Category Archives: Patient representatives

A bigger and bigger deficit in West Wales…… Now at £600 per head……

Pembrokeshire, Carmarthenshire and Cardiganshire are broke. According to the latest published overspend for Hywel Dda we have used £400 per head, extra, over the last three audited years. We are nearly at the end of another unaudited year, and can expect the overspend to top £70m this year alone. If we total the last 3 years it comes to £150m, and divide by 372,320 population of Hywel Dda we get to a figure of £402 each. If we add this year, another £200 is minimum… In 3 years time £1000 per head is predictable. We should stop making comparisons with the USA, but make comparisons with Canada, Germany, France or Holland. Even Ireland has a system which spends little to give very reasonable results… and is financially sensible. There is no perfect system, but there are examples of excellence in many. Spending less (with consent) as a % of the total in our last year of life is also important. The decisions taken in Scotland will be a sign of whether “reality” has sunk in to their politicians. Sustainable solutions are beyond our current leaderless houses..

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BBC News reports 8th Feb 2018: Hywel Dda health board facing bigger deficit

The health board in Wales with the highest level of overspending has seen its financial situation worsen.

The projected deficit this financial year at Hywel Dda, which covers west Wales, has increased to nearly £70m.

The health board blamed increased pressure on services in the autumn for the overspend, which follows deficits of £49m in 2016-17 and £31m in 2015-16……

on 6th February the BBCs “Reality Check Team” (Nick Triggle – did he pinch reality from NHSrealaity?) published: Reality Check: Does UK spend half as much on health as US?

If you look at all healthcare spending, including treatment funded privately by individuals, the US spent 17.2% of its GDP on healthcare in 2016, compared with 9.7% in the UK.

Chart showing health spending as proportion of GDP shows US spends more than UK

In pounds per head, that’s £2,892 on healthcare for every person in the UK and £7,617 per person in the US.

So as a proportion of the value of the goods and services produced by all sectors of the economy the UK spends a bit more than half what the US spends, and in spending per head it’s a bit less than half.

Bar chart showing spending per capita is higher in US than UK

The difficulty is, when it comes to comparing healthcare in different countries, you’re never exactly comparing like for like.

Almost all health systems are a mixture of public and private – it’s the ratio that varies.

In the UK, the public health system can be accessed by all permanent residents, is mostly free at the point of use and is almost entirely paid for through taxation.

Americans are far more likely to rely on private insurance to fund their healthcare since accessing public healthcare is dependent on your income.

Many European countries, meanwhile, have a social insurance system where insurance contributions are mandatory. This doesn’t fall under general taxation but is not dissimilar from paying National Insurance in the UK and means everyone can access healthcare….

Safety, affordability and efficiency

In the summer, US think tank the Commonwealth Fund ranked the NHS the number one health system in a comparison of 11 countries for safety, affordability and efficiency. It did less well when it came to cancer survival

The US was ranked last out of the 11 countries.

The American health system came off badly in comparison when it came to infant mortality, life expectancy, and preventable deaths, but did relatively better on cancer, heart attack and stroke survival.

Meanwhile, the UK’s cancer survival rates have historically been below the European average, although they are improving for certain cancers.

The UK has fewer doctors, nurses and hospital beds than the OECD average.

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Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

If the NHS really is the envy of the world, why don’t countries copy it?

Performance relative to other countries. Commonwealth fund “mirror”.

Self Sufficiency is a dream Mr Hunt. Rationing of Med Students means it will take over 15 years – starting now  – April 2017

Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

Why NHS money matters

In Search of the Perfect Health System – a new book reviewed

Not many first world countries have gone backwards in health provision, population health and life expectancy. The UK may be the first…

Life would be better if we faced up to death…. important conversations are put off until too late

NHS in Scotland must face up to “difficult decisions” to remain sustainable BMJ 2018;360:k567

Time is rapidly running out for Scotland to develop and implement solutions that will create a sustainable health service, a high level report warns.

