Category Archives: Medical Education

Doctors will ration health care if they have to. But the situation that led to the under capacity- shortage of staff, equipment, beds, plant and then morale, needs an independent enquiry.

Health has become the political issue of the day. We have to ration health care and it has to be seen to be rationed fairly…. Doctors will ration health care if they have to. But the situation that led to the under capacity- shortage of staff, equipment, beds, plant and then morale, needs an independent enquiry. It is our short term horizons, and first past the post electoral system that stinks… and ensures that the under capacity will continue after the crisis is over.

The Times’ Daniel Finkelstein opines 17th March 2020: Doctors need help deciding who lives and dies – Parliament must take the lead in weighing up the economic and medical trade-offs that will be required in this crisis

In the summer of 1944 a new and terrible weapon was unleashed on Britain. The first V1 bombs began to land shortly after D-Day. The Germans had developed a way of killing that didn’t require a pilot and could destroy the centre of London and cripple its government.

Only it didn’t. The bombs landed, and kept landing, primarily to the southeast of the capital. Thousands did die and many buildings were destroyed, but the consensus of historians is that if the centre had been hit many more would have died and much more would have been destroyed.

And this judgment is important, because the diversion of the bombs to the south was a deliberate act. Winston Churchill sanctioned a programme, using double agents, that deceived the Nazis about where their bombs were landing and made them carry on missing the administrative centre of London.

Was this “playing God”, as one cabinet minister argued at the time? Was this sacrificing the less powerful so that the seat of government could escape? Or was it a difficult but acceptable choice in the circumstances?

The moral dilemma that faced Churchill is one that we grapple with all the time, as we make decisions on rail safety, to give one example. If you stop all the trains you can ensure 100 per cent safety on the railways, but people may travel by road and that can be more dangerous. Yet most of the time we don’t discuss the trade-offs we make. It’s too uncomfortable.

The present crisis means this silence is unsustainable. The government, scientists, economists and health workers are all facing agonisingly hard decisions, and they shouldn’t make them by themselves. Apart from anything else it isn’t fair on them.

In his splendid short book Would You Kill the Fat Man? the philosophy writer David Edmonds recognises in Churchill’s dilemma an example of what is known as the trolley problem. Over time this thought experiment has become fearsomely complicated. But at its core is something simple.

A tram (or as Americans call it, trolley car) is heading for a group of five people tied to the tracks and will kill them. You have the chance to divert the trolley by pulling a switch, but if you do it will go down a spur and kill one person. What should you do?

But here is another version. It isn’t a spur, it’s a loop. If the trolley was left unimpeded after you switched the signal, it would eventually loop around and kill the five people after all. It only doesn’t do that because it is stopped by the body of the one person. In the spur version you would be delighted if the one person leapt up and escaped. No one would die. In the loop version you need the one person to die because their body will stop the trolley. Should you pull the switch?

Or yet another version. A trolley car is hurtling towards five people who are tied to the track. You are standing on a bridge above it all. There is a fat man next to you and you realise that his bulk is just large enough that he will stop the train if you push him off. He will die but five will be saved. Should you kill the fat man?

Spur seems pretty straightforward, at least at first. You can save a net four lives. Pull the lever! But loop and especially fat man are much harder. They save the same number of people but they involve intent to kill, and the more intent they involve the more our intuition rebels against it.

There was something of this in the debate over the weekend about herd immunity. Part of the debate was about how many lives could be saved by immediate action. But part was about intention. It may be (and this depends on vaccines and other medication) that in the end we have to rely on herd immunity to bring an end to this crisis. But it is one thing arguing that herd immunity might happen in the end, and quite another arguing that herd immunity, which can only happen as a result of many people dying, should be an intentional aim.

I said that the spur option seemed straightforward but even with this there are complications. It’s all easy when the six different people tied to the track are anonymous and undifferentiated strangers. But what if the one is a child, and the five are old? Or the five are very sick and the one is full of vigour? Or the one is your relative and the others are people you don’t know?

Gordon Brown, when he was prime minister, once had a trolley-type question put to him after a speech on globalisation. If there were a tsunami and he was on the beach and could warn only one British person or five Nigerians, what would he do? Rather cleverly he instantly replied, while acknowledging his responsibility as British PM, that modern communications would allow him to warn both and he then spoke about the need for early warning systems.

