Category Archives: Interviews or replies

Richard Smith: Chair of NHS England wants a £50 billion NHS bond, culture change, a good relationship with the private sector, and innovation

Things are getting desperate. When you cannot raise the money from the treasury, you try to raise it from the citizens in a “bond”. I and most others would rather pay for private health care than trust the government too use my bond money any better than they have used money in the past. It is the system and the fundamental assumptions which need to change. ? Everything for everyone for ever ?

Richard Smith: Chair of NHS England wants a £50 billion NHS bond, culture change, a good relationship with the private sector, and innovation June 6th BMJ Opinion

Lord Prior, the chair of NHS England, is tall and thin, has a playful smile most of the time, and answers questions with a directness unusual in the higher echelons of the NHS. A barrister, he has worked in finance and industry, been a member of parliament, and chaired multiple NHS bodies. He spoke earlier this week at a meeting of the Cambridge Health Network, which brings together people from the NHS, private sector, charities, and academia. Usually its meetings are held according to the Chatham House Rule, meaning that people can be quoted only with consent, but Prior’s meeting was open.

Prior began by emphasising the deep significance of the NHS to the British. He’d been listening on the radio to the American ambassador discussing access for American companies to the NHS and had realised that the ambassador just didn’t understand the cultural importance of the NHS……

Equity Derivatives cartoons, Equity Derivatives cartoon, funny, Equity Derivatives picture, Equity Derivatives pictures, Equity Derivatives image, Equity Derivatives images, Equity Derivatives illustration, Equity Derivatives illustrations

….In short, the NHS is, said Prior, “capital starved.” More investment is needed, particularly in information technology. Government, he pointed out, can borrow money at around 2% interest, whereas trusts are paying 10-12% of private finance initiatives, totalling almost £1.5 billion annually. The case for a government bond for the NHS, concluded Prior is “almost unarguable.”

Several people asked whether the NHS was becoming more anti-private sector. Prior said that it would be “very sad” if that was the case as new ways of doing things often come from the private sector. He said that as far as he was concerned the private sector is “part of the system” not outside the system.

Somebody in the audience said that selling innovative technology into the NHS was difficult because NHS organisations had no money, had a risk-averse culture, and needed to see an immediate financial return. Prior said that he hoped that the creation of NHSX [the new joint organisation for digital, data and technology] would lead to a “gear change.” “You,” he said to the questioner, “are crucial.” Innovation is good for the NHS and for the British economy. Asked at the end what one thing he would like to see if he had a magic wand Prior concluded “innovation.”

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When he means the opposite: what it will not be possible to deliver….

British Telecom reports on the Budget November 2017: NHS bosses to discuss ‘what is possible to deliver for patients’ – The NHS was handed £350 million to cope with winter pressures.

‘We’ve had to ration some of the letters.’

NHS bosses are to meet to discuss “what it is possible to deliver for patients with the money available” after the health service in England did not get the funds it requested from the Treasury, officials have indicated.

Sir Malcolm Grant, chairman of NHS England, said the money promised by the Chancellor “will go some way towards filling the widely accepted funding gap”.

But he said the NHS “can no longer avoid the difficult debate” on what can be provided by the health service on the funds it is operating on.

In a statement, Sir Malcolm said: “The extra money the chancellor has found for the NHS is welcome and will go some way towards filling the widely accepted funding gap.

“However, we can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.

“The NHS England board will need to lead this discussion when we meet on November 30.”

Meanwhile, Professor Sir Bruce Keogh, national medical director for NHS England, said the money promised by Chancellor Philip Hammond will “force a debate about what the public can and can’t expect from the NHS”.

He warned that longer waits for care seem “likely/unavoidable”.

The comments come after the Treasury pledged more money for the NHS in England, with the specific aim of helping the health service “get back on track” with soaring waiting lists and A&E targets.

Mr Hammond acknowledged the NHS is “under pressure” as he committed resource funding of £2.8 billion to the NHS in England.

This includes £350 million to cope with pressures over the coming winter, £1.6 billion in 2018/19 and the rest the year after.