The report,1 from the Royal College of Physicians of Edinburgh and the Good Governance Institute, makes key recommendations for securing the NHS’s future in Scotland, including difficult decisions about what the NHS can afford in the future….

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Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Jenni Russell reports in the Times 8th Feb 2018: Wise doctors will retreat from the front line now

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians for their long term rationing, denial, and collusion of anonymity. Other countries and their leaders cannot understand us, including Mr Trump. (Stephen Glover in the Daily Mail)

Overwork and the risk of negligence cases make safer specialisms preferable to acute medicine

I was once responsible for a patient’s death. Or that’s how it could have been seen. It was years ago, in a gap year job, but the experience was so searing I can relive it with terrible clarity.

I was working as a nursing auxiliary on a hospital ward. At 9pm all the nurses were gathered in the sister’s office, two doors and 30 metres away, handing over to the night team. A physio was with an elderly asthma patient when she threw open the curtains around the bed and shouted: “Resus! Nurse, get the resus trolley!”

She meant me. I was the only person in a nurse’s uniform in sight or earshot. I ran. The heart resuscitation team was bleeped. I dragged the trolley, which was new on the ward that month, to the bed. I unwound the electric cable, seized the plug, looked around for a socket. And looked. And looked.

This was an old ward in a crumbling outbuilding and there was nothing logical about its power points. As the newest and most junior person on the team, no one had thought it necessary to show me where they were. While I hunted, with rising panic, ducking between beds, the old lady’s heart began to fail. The heart team arrived, a nurse grabbed the plug from me, the old lady died.

Was this my fault, or the system’s? If I had been faster that woman may have lived. Is someone who tries their best when they don’t have adequate backup the guilty party, or is the system around them also responsible, for not providing the support they need?

Any sane person would think the latter, but thanks to the punitive decisions of the GMC and the High Court in pursuing the striking-off of Dr Hadiza Bawa-Garba after an error which led to a child’s death, every doctor and nurse in the country now fears that they may lose their jobs, futures and reputations for a single serious mistake.

The doctor was under extreme pressure, covering for an absent registrar while overseeing six wards on four floors, on a relentlessly demanding twelve-hour shift. It was her first day back after maternity leave and she had had no induction training. The nursing rota was understaffed and the IT system was down for hours, meaning blood test results were critically delayed. Her consultant wasn’t present. All the evidence given testified to her being a committed, above-average doctor, and yet she has been thrown out of the profession.

The chilling lesson of the Bawa-Garba debacle is that context, character, remorsefulness and a good record will be no defence.

The unintended consequences of this hardline decision by the GMC are going to damage the NHS, not protect it. Doctors across the country are aghast, feeling, as an editorial in the BMJ said, that “there but for the grace of God go I”. Furious senior doctors are reporting themselves to the GMC for long-ago errors, to make that point. Newer doctors are now afraid to admit to theirs in case it backfires on them. And the devastating practical effects are now unfolding, unseen.

“I’m practising defensive medicine now,” one doctor told me. “We all are. I’m not taking risks. If someone turns up with a non-specific lump, I might before have used my judgment, said wait and see. Now I’m sending them for scans, second opinions, follow-ups, blood tests. Lots of that will be unnecessary, the NHS is already overloaded, and I’m adding to that. But I feel now I’ve got no protection, I’ve got to watch my own back.”

His fears are widely shared, an A&E consultant tells me. It’s going to cut the numbers willing to work in areas of acute medicine that are already routinely understaffed, like paediatrics or emergency medicine. If doctors know, as they do, that those are the jobs where they must take what are now career-threatening high-risk decisions, while covering rota gaps, fewer people will apply. “They’ll retreat to safer options — dermatology, genito-urinary clinics, specialisms like that.”

He warns that it’s going to mean a rise in staff going off sick in high-pressure disciplines, as people assess the new pressures of being conscientious. Instead of putting the patients first, many doctors will choose caution. “If you’re feeling a bit off, why would you risk putting yourself in the firing line? It’s going to be a lot safer to stay at home.”