He was quite right, of course. The first response must be to try to save as many lives as possible and to reduce the dilemmas. But it’s obvious it won’t dissolve the problems entirely. Hospital staff are going to have to choose between patients — young and old, sick and less sick, acute and less acute. They are already doing it, actually, as they put off operations to keep intensive care beds free.

Parliament and government need a proper debate and must provide guidance, and if necessary law, to assist medical staff in this unenviable task. If, for instance, young are to be preferred to old we had better discuss that preference in all its complexity.

But it isn’t only medical staff who face a dilemma. Our entire strategy involves a trade-off. We are choosing to suppress the disease in a way that will do great harm to the economy. And that seems the right choice, to me at least. But we should recognise, at least, the cost. There will be a cost to pay in terms of human life in an economy that, however much is done to pump it up, will be smaller than it once was — not just in less life quality, but in the amount of lives.

If we are poorer, we will have less that we can spend on healthcare and on fighting disease and people will die. I would like to see the government modelling on this, too, as we consider when and if to take breaks from suppression over the coming year.

And not only modelling on the impact now. The economic impact will be felt for years to come. It’s another spur complication. If one person would be saved but five people yet unborn might die young, would you pull the lever?

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What nonsense from Mr Drakeford…. Politician afraid to acknowledge the poor manpower planning, and his responsibility to the whole population..

Politicians should make the decisions about populations and their health. Doctors, apart from public health specialists, should “put their patient at the centre of their concern”. So when the BBC publishes 3rd Feb 2020: Royal Glamorgan: First minister criticises politicians on A&E plans they are never questioning Mark Drakeford’s comment:

“It is for doctors, not politicians, to decide the future of the Royal Glamorgan Hospital’s A&E department, Labour First Minister Mark Drakeford has said”.

This downgrading and closing of hospitals is driven by staff shortages. Its the same in Haverfordwest, Blackpool, Scarborough and all the peripheral and deprived areas without a teaching hospital and tertiary care. Mr Drakeford has relatively little power over the short term supply of doctors, but he could initiate the virtual medical school, and allow far more people to train. And that gives a long term solution. Meanwhile its going to get worse.. and worse.

Some good news on new medical schools. Lets hope the politicians seize the real opportunity for virtual medical schools living in local communities

There are just not enough geese to lay enough golden eggs. The cupboard is bare. We cannot be cloned.

There is a National shortage of GPs across all the 4 health dispensations. When the Department of Health primes reporters such as Chris Smyth, in the Times 7th Feb 2020, I am surprised by his naïve acceptance, seemingly without question. The bribes will not work as there is a 10-15 year shortage…A GP might move for 20K but he will not wish to move to a deprived area, and that is where the doctors are needed. SO what sort of perverse behaviours can we think of? Changing practice repeatedly and, like Monopoly, collecting £20k whenever you become a partner? There could even be a mutually beneficial merry-go-round…. There are just not enough geese to lay enough golden eggs. The cupboard is bare. We cannot be cloned.

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We could make it an obligation for all new doctors to work in deprived areas at first. ( Breaking EU convention human rights?) but would that deter some from applying? There were 11 applicants for every place up to recently, so it’s worth a thought.

Just as we could move our MPs to the midlands or S Yorkshire, the change would sort out those with real commitment. How many MPs are in the house because of the opportunity in London? Moving either house will test its members. Committing doctors to deprived areas for say 2 years, would test their altruism.

Bribes belittle the profession. They encourage distorted and perverse behaviours. In the long term deprived areas are best addressed by overcapacity. There is another distortion, and that is the temptation to go abroad, and that is best addressed by cultural change, making the doctors and staff feel valued, and an honest language, And Exit Interviews: what are they? Why not obtain from GPs?

Doctors to be given £20,000 for taking over local surgeries. Chris Smyth in the Times 7th Feb 2020.

Family doctors will be given £20,000 golden hellos for taking over local surgeries as the NHS struggles to deal with a GP crisis.

Care home residents have been promised weekly visits from surgery staff as part of government efforts to boost local care and keep elderly people out of hospital.

Thousands more pharmacists, physiotherapists and dieticians will be recruited as the NHS plans to boost an “army” of support staff to 26,000.

