment is not based on work done but on what is ludicrously known as “units of dental activity”. I have no idea why the government decided some 20 years ago that it was necessary to destroy a system that worked and provided dental services to most of the population and replace it with the system of chaos that has been in place since then.
Brian Smith
Wells, Somerset

DENTAL SERVICE PLAN
Sir, Brian Smith (letter, Apr 27) says he has no idea why the government decided it was necessary to destroy a system that worked and provided dental services to most of the population. I can tell him why: money. In the 1960s, 1970s and 1980s I also worked as an NHS dentist. When we dentists discovered that our remuneration was based on piece work we all worked twice as hard and earned good money. The government then found that the dental bill was twice as much as it thought it would be, and cancelled that system of remuneration.

That is why we have “the system of chaos” that we now enjoy.
John Fox
Edgware, Middx

Sir, Brian Smith describes the piecework system of NHS dentistry that resulted in my having almost every tooth filled by the age of 16. I do not recall ever being examined by a regional dental officer. A mouthful of amalgam fillings is the dubious legacy shared by many 1960s “boomers”.
Libby Earle
Duxford, Cambs

NHSreality posts on Dentists

What is the profession thinking….. and feeling while drowning?

GPs are drowning in a leaking boat with bricks being thrown at us (see below). NHS consultants are to be balloted over potential strike action. Press releases by NHS England (they don’t apply to the whole) are prescriptive: Consultants to sign new NHS contracts & Future consultants to be tied to NHS. The Guardian is clear, and closest to the feelings, as most doctors are “liberals” (non political): Pension pot offer won’t fix NHS workforce crisis. We already have means tested social care, and dental care, so why not extend the system to health. In this workforce crisis politicians could give tax relief for Private Medical Insurance and private payments, until the long term effects of political denial and collusion with unreality have been addressed. Means tested co-payments for health care would be progressive, but to ensure a sustainable fair & universal system fit for the future, we need to learn and choose from EU and Australasian system models.

Alice Barber in the BMJ?: A front row seat for the exodus—is the NHS crisis scaring medical students away? BMJ 2023;380:p525
Over the past year, I and many other medical students have witnessed a growing number of doctors and other healthcare professionals leaving the NHS. This is supported by wider data. A survey of 4553 junior doctors by the British Medical Association found that four in 10 junior doctors plan to leave the NHS as soon as they are able to find another job.1 Similarly, a survey of almost 8000 doctors found that four in 10 consultants plan to leave or have a break from working in the NHS over the next year.2 Although these numbers reflect those intending to leave, there is evidence that doctors are following through on this intent, with a record number of NHS workers taking retirement in April 2022.3 Workforce data also indicate the scale of the problem in general practice, with the equivalent of 279 full time GPs leaving in one year alone, 91 of whom left in January 2022.4 These numbers show that this is not a future theoretical problem: this is happening right now with wide reaching effects…..

Graham Martin et al in the BMJ editorial: A decade after Francis: is the NHS safer and more open? BMJ 2023;380:p513 Recurrent organisational catastrophes remain a disheartening reality .
It is 10 years since Robert Francis published the three volume report of the public inquiry into failings at Mid Staffordshire NHS Foundation Trust……

Helen Salisbury: Helen Salisbury: The new GP contract doesn’t deliver BMJ 2023;380:p590

“We are drowning, and you throw bricks at us.” This was just one of the despairing responses to the latest general practice contract, published in outline by NHS England on 6 March.12

With a growing population and record numbers waiting for hospital treatment, demand for GP appointments has increased markedly, while the number of qualified GPs has fallen. The new contract information acknowledges that 11% more appointments were delivered in January 2023 than in January 2020, but it fails to mention that this was done with 842 fewer full time equivalent qualified GPs.3

Practices are struggling not only with falling numbers of doctors but also with rising costs and wage bills. Those negotiating on our behalf have asked for help in the form of reduced box ticking and bureaucracy, financial support for energy bills, and help in retaining doctors.4 The new contract doesn’t deliver on any of these counts.

I looked up various definitions of “contract,” and in the hands of NHS England the meaning seems to have shifted from “an agreement” to “an imposed set of instructions.” One of the essential elements of a legally binding contract appears to have gone missing: that of “acceptance of an offer.”5 Perhaps somewhere in the past we all signed some forgotten statement along the lines of: “NHS England is free to adjust the contract in any way it likes and we will meekly submit, however ridiculous the ask.”