There is particular fury at the GMC’s attempt to cover its back by issuing guidelines telling doctors that if they are in understaffed, unsafe environments they must create a paper trail flagging that up. As one enraged doctor pointed out to me, hospitals already know exactly when their rotas are missing staff. And as a fine column in the BMJ by the consultant in geriatrics David Oliver points out, now we are ordering overworked doctors to spend more of the time they don’t have in documenting that they haven’t got it. It serves literally no purpose, since if nothing goes badly wrong on their shifts nobody cares that they were overloaded, and if something does go wrong, that record won’t protect them.

The NHS is clearly alarmed by what has been set in train here, with many hospitals declaring they stand by their staff and the health secretary Jeremy Hunt setting up an inquiry into the implications of the Bawa-Garba case. But warm words mean nothing laid against the cold legal danger doctors are now in. They need safer staffing levels and an absolute assurance that when they make mistakes their institutions will share responsibility too. Until they get that, the health service is going to be weakened by this cruel and foolish pursuit.

Laura Donelly in the Telegraph 6th February reports: Hunt orders review of Medical Malpractice and Doctors Outcry  over manslaughter case:

Dr Hadiza Bawa-Garba was struck off the medical register after she was found guilty of mistakes in the care of a six-year-old boy who died of sepsis.

The case has been met with a backlash among medics, with thousands sending letters of support for the doctor, saying the decision ignored NHS failings and staff shortages which contributed to the death.

Dr Bawa-Garba was originally suspended from the medical register for 12 months last June by a tribunal, but has now been removed from the medical register following a High Court appeal by regulator the General Medical Council (GMC).

The GMC said the the original decision was “not sufficient to protect the public”.

Mr Hunt had already expressed unease about the situation, saying he was “totally perplexed” by the actions of the watchdog.

In particular, he raised concerns that doctors would no longer be open about errors, and be honest in their self-appraisals.

In a statement to the Commons, the Health and Social Care said clarity was needed about  drawing the line between gross negligence and ordinary errors.

Speaking in the House of Commons today, Mr Hunt said Sir Norman Williams, former president of the Royal College of Surgeons, will lead a national “rapid review” of the application of such laws.

He said Sir Norman will review how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.

Mr Hunt said the review will also look at the role of reflective learning, to ensure doctors are able to open and transparent and learn from mistakes.

The review, which is due to report by April, will also consider lessons to be learned by the GMC and other regulators.

Charlie Massey, chief executive of the General Medical Council said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England. The issues around GNM within healthcare have been present for a number of years, and we have been engaged in constructive discussions with medical leaders on this issue.”

He said the watcdog was committed to examining the issues, and to ensure fair treatment of doctors working in situations where the risk of death is a constant and in the context of systemic pressure.”

“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure. We know that we cannot immediately resolve all of the profession’s concerns, but we are determined to do everything possible to bring positive improvements out of this issue,” he said.

The GMC is carrying  out its own review, and would endure the findings from the new review feed into it.

Dr Bawa-Garba was struck off over the death of Jack Adcock, aged 6, at Leicester Royal Infirmary in 2011.

The child, from Glen Parva, Leicestershire, was admitted to the hospital in February 2011, his sepsis went undiagnosed and led to him suffering a cardiac arrest. The courts heard Dr Bawa-Garba, a paediatrician, committed a “catalogue” of errors, including missing signs of his infection and mistakenly thinking Jack was under a do-not-resuscitate order.

But they also heard the doctor was working amid widespread staff shortages, with IT failures and delays in test results

At the time of the ruling, Jack’s mother, Nicola, said: “We are absolutely elated with the decision. It’s what we wanted.

“I know we’ll never get Jack back but we have got justice for our little boy.”

The Medical Protection Society, which represented Dr Bawa-Garba, said at the time: “A conviction should not automatically mean that a doctor who has fully remediated and demonstrated insight into their clinical failings is erased.”