Earlier this month, NHS England boss Simon Stevens said that without more money for the NHS, the number of patients waiting to be admitted to hospital in England to have surgery will rocket to five million by 2021.

This means one in 10 adults will be on the waiting list, he said.

Mr Stevens also indicated that controversial rationing policies adopted in some parts of the NHS could be rolled out nationally without more money and he said expansion plans for mental health and improvements in cancer care could stall.

He drew on a new analysis by the Health Foundation, the King’s Fund and the Nuffield Trust which calculated the NHS needs £4 billion more next year to prevent patient care from deteriorating.

In his Budget speech, Mr Hammond said: “We acknowledge that the service remains under pressure and today we respond.

“First we will deliver an additional £10 billion package of capital investment in frontline services over the course of this parliament to support the Sustainability and Transformation plans which will make our NHS more resilient. Investing in an NHS fit for the future.

“But we also recognise that the NHS is under pressure right now.

“I am therefore exceptionally, and outside the Spending Review process, making an additional commitment of resource funding of £2.8 billion to the NHS in England – £350 million immediately to allow trusts to plan for this winter, £1.6 billion in 2018/19 with the balance in 19/20, taking the extra resource into the NHS next year to £3.75 billion in total.

“Meaning that our NHS will receive a £7.5 billion increase to its resource budget over this year and next.”

‘Due to cutbacks we’ve had to accept a sponsor for your stitches.’

Criticism of the NHS should not be seen as an attack on healthcare itself

Mark Little wood in The Times 17th July opines in the business section: Criticism of the NHS should not be seen as an attack on healthcare itself

The NHS occupies the most curious and inconsistent of places in our national psyche. On the one hand, we seem permanently concerned that it is on the brink of collapse, that it is chronically underfunded and that staff morale is on the floor. On the other, our unusual approach to healthcare provision is frequently heralded as Britain’s greatest postwar achievement and even as the very encapsulation of the underlying values of the United Kingdom.
Those who see it as being worthy of passionate flag waving will be heartened by the most recent analysis of different healthcare systems in 11 of the world’s richest countries. According to the Commonwealth Fund, a US think tank, we come right at the top of the list, with Norway, Switzerland and Canada trailing in our wake.
Jeremy Hunt, the health secretary, could not contain his glee. This report meant that “the NHS has again showed why it is the single thing that makes us most proud to be British,” he fawned. In fairness to Mr Hunt, he was not castigated for absurd hyperbole. On the contrary, his view probably represents mainstream opinion throughout the land……

….Underpinning such widespread support for the NHS is the understandable desire to ensure every single person is guaranteed to receive a good standard of healthcare, irrespective of their means. But virtually every developed country achieves this without seeing the need for the state to actually run and control the healthcare system from top to bottom. A standard model would be an insurance-based system where those of limited means have their premiums subsidised, or even paid for entirely, by the government. When illness strikes, patients elsewhere can more readily choose between an array of different providers, with this competitive dynamism encouraging innovation and efficiency. In Singapore, for example, a system of personal savings accounts doesn’t produce obviously better outcomes than we get here, but it manages to do so at about half the cost.

Too often, any criticism of the NHS is seen as an attack on universal health provision or even on healthcare itself. The British debate about improving healthcare is stymied by an inability to detach a key moral principle (that everyone should be able to be treated irrespective of their means) from a more prosaic and technical discussion about how best to achieve this. Our failure to consider those two issues separately is useful for those who benefit from using the NHS as a political football, but is not good news for those of us whose primary interest is staying alive.

Mark Littlewood is director-general of the Institute of Economic Affairs. Twitter: @MarkJLittlewood

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RCGP Chairman misses the opportunity to tell it as it is.

Helen Stokes-Lampard, the RCGP Chair missed the opportunity to tell it as it is on BBC1 this morning. She skied graciously away from party politics, but failed to say that:

There is no NHS – and talking only about England is belittling, especially when Wales is so bad.

The WHO agrees with the above.

That standards of access to care are appropriate for different individuals. The “cry Wolf” person/family is treated differently appropriately: But also people in work have a right to attend a doctors appointment.