A shortage of GPs is one of the most pressing problems facing the NHS, with numbers falling even as the government has repeatedly promised more. Recently Boris Johnson pledged to boost numbers by 6,000.

Efforts to hire more have been hampered by younger doctors’ reluctance to become full-time owners of surgeries but, in an effort to tie them in for the long term, all new GP partners will be eligible for £20,000 bonuses plus help with training.

Under a deal struck yesterday between NHS England and the British Medical Association, £1.5 billion of a £4.5 billion pot allocated for primary care will be allocated to encourage GPs to stay in the NHS.

Sir Simon Stevens, NHS chief executive, said that the agreement was a “vote of confidence” in the GP system. “This agreement funds a major increase in general practice staff — including GPs, therapists and pharmacists — so that patients can get quicker appointments with a wide range of health professionals at their local surgery,” he said.

“These extra staff will be offering expanded services, including regular health checks for people living in care homes, action to boost vaccination uptake, earlier cancer detection and better support for people with learning disabilities.”

Health checks for new mothers and consistent medication reviews are also promised under contracts that pay GPs for providing them. Doctors will be encouraged to prescribe exercise and arts groups to expand “social prescribing”.

Richard Vautrey, of the BMA’s GP committee, said: “The significant investment in and focus on recruitment and retention, including payments to incentivise doctors to take up partnership roles and work in under-doctored areas, is a vote of confidence in the partnership model and a much-needed first step if we are to reverse the trend of falling GP numbers.

“An expanded healthcare team working in GP practices as well as increasingly closely with community colleagues across groups of practices, will mean patients have access to a wider range of staff, allowing GPs to see those who need them most more quickly.”

Matt Hancock, the health secretary, said: “This new contract is the first step to delivering our manifesto commitment to make it easier to get a GP appointment when you need it by delivering 50 million more appointments a year in general practice.”

2019: To paraphrase Spike Milligan: “I told you the Health Services were all ill”.

2019: A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

2017: The decline of General Practice.. Bribes may be too late…

2017: The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

2016: The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

2015: Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

A new and very different type of NHS in England (BMJ 2011)

May 2011: BBC Panorama Report By Undercover Investigator

2012: Nuffield Trust Report on Rationing

2012 The Health and Social Care Bill 100 Voices on NHS Reforms

2013: Burnout forces almost 10% of GPs to take time off work as pressure on occupational health services grows

2013: Mid Staffs – Who, if Anyone, Will Be Accountable?

2013: The Demographic Time Bomb

The skill of “doing nothing” is valuable, and is what makes the GPs so efficient.

The UK trains many doctors, especially Scotland, and some of them go abroad. We import some 30% of the doctor labour force. Wales trains many GPs. But we then have too few. We export them to England, and places where they aspire to bring up their families. Better infrastructure and education plays a great part in where doctors choose to live. With 80% of medical school places being allocated to female candidates, there is more incentive to stay near their home. Inner city and suburban schools provide most doctors for training. Whatever plan the government comes up with it needs to reverse these trends.. Inducements for doctors to work in poorer areas could be a lot greater….

Meanwhile we are promised a new brand of fast track doctor, who might have been a pharmacist or a paramedic beforehand. Lets hope they cut the mustard, and are asked to pass the same exams. NHSreality predicts that these people will not be able to live with uncertainty. Doing nothing for a short period of time allows diseases to take a natural course… The skill of “doing nothing” is valuable, and is what makes the GPs so efficient. If they cannot do this, and we know consultants find it hard, they will elongate the waiting lists for investigations. This will cause adverse outcomes, and those right enough will go privately. The perverse outcome of well intentioned but ill thought through change.

Read the damning nature of this joint report.. GP shortages …. Our very own post-code lottery.

Welsh NHS has ‘nothing to hide’, says health minister. Listen to Mr Drakeford…

Wriggling on the hook of Dr under capacity. Any solution, ethical or not, will be considered. On the other hand anyone who passes the final exams, however they learned, should be allowed to be a doctor.