An online appeal set up by concerned doctors has raised more than £320,000 to help pay the legal costs of Dr Bawa-Garba.

Agency nurse Isabel Amaro was also convicted of manslaughter on the grounds of gross negligence relating to the same incident and struck off by the Nursing and Midwifery Council.

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

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

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

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

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

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

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

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

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

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

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

extract:

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

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Who wants to be a Hywel Dda board member? “Hywel Dda health board looks at hospital closure options”. The obvious solution is to promise a new build at Whitland, and a dualling of roads west.

Health Boards in Wales are made up of professionally experienced people, some from the locality, but others from away. Their brief is to make utilitarian decisions (greatest good for the greatest number) within their area. The area is chosen and defined by the politicians. Hywel Dda is an anathema to Pembrokeshire people because they feel socially and culturally different to the people in Aberystwyth and Carmarthen. This is an accident of history, where Pembrokeshire remains the “Little England beyond Wales”. So any decision which takes away from Pembrokeshire will meet great opposition. The demographics, where more people live in the West, where there is giant important industry in Milford Haven with disaster potential, and where there are more holidaymakers for 4 months in the summer, mean that there has to be a hospital in Pembrokeshire. The lack of a proper dual carriageway road, or failing that a full time air ambulance, compounds the risk for citizens. Life expectancy in Wales is already worse than the rest of the UK, and is going to get even worse.  Some time ago the then board recommended a “New Build” near Whitland, but in our single pressure group (SWAT) and press led society this was rejected. Today the people of Pembrokeshire would welcome a new build on the Carmarthen shire border with open arms, because the proposed option is so much worse. Who wants to be a board member? I was once.. Withybush is already attracting more GP trainees, and a review of the situation might find the obvious solution…

Breaks Ranks 24052006

BBC News 22nd Jan 2018 reports: Hywel Dda health board looks at hospital closure options

A radical shake-up of health services in mid and west Wales includes options to close hospitals.

A leaked document shows hospital closures in seven out of nine options.

Hywel Dda health board will be presenting its preferred options in the spring but said it needed a modern healthcare system, while “keeping hospitals for those who really need hospital care”.

Last week a review urged a “revolution” in health delivery in Wales.

The independent panel said without “significantly accelerated” change, services which are already not fit for the future, will decline further.

All health boards are under pressure from Health Secretary Vaughan Gething to move forward with plans for reform the NHS.

Hywel Dda said it faces spending demands of £200m over the next five years on top of its existing budget – currently £800m – if it carries on as it is.

Health board map

The health board – which is responsible for four general hospitals in Carmarthenshire, Ceredigion and Pembrokeshire – has already had an early “listening” exercise with the public and is now designing different potential models for how future services will look.

A document with nine of the options has been leaked to the media – but health bosses say they will be narrowed down and assessed before being presented to the public.

All options currently being considered include a network of community hubs with beds and none of the options involve closing Bronglais in Aberystwyth.

  • Seven of the options in the leaked document include closing one or more hospitals in Carmarthenshire or Pembrokeshire
  • Five of the options would involve the closure of Withybush hospital in Haverfordwest
  • One option suggests a new, major urgent and planned care hospital in an unspecified location to replace Withybush, Prince Philip in Llanelli and Glangwili in Carmarthen, which would all close
  • Two options include keeping all hospitals open but with urgent care being centralised in either Glangwili or Withybush
  • The health board has issued a statement saying it is discussing, “rigorously testing” and narrowing down the options with doctors, nurses and wider staff groups and will be “open and honest” about its preferred option.

    It said all propose “significant change” and a focus on transferring more hospital services into the community where appropriate.

    “A fewer number of preferred options will be released publically in the spring, when the health board is confident they are viable, safe and an improvement on what is currently provided,” it said.

    Medical director Dr Philip Kloer said: “This is a once in a lifetime opportunity for our health service and community to work together to design an NHS which is fit for our generation and beyond.