Evening and weekend surgeries are all very well for large practices, but not for smaller and rural ones, and especially in areas of high unemployment. Having “access” does not mean these appointments are used properly… are GPs going to be allowed to exclude the unemployed and retired from these surgeries?

Patients receiving a “free” service where nothing is “excluded” will doubtless indicate they want more of everything.

The Health services have to be honest about what is not going top be available, and that includes, for the next 10 years, enough diagnosing doctors.

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Chris Smyth in the Times 27th April reports: Workers miss out because they can’t get to see doctor

Working people get a worse GP service because they cannot get convenient appointments, NHS England claims.

MPs also claim that patients in some areas find it hard to see a doctor because some surgeries close during working hours for no good reason.

The public accounts committee (PAC) criticises family doctors for erratic opening hours at the same time as warning that ministers are pressing ahead with out-of-hours appointments while failing to understand the problem. Taxpayers risk paying too much for evening and weekend appointments because they are 50 per cent more expensive than the out-of-hours services they are duplicating, a report published today claims.

A political row erupted earlier this year when Theresa May ordered GPs to open at evening and weekends, blaming those who did not for fuelling a winter crisis in A&E. She pointed to figures from the National Audit Office showing that almost half of surgeries close between 8.30am and 6pm. One in five close for at least one afternoon a week, rising to three quarters in some areas.

Higher A&E attendances were linked to surgeries with shorter opening hours.

Meg Hillier, chairwoman of the PAC, said that afternoon closing was a “ historical remnant” that had become normalised in some regions. She said: “If you can’t see your GP you are more likely to attend A&E and suffer poorer health outcomes. So we need to have GPs open at the right times.”

Three quarters of surgeries that are paid to offer evening and weekend appointments close during the working day. Ms Hillier said: “Staying open during core hours would be a cheaper way of providing more contact time with GPs than providing extended hours.”

Rosamond Roughton, of NHS England, told the committee, however, that they were prioritising out-of-hours appointments because people with jobs found it so hard to see a doctor.

“If you are in work and aged between 18 and 50, you will have a worse experience of general practice,” she said. “The older you are, the better your experience of general practice is. In terms of convenience of appointments, working-age people find it much harder to get an appointment.”

Chaand Nagpaul, chairman of the GP committee of the British Medical Association, said that there was an acute shortage of family doctors.

He said: “In this climate, it is inevitable that despite the continued hard work of NHS staff, there are not enough appointments being delivered to patients.”

An NHS England spokesman said: “Seventeen million people now have access to GP appointments at evenings and weekends and the public are clear that they want this across England. Directions have been issued which mean that practices that shut for half-days each week will lose their share of the £88 million enhanced-access scheme.”


If you dont like the message, shoot the messenger Mr Hunt: your pointless denial will leave you the scapegoat…

In the war of words in the media in the last few days, there has been an allusion to a solution, but once again without politicians’ mentioning the R word. (Rationing), When Plutach referred to the first killing of the messenger he was illustrating the pointlessness of political denial. Mr Stevens has tried to tell the truth, without losing his head by mentioning the R word as a possible solution. If we ration overtly we will all know what is excluded… even if it ends up different for different Regions, (Simon Stevens Interview) Mr Hunt rather than Mr Stevens will be the political scapegoat as we descend further into unreality. It’s going to get worse..

Sam Coates reports in The Times 11th Jan 2017: No 10 blames NHS chief as hospital chaos grows – Downing Street irritated by ‘unenthusiastic’ Simon Stevens

Toby Mejes for Metro 12th Jan 2017 reports: Doctors forced to choose between saving cancer patient or woman bleeding to death and Adam Radnedge reports “NHS boss tells No.10: Don’t pretend there is not a big problem and Chris Smyth in The Times reports:  “May accused of ‘stretching the truth’ on NHS crisis”.