Nurses and pharmacists to replace GPs for 1 in 4 visits

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Teetering on the edge? Living with uncertainty… something consultants are never trained for.. General practice is not a retirement home for hospital physicians (Let alone pharmacists and paramedics)

 

Ways of reducing the bill for NHS negligence – The perverse incentives and outcomes …

Every doctor and student of medical systems needs to understand the perverse incentive. I define this as a “driver within a system that works against the overall objective of the system”. Claims for medical Negligence in our tort driven system are necessary to arrest or slow down the continuing decline in standards. Unfortunately Dr Barton is correct: the 4 health services have lawyers who are salaried and paid win or lose, and 80% of claims result in success! The argument for no fault compensation has been addressed properly in NZ and several other countries, and Australia appears to have found a half way house…

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Times letters 24th Jan 2020: Ways of reducing the bill for NHS negligence

Sir, Your article “£4bn budget for legal fees in NHS negligence claims” (Jan 22) points out that the health service faces legal costs of £4.3 billion as part of a compensation bill for clinical negligence claims of £83 billion. The extent of this crisis cannot be overemphasised, as over the past three years the bill appears to have risen from £54 billion, according to the Department of Health. Apart from the usual platitudes about being careful, no one appears to be interested in addressing this parlous situation.

I previously worked for seven years in Australia, where this became a big problem and was addressed by an act of parliament transferring the liability risk away from the provider, unless it was ruled criminal negligence. This has led to a year-on-year fall of medical protection and indemnity fees for colleagues in Australia, while those in the UK have risen inexorably, providing yet another reason why doctors are giving up in droves and taking early retirement.

The start of a new government offers an ideal moment to address this festering sore on the NHS’s future.
Professor Angus Dalgleish

Foundation professor of oncology, University of London

Sir, As medical litigation costs spiral and threaten the future of the NHS, the case for a no-fault compensation system becomes overwhelming. At present, if a patient cannot prove medical negligence, they will receive no financial compensation — the decision sometimes having more to do with inadequate record-keeping than true clinical incompetence or negligence. As a result, two patients may have identical medical injuries but one will receive nothing whereas the other may be well compensated after perhaps years of litigation.

New Zealand has had a successful no-fault compensation scheme since 1974, with changes in 2005 ironing out some of its early anomalies, resulting in most claims being resolved in weeks rather than years. Litigation lawyers are the only people benefiting from the system in the UK.
Dr Andrew Quayle

Retired GP, Martock, Somerset

Sir, The cost of medical negligence (or accidents) is indeed high, but the possibility that the size of a giant claim might be reduced means that many cases end up in court because the legal fees justify an expensive defence. However, with court and legal costs of about £2,800 per day on top of barristers’ and solicitors’ fees it is often cheaper for an NHS Trust to settle a little case for a small sum than to defend it. While this is often done without an admission of liability it is open to abuse, because once word gets around it may generate frivolous or spurious “me too” claims that result in a payment of a few hundred pounds without many questions being asked. The system needs to address this as well as the top-end settlements.
Dr Andrew Bamji

Rye, E Sussex

Sir, NHS legal costs are inflated partly because of perverse incentives. NHS lawyers are paid win or lose, which encourages “deny, delay, defend” behaviour and promotes speculative defences. By contrast, claimant lawyers are generally paid “no win, no fee”; payment is by result, which imposes commercial prudence. This is amply borne out by NHS Resolution figures which show that compensation is paid in 80 per cent of cases where proceedings are issued. NHS lawyers should be paid by result and not rewarded for failure.
Dr Anthony Barton
Solicitor, Medical Negligence Team

Professional Liability Insurance : Market Global Report Jan 2020 – Fusion Science Academy

New York Telecast: Global Liability Insurance Market Status (2015-2019) and Forecast (2020-2024)

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Lexicology: Wright Hassall LLP The most notable medical liability case in 2019

United Kingdom August 27 2019

The NHS is facing an existential crisis. The negotiations over junior doctors’ pay and conditions and widespread dissatisfaction among GPs, combined with a £2.45bn overspend by NHS Trusts, is impacting on patient care. The NHS is treating more patients than ever before, including a rapidly growing number of elderly people whose care, in many cases, is caught in a Mexican stand-off between the NHS and social services.

The NHS announced it has paid out more than £1.63 billion in damages for medical negligence in 2017/18; this is an increase from £1.08 billion in 2016/17 with the highest number of claims coming from emergency medicine. The number of claims made as a whole has decreased slightly (0.12%), but the cost to the NHS continues to increase.