    “It has been acknowledged for some time across the UK that healthcare services are challenged like never before and we need significant change.”

    ‘Scattered communities’

    He said they would be looking to the latest technology in “fit for purpose facilities”.

    The health board serves 384,000 people.

    “A number of our services are fragile and dependent on significant numbers of temporary staff, which can lead to poorer quality care,” said Dr Kloer.

    “For us specifically in Hywel Dda, the geography we cover is large, with many scattered communities that are getting older, needing more holistic health and social care treatment and support.”

    Dr Kloer said they appreciated the attachment people had to their local hospitals but said it was “about more than the buildings”.

    He added: “This is about investing in our communities, attracting doctors, nurses and therapists by operating a modern healthcare system and keeping hospitals for those who really need hospital care.”

West Wales needs a new Hospital – not improvements to Glangwili Hospital in Carmarthen. Failing to act in a utilitarian way may well lead to unrest..

West Wales Health has to have a future – somewhere in the “middle” ground… Back to 2006 and reversing the wrong decision taken then not to build a new Hospital.

Ominous news for the peripheral DGH. MPs grant powers to close local hospitals..

Closing hospitals can help us save the NHS

Making rural hospitals sustainable – It is both quality hospital doctors and GPs we are short of… Please don’t be tempted to reduce standards..

Local politics and health: Hundreds from West Wales (Pembrokeshire) to protest at the Senedd against ‘downgrading’ of Withybush Hospital

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

Reflections on the BMA conference in Bournemouth. A complete lack of trust..

Imposter? Many of our own go abroad. With so many Drs from overseas, how many of them have “fake” degrees?

Without overseas staff, doctors midwives and nurses, the Health Services would collapse. Many of our own fo overseas. The majority of doctors from the Indian subcontinent have been trained at private medical schools, and although the state does train many, they are a minority. With the media exposing false and illicit degrees, the 4 health services in the UK need a healthy scepticism when examining the CVs of desperately needed staff. This includes midwives and nurses. As the Health Services implode further, Trusts may be so desperate that they really don’t mind imposter degrees servicing their citizens. The perverse incentive to appoint and examine the evidence later may be too great..

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Duncan Geddes in the Times 17th Jan 2018 reports: Fake degrees from Pakistan sold to doctors

A “diploma mill” in Pakistan has sold fake degrees to thousands of British workers and companies, including NHS doctors and a defence contractor, according to leaked documents.

Axact sold more than 3,000 qualifications in Britain over two years, including PhDs and medical doctorates, an investigation by BBC Radio 4’s File on Four found. The company has invented hundreds of universities online and uses fake news stories in an attempt to fool employers who check fake references on CVs.

Buyers of fake post-degree qualifications between 2013 and 2014 included NHS nurses, consultants and an ophthalmologist, according to the BBC. A British engineer based in Saudi Arabia spent almost half a million pounds on fake documents, it was claimed.

Dozens of websites selling fake degrees have been closed in recent years but the authorities struggle to keep up because they are usually based abroad. Pakistan opened an investigation into Axact nearly three years ago but the company continues to operate a global network from a call centre in Karachi.

In Britain the crackdown on bogus degree sellers is led by Higher Education Degree Datacheck. Its chief executive, Jane Rowley, said that only a fifth of British employers properly checked qualifications when hiring staff.

The BBC investigation claimed that the defence contractor FB Heliservices bought fake degrees for seven employees, including two helicopter pilots, between 2013 and 2015. Its parent company, Cobham, said disciplinary action had been taken.

The purchases were a “historic issue” and had no impact on safety or training, Cobham said.

Axact denies all wrongdoing.

Not enough doctors – just keep lowering the bar & reducing the funding

Making doctors stay….. in a neglected NHS. Letters in the Telegraph. Altruism destroyed early..