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Andrew Sparrow in The Guardian 12th Jan 2017 reports: NHS England chief says May ‘stretching it’ to say NHS getting more extra money than it asked for – politics live

Simon Stevens, the NHS England chief executive, has undermined Theresa May’s claim to be funding health properly by flatly contradicting her assertion that the service has been given all the money it wants. He made the point during an assertive appearance before the Commons public accounts committee during which he also disagreed openly with Chris Wormald, permanent secretary at the Department of Health. Wormald said spending on health in the UK was in line with the OECD average. Stevens said that that was misleading because the OECD figures included countries like Mexico, that the UK spent less than on health than comparable advanced nations, and that it spent 30% less on health per head than Germany. May has repeatedly said that the NHS was given more than Stevens requested when he set out his five-year plan. But Stevens denied this.

Simon Stevens Interview –

Dr Mark Porter in the Evening Standard opines: There’s little evidence of a ‘shared society’ in our crowded hospitals – The NHS is at breaking point, and it needs cross-party action and longer-term investment to secure its future, says the chairman of the British Medical Association

…”it is now commonplace for care to be rationed, with the working lives of staff dominated by decisions about which patients take priority…

Read the full text: dr-mark-porter-in-the-evening-standard

It's like a jungle sometimes it makes me wonder How I keep from going under



Cancer doctor (Ann Barnes MBE) quits over understaffing at Withybush

Abigail Neal interviews Anne Barnes for the BBC Wales news 10th February 2015:  Cancer doctor quit over understaffing at Withybush

Dr Barnes has kept quiet for some time now, probably in the hope that she would be replaced. However, general disinvestment in Withybush, and a recruitment crisis due to poor manpower planning and chronic undercapacity has led to little competition for jobs in rural areas such as Pembrokeshire.

A former cancer specialist says she had to leave her post at Withybush Hospital in Haverfordwest because of inadequate staffing and service changes.

Dr Anne Barnes retired from the Pembrokeshire hospital last summer but came out of retirement hoping to give the health board time to replace her.

However that never happened, and she now says she cannot do “half a job”.

Hywel Dda Heatlh Board said is fully committed to the provision of safe cancer care services at Withybush.

Dr Barnes, who worked as a specialist oncologist in Pembrokeshire for 17 years prior to her retirement in July, said changes to the system had led to delays and left the service understaffed.

From September a new model was introduced to bring Withybush more in line with other district general hospitals.

Patients were being admitted under the care of a general physician rather than a specialist oncologist, sometimes to the specialist cancer ward, and sometimes to others depending on their clinical problems.

Dr Barnes said: “Currently there is no dedicated doctor there in Withybush.

“We haven’t got the junior doctors back, the cancer beds have been put under general medicine, and lots of the patients have said to me, ‘where are we going to go?’

“‘Who are we going to contact – do we have to sit for six hours in A&E and wait to be seen?’ And the answer now I’m afraid is yes.”

‘One crisis to another’

She came out of retirement hoping it would give the board time to replace her but quit in frustration last month when that did not happen.

“There’s no forward planning; it doesn’t happen. It’s crisis management; it just goes from one crisis to another at Hywel Dda.

“I can’t do the job as I feel it needs to be done and if I can’t I would rather not be doing the job at all,” she said.

Hywel Dda University Health Board said Ward 10 at Withybush remained the designated cancer ward and oncology, palliative care and chemotherapy treatment continued to be provided by a team of doctors and nurses.

In a statement, it added a palliative care consultant was providing cover two days a week on a temporary basis and the board was actively recruiting for a full-time candidate.

Other doctors from both their board and Abertawe Bro Morgannwg University Health Board were providing cover for the chemotherapy day unit.

Dr Sian Lewis from the board said they had been sorry to see Dr Barnes go, but added: “We can reassure patients that her withdrawal does not affect the new service introduced in Withybush Hospital and provided by a team of doctors and nurses.”

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A first debate in West Wales BMA – on rationing – wins a majority in favour

The former collegiate nature of our profession as doctors has disintegrated.

Meetings between consultants and GPs occur much less frequently than they used to. The unofficial debates that occurred at the fringes of the regular meetings were much appreciated by many “old lags” such as myself. There were discussions around problems of individual cases, information about new investigations and imaging, and the confidence of choosing a consultant that one knows for ones patient. At last the BMA has had a debate. The “notice of motion” was “This house believes heathcare rationing should be overt”, and was proposed by myself, and opposed by Dr Clive Weston from Swansea. Here is both the written and the audio for the debate:

Roger Burns text: Debate Rationing final

Roger Burns speech.