The cases outlined below are some of our most notable and an indication of what can go wrong when the caring services come under pressure – and these are just the tip of the iceberg……

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Update 29th Jan Times letters 2020:

NHS LEGAL CLAIMS
Sir, I would be delighted to accept the challenge from Dr Anthony Barton that NHS lawyers should be paid by results (letter, Jan 24) so long as in return he accepts that claimant lawyers should pay NHS costs when they lose. This should include the more than 80 per cent of cases that never reach court, often because they were frivolous claims which were pursued regardless of commercial prudence. These nevertheless incur NHS legal costs and waste vast amounts of NHS staff time, which often leaves them inadequate time to care for their patients.
Martin Sheppard

Retired NHS consultant
Haverfordwest, Pembrokeshire

 

The reaality of cultural dissonance.. A GP Trainee recalls her hospital experience of discipline..

A letter in the Times from Dr Katie Musgrave 20th January informs readers of the reality of being a junior doctor in todays overmanaged health services. Read it at the end of this post.

The Bury St Edmonds terrorising of staff, threatening them with fingerprinting, and generally demoralising them further, is indicative of the whole of the 4 health services. 

The idea that managers can treat doctors as staff on a factory production line has led to this situation. Changing a culture is very difficult... especially for a state monopoly which most people still love the idea of… especially when the trust are all bust. No single person I have asked seems to realise that with the Brexit devaluation of the pound all costs have risen by 18%…

Add to this the overhead inherent in Wales (As opposed to Scotland and N Ireland) because of the Welsh Government..

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Bury St Edmunds Hospital in the dock. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn,

Missed appointments dont cost except in a factory model of General Practice. 20,000 missed appointments is actually welcome to most GPs. Now if there was a disincentive to make a claim….

Kent NHS ‘to send surgery patients to France’ – setting a precedent? Can the fragmented UK health services recover without some form of zero-budgeting and revolutionary reconfiguration based on overt rationing?”

NHS WHISTLEBLOWERS
Sir, Your report on West Suffolk Hospital (“Anger over ‘witch hunt’ in hospital”, Jan 17) will be shocking to many but did not surprise me. My husband (a GP) and I have just exchanged memories of times when, as junior doctors, we were both brought before committees accused of minor misdemeanours. He had logged into a results system online and forgotten to log out. Someone had subsequently used his account to look at a consultant’s personal medical results. He was made to “confess” and sign a document admitting his negligent behaviour. I was once accused of dropping a blood bottle into a regular bin rather than a clinical bin. The bottle had been traced to me and a committee put together to sanction me for this crime. At another hospital I was called to answer for having examined a child in the wrong clinical room. Apparently I had been anonymously reported. Such bullying tactics are widespread in the NHS and do indeed keep doctors from raising genuine concerns about patient safety. If, from your early years of training, you have been consistently threatened and undermined, it can be very difficult to maintain the resilience to speak up. We need independent advocates for NHS whistleblowers.
Dr Katie Musgrave, GP trainee
Loddiswell, Devon

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Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations

The experts on trends in health care, and especially private health care, and Private Medical Insurance (PMI) are Laing and Buisson whose reports cost a great deal.

Their reports into “Private Acute Healthcare, Mental Health Hospitals, Cosmetic Surgery, Children’s HealthCare Services, Digital Health and the UK Healthcare” are all “Market Reports”. This is a market where you pay for what you get, and sometimes for what you cant get. In the case of taxpayers at the peripheries of the country, these lacunae of services are greater than centrally. Especially worrying is the report on Private Acute Healthcare. British citizens may all have to consider choices and whether to travel long distances to centres of excellence, even for emergencies, in the next decade. The figures provided by the BMA in 2018 have got worse, and remember these only apply to England!

Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations, and the hard choices ahead for all of us. With obesity and diabetes the main demands.. But there’s always denial.

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PressReader and the Independent report 19th Jan 2020: Britons spend more than £1bn on private surgery.