The stated aim of this new contract is to improve access to primary care. Yet it’s hard to work out from the information circulated so far what exactly we’re expected to do, how this will be measured, and what kind of sanctions (presumably financial) will be imposed when we fail. It says that “patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice.” But what does this mean? That every time a receptionist answers the phone they must do a full triage of the clinical problem? If so, we’ll need a greatly increased number of highly trained reception staff. Some GPs are already suggesting that we will inevitably, collectively, be in breach of contract, as it won’t be possible to deliver what’s being demanded of us. Perhaps it was never intended to be workable and is just more political messaging from the government, another populist stick with which to beat GPs.

If the intention really is to improve patient access, the effect is sadly likely to be the opposite. Encountering bricks when we asked for a lifebelt will be the final straw for many GPs, leading to yet more early retirements and diverted careers. For those with enough energy left for the struggle, industrial action becomes more likely. This decision is difficult for all doctors but particularly complicated for GP partners. Aside from our self-employed status, we feel a personal obligation to the patients we know and care for.6 We could just stop our non-clinical work—but if all we refuse to do is tick the boxes, engage with the Care Quality Commission, and attend our appraisals, will anyone notice?

The workforce plan that could be meaningless may arrive shortly. Political collusion and denial means many more deaths while the “honest debate” awaits..

Nobody is proud of working in a failing institution. The trouble is that many no longer care about the system: only about their patients.

None of the Health Service staff I know is proud to work in a failing institution. The warnings of failure go back to before I retired in 2012, and NHSreality has been telling anyone who cares to listen that the slow decline would end in implosion. NHSreality fears that this is now the cas, and the service is beyond recovery. The sooner we endorse an insurance based universal coverage, as advocated by Dr Cottam below, the better. At lease the “rules of the game” will be clear, and the services that are excluded, or unavailable will be known beforehand, and “rationing” will be overt. Many doctors are leaving or tretiring and many no longer care about the system: only about their patients. Time management when you have a family is more and more valuable to the new doctors. They know the system is unsustainable. The ill informed solutions put forward by members of the public are harking back to a celestial age when rationing was accepted although covert. In the “Information Age” getting away with this is not possible. The trouble is that “nobody cares how much you know, until they know how much you care“, and the staff have got beyond caring (for the system).
The Times letters 28th September 2022: REFORM OF THE NHS
Sir, We don’t need a royal commission on the NHS (“Unhealthy System”, Sep 23) to take five years to tell us what is obvious. Health systems that perform better than the NHS have one thing in common: they include some form of co-payment and are not free at the point of delivery. Direct payment by the patient not only brings in more money but it makes patients think twice about whether they really do need to see a doctor; it generates more responsibility in society to avoid becoming sick in the first place through poor lifestyle choices. Only health professionals in the UK refuse to participate in collecting payments as if it violates some clinical axiom: in other countries it is perfectly normal.
Dr David Cottam
Montauriol, Lot-et-Garonne
Sir, Fifteen years ago I was invited to a small forum in Italy to discuss medical training in my specialty in Europe. Each of us was asked to give a brief introduction on our health systems, and I commenced by stating that in the UK we were brought up to believe we had the best health service in the world. The resulting laughter still echoes in my ears.
Humphrey Hodgson
Emeritus professor of medicine, UCL; London N10

In The Guardian letters: o longer care about the system: The NHS is being put in peril by a fall in funding and the rise of private care. The miracle of a classless service will not survive the deterioration of standards of care now becoming apparent. Jeanne Warren from Oxfor has her own solution, but she is not a medic. Put clinicians back in control. Get rid of the market in the NHS and save the 10% of the budget that goes to administer it. Then fund the NHS adequately, up to the level of our European neighbours, from general taxation as originally intended. National Insurance cannot provide adequate sums and was never designed to fund the NHS. Those who have become increasingly wealthy in the last 40 years should pay the most, as with other core government expenditure.
Jeanne Warren
Garsington, Oxford

The Magic Money Tree for the NHS

The Independent on Eating Disorders and Rationing Care (It always is and was rationed)

The Economist: How not to run a country

Threat of reversal of hospital plans: more deaths in West Wales: Chest pain and death will become more commonplace with long waits at understaffed hospitals. Practices in forgotten places like Johnson, near Neyland in Pembrokeshire are rightly closed when staff shortages are so great.

Helen Stokes Lampard opines in the Times: This winter, soldiering on won’t work for the NHS

The Health Secretary has her head in the sand when she opines that numbers of GPs are stable. 30 % are due to retire in 5 years, and those in training only want to work part time. She knows nothing, and it will take as long as it took Mr Hunt, until out of office, to understand.