2nd October 2014

Since this disintegration there has been a professional silence and an unofficial collusion to disengage from the political process. Power has shifted from clinicians to managers, and the open nature of debate has been stopped for fear of “gagging” punishments… Whistleblowers have their careers ruined, and there are so few exit interviews that Trust Boards rarely hear what retirees think. The opinions of experienced consultants, GPs and Nurses are not being heard. They are however getting stress related problems (Stressed doctors urged to work part-time in bid to avoid burnout – LYNDSAY BUCKLAND in The Scotsman 30th September 2014)

With this in mind I have attempted to bring the art of debate back to the professional life of doctors in Pembrokeshire. I am grateful to Clive Weston from Carmarthen for agreeing to oppose the motion, but I am also surprised and disappointed that none of the BMA members in the Trust Management are opposing, or seconding.

The debate fits nicely with the move from a deference society to  reference society, (or autocratic to facilitative) as advanced by George Pitcher and Sir Tim Bell, and in the book “The Death of Spin” 2002

Everything for everyone for ever

The Information Age

Nigel Hawkes BMJ 2014;349:g5907  1st October 2014 opines: How to tackle the NHS funding crisis? Levy charges

My three handouts in the debate were:

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

Sheerders Sieves

Scheerder's Sieves

Then finally The Information Age.  Why not ask your MP or WG member whether they agree that health care needs to be rationed overtly? See his discomfort…

Peter Brookes cartoon

Watch the debate as the election approaches in 2015. Health is important for all of us, and the politicians wonder why there is a disenchantment with politicians when they conspire in denial and collude to pretend that rationing does not exist.


Peter Brookes cartoon

 The West Wales BMA debate had a low turnout, but of the 24 or so present there was a clear majority in favour of the motion.  This should tell the politicians and administrators why the profession is and will remain disengaged – until this debate goes national… One of the arguments against rationing is that it creates and legitimises inequalities. I would suggest that reducing inequalities is a role of government, by progressive fiscal legislation, but that they can never be removed. Certainly a less unequal society is desirable, and will find rationing more acceptable.

The Spirit Level: Why More Equal Societies Almost Always Do Better Richard Wilkinson & Kate Pickett [2010]

GP partnership model dead within 10 years, says NHS England GP

Colin Cooper reports on an interview with Mike Bewick in GPonline 10th September 2014: GP partnership model dead within 10 years, says NHS England GP

The GP partnership model will disappear in a decade and primary care will be provided by organisations the size of CCGs, according to the deputy medical director of NHS England.

I would agree with Mike, and furthermore, I would say that in future the “real doctor” in the community will be one who maintains his emergency skills, is able to manage Out of Hours, and at the same time is involved in teaching and end-of-life care. Such individuals will be really valuable, especially now that successive government administrations have rationed the number of doctors in training so that we need to import for the next decade..

Dr Mike Bewick, a former GP in West Cumbria, said the combination of a growing shortage of GPs and the changing needs of patients and local populations, would require a major restructuring of primary care.

The advent of co-commissioning by CCGs, and the need to provide services ‘at scale’, meant it was now ‘squeaky bum time’, he told a Westminster Health Forum conference in London.

‘This is the time when we actually have to say what we are going to do. And I am going to say just two things that I think are going to be true.

‘One is that in 10 years’ time the term independent contractor will be anachronistic and probably it will be gone.

‘And the second is that we will not talk about primary care, we will talk about out-of-hospital provision and out-of-hospital providers.’

GP shortage damaging partnerships

He said the lack of new GPs being trained meant that ‘we are going to lose doctors from the frontline very, very quickly’, and this would impact on the partnership model of general practice.

‘If you look at primary care, more than 50% of the doctors are salaried. There will be a force majeure to move away from a partnership type organisation because it will not serve them. And equally if you cannot recruit to partnerships you will need to think of something different.’