The Nuffield Trust report in 2016 indicated that much more money was needed just to keep up with internationally comparable countries;

Since then (2009) , however, the gap has started to widen (particularly against countries that weathered the global financial crisis better than the UK) and looks set to grow further. UK GDP is forecast to grow in real terms by around 15.2 per cent between 2014/15 and 2020/21. But on current plans2, UK public spending on the NHS will grow by much less: 5.2 per cent. This is equivalent to around £7 billion in real terms – increasing from £135 billion in 2014/15 to £142 billion in 2020/21. As a proportion of GDP it will fall to 6.6 per cent compared to 7.3 per cent in 2014/15. But, if spending kept pace with growth in the economy, by 2020/21 the UK NHS would be spending around £158 billion at today’s prices – £16 billion more than planned.

The London School of Economics opines 1st October 2019: Flawed data? Why NHS spending on the independent sector may actually be much more than 7%

,,,the amount spent by NHS England on the independent sector was around 26% of total expenditure, not 7% as widely reported. 

Cannabis is not a frontline drug, but some people seem to benefit.. Just like with dementia drugs the value is very small.. Andrew Ellson in Jan 2020 reported in the Times; More than a million Britons buying cannabis illegally to treat illness

The French have rationed out dementia drugs, and will be able to give much more care. The same argument may apply for cannabis, depending on numbers, and remember demand always increases once a service is free.

The Scottish Daily Mail (Pressreader) points out that there are 3700 visits to A&E every day (In Scotland alone) which could have been dealt with by GPs is there were enough of them, with enough time and resources. What an incentive to start private general practice.

Mailonline December 2018 reports that: Patients spend a record £1.1BILLION on private healthcare to avoid soaring NHS waiting times which leave them ‘let down and suffering’ and this has been updated for just surgery by the Independent.

The BMA opines 7th Dec 2018 on: Hidden figures: private care in the English NHS (and its got worse since)

Breaking Point, NHS info graphics
Do (ISPs) independent sector providers give good and good value care? NHS spending on (ISPs) independent sector providers keeps increasing.

The health service in England is facing the greatest financial challenge in its history, and yet the independent sector is increasingly involved with the provision of patient care within the NHS.

The English health service is heading towards a projected £30 billion funding gap in 2020/21; the government has committed £10 billion to help mitigate the situation, although the BMA has argued that in real terms, and factoring in the cuts to other services, the figure is closer to £4.5 billion. Within this climate, one of the few areas where funding is increasing is amongst ISPs (independent sector providers) of NHS care.

We want to find out what this means for the provision of patient care.

Key points

Building on our 2016 report on privatisation within the NHS in England we’ve looked into the data behind these headlines.

Our analysis uncovered the following key points:

  • NHS spending on non-NHS and independent sector provision grows each year (there was an increase of £2.6 and £2.1 billion respectively between 2013/14 and 2015/16);
  • The proportion of the total Department of Health budget spent on ISPs is also increasing (from 6.1% in 2013/14 to 7.6% in 2015/16);
  • There needs to be more transparency about the level of private provision of NHS services;
  • The principal area of spending on ISPs is in the community health sector;
  • The NHS relies very heavily on a small number of ISPs despite acknowledged risks from individual ISPs having an excessive market share;
  • CCGs spending a higher proportion of their budget on ISPs received worse ratings from NHS England than their counterparts.

Claire Milne for Full Fact reports before the election on How much public health spending goes to the private sector? 

…..This takes as its starting point the £13.7 billion figure from the DHSC accounts.

The £1.3 billion spent by NHS trusts on services from non-NHS organisations is added to that.

Added to that is the £14 billion the NHS spent on commissioning primary care from the private sector. This includes things like GP services, pharmacies, and opticians. This may not be what everyone things of when they think of the NHS spending money on private providers, but technically they all are. Mr Rowland acknowledges there is “genuine debate” as to whether the provision of GP services fall under private spending “given that they derive almost all their income from the NHS”.

Finally, it includes the £830 million the NHS in England spends on social care services and a lot of these are provided by private organisations.

Another health think tank, the Nuffield Trust, has used a similar method to determine that, over the last decade, between 20% and 22% of annual public spending on health in England has gone towards procuring healthcare services from private providers.

Sensible rationing of dementia drugs – a lead from France

‘Wasteful practice’ CQC says is due to ‘ongoing issues with poor recruitment, training and safeguarding processes’ Private ambulances and Taxis: The Independent reports 27th August 2019.