Dr Bewick said that ‘organisational nihilism’ in the NHS was preventing the system developing to meet changing priorities.

Primary care unsustainable

‘I do not believe that the current organisational structure of primary care is sustainable or, increasingly, desirable.

‘I do believe that in the end, the whole of the out-of-hospital service needs to come together to form a more integrated service.’

He expected new provider organisations to develop, each covering populations of about 300,000 – the average size of a CCG. ‘The provider at scale is in the six figures. It is not in four or five figures.’

Pharmacists and other healthcare professionals would be better utilised to fill the gaps left by GP recruitment problems.

But the move to large-scale primary care provider organisations would not mean the loss of local, personal healthcare services, said Dr Bewick.

‘I do not think we should be confusing that with not delivering healthcare by people you know in your locality. Localism is in my blood.

‘We should be forming organisational mergers with either community trusts or secondary care, or with other providers from other sectors. Providing they have the values of the NHS at their heart, I am not too worried about who delivers but more how it’s delivered and the outcomes for patients.’

Mr Cameron has to instruct CEOs, Board members and Chairman to give exit interviews

Mr Simon Stevens is going to meet Raj Mattu … but “fear leaves us frozen” (Hannah Devlin in The Times April 23rd)

I am afraid that very little will change the “alarming culture of fear” unless the politicians listen to the evidence and change their instructions to the Chairman and CEOs. They need to instruct them to give exit interviews, and to say they will not get a gong if they don’t…… Nothing short of this will reverse the current situation, and the cynicism in which the NHS is viewed by it’s staff. Once this process of honest feedback has begun, only then can we correct the damage done by the toxic mix of performance management and covert post-code rationing, political dishonesty and cowardice, and short-termism.

Whistleblowing and the NHS culture of fear. letters in The Times

 A new philosophy- What I believe


The New Year’s Honours (RHS) List 2014

NHSreality has awarded the following three levels of New Year’s Honours. Don’t be afraid to apply for a gong….. But remember you wont get a royal award if you speak out.. In an age when whistleblowing is renamed non-disclosure, and is covered in CEO and Chairman’s contracts, I do not expect many volunteers from those in post, but I believe we have a duty to aspire and speak out…

The three NHSreality RHS (Regional Health Service) awards are:

1. The Nye Bevan RHS award for honesty. This is given to those who have agreed to Exit Audio Interviews on their working lives, usually starting in the NHS, and then in the different health services. Nye Bevan had a clear view of what he wanted to achieve. NHSreality respects his intention, but also feels that technology and society have moved on so that we can no longer afford “Everything for Everyone, for Ever“.

Interview with Paul Davies, Welsh Assembly Member (Conservative Party)

Interview with Kim O’Doherty, retired GP from Saundersfoot, Pembrokeshire.

Interview with Roger Burns, former GP Educator and site author

Interview with Glan Phillips, Orthopaedic Surgeon Pembrokeshire

Interview with Julie Milewski, retired Nursing Sister

Interview with Peter Milewski retired General Surgeon

An Interview with Bill Clow, retired Consultant Obstetrician & Gynaecologist, and now Locum in NZ

Interview with Jon Skone, retired chief of the combined Social Services and Health budget in Pembrokeshire

2. The Emperor Nero RHS award for “fiddling while Rome burns”. This is given to those who agree(d) to an interview, but have not delivered, or who are considering whether to do so. In Pembrokeshire this includes representatives of the Community Health Council.

I don’t intend to publish names …. guilt may change their minds..

3. The Charles De Gaulle RHS award. This is awarded to important people who say “Non” to requests for interviews on the health service to be posted on NHSreality. In 2014 It is awarded to Stephen Crabbe  MP and The Welsh Labour Party who have not responded to several requests for interviews on NHSreality.


Pre retirement and retirement interviews: the opportunity lost

CQC recommended to conduct exit interviews?

The Telegraph’s Fraser Nelson reports 12th December 2013:

Telling harsh truths about the NHS is a bitter but necessary pill

Health Secretary Jeremy Hunt has begun a hard but vital journey to transfer   power to patients