Thousands of fake degrees sold in UK – BBC – 4 days ago

Pakistan-based IT firm sold thousands of fake degrees to UK citizens … The Times of India 3 days ago

‘Diploma mill’ in Pakistan sells fake degrees to Brits | Daily Mail Online 3 days ago

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

A day on the frontline. Numbers of NHS doctors registering to work overseas could reach unprecedented record

10% increase in vacancies. “Industrial scale” recruitment from overseas is a clear admission of recurrent cross party political failure.

Declining training standards prompt rescue action

 

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Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

There is no perfect healthcare system, but some are better than others in results, and others are better in sustainability. The UK thinks it’s 4 healthcare systems are good enough, but most people are stoically accepting of shared rooms, cross infections, lack of post-code equality, and long waits for access…. until they themselves are victims. Then it’s too late, and if they can afford it they go privately.

Mark Littlewood (director-general of the Institute of Economic Affairs.) opines in the Times business comment 15th Jan 2017: Winter has come and Britain needs a cure for its ailing health service

In the hit television series Game of Thrones, there is a recurring and unsettling meme. “Winter is coming,” mutter the leading characters in hushed tones. We, the viewers, are left in no doubt that the impact of this seasonal event will be dramatic indeed. Little can be done, apparently, to prepare for it, you just need to brace yourself for its icy grip and its life-threatening impact.

Those who fret about the state of the National Health Service often seem caught in this same cycle of despair. Each year, we can be certain that the weather will worsen and the temperature will drop in the Christmas and New Year period, but we can’t seem to do a great deal to equip ourselves to tackle the associated impact on people’s health.

Although some winters are worse than others, this is now an annual event. We can simply expect, every year, there to be a lack of available beds, missed targets on treatment times and the cancellation of a swathe of operations. Lives are lost and patients remain in pain and misery as a result. The only upside seems to be that the high level of human suffering is at last opening up the beginnings of a measured debate about whether there may be alternative models of healthcare provision that are preferable to the UK system. Other European countries also have winters, but they don’t appear to be accompanied by high-profile political battles about the unbearable stresses and pressures on their health services.

A rational approach to considering whether we have more to learn about healthcare from the rest of Europe than to teach it needs to have some agreed parameters. First, we need to be clear about where we stand on funding. This should, in theory, be relatively straightforward. The UK spends about 10 per cent of GDP on healthcare, both public and private, up from a more miserly 6 per cent at the start of the century. This is a little lower than some other rich EU countries but not by an order of magnitude. In the same way that you might expect a £30 bottle of wine to be of modestly higher quality than a £25 bottle, you might also expect Swiss or German healthcare to be just a little better than its British equivalent. There shouldn’t be a great deal in it, especially if the producers of the £25 bottle purport to be the envy of the entire world.

Enhanced funding might well improve results, but it cannot be the only factor in explaining wildly different health outcomes, given that the UK finds itself broadly in the middle of the pack on expenditure.

Second, we should accept that there is almost unanimous agreement about two underlying principles of healthcare provision, right across the political spectrum. High quality healthcare should be universally accessible and essentially free at the point of delivery. Of course, the NHS itself occasionally diverts from the latter rule, with modest charges for prescriptions and the like, but the key idea is that everyone needs to be able to access treatment and surgery and no one should need to pay prohibitive fees to receive it. Very likely, the staunch public support for the NHS in opinion polls is really a reflection of an underlying commitment to universality and no material charges at the point of need, rather than for the NHS branding or name. Where debate tends to veer off up a blind alley is the unspoken assumption that the UK system is unique in the world in adhering to these two vital principles. The truth is that virtually every developed country has embraced both principles with the same unbending commitment that we have in Britain.

Third, we need to agree that anyone who frames the choice over healthcare systems as essentially being a binary decision between the NHS and the American system should be excluded from the debate. It is an extraordinarily Anglocentric and narrow-minded approach to assume that no country other than the UK and the US should have their own system even considered as a viable option. I have met no one who wants to adopt the American approach to healthcare on this side of the Atlantic; it is fiendishly expensive and appallingly bad at securing access to good treatment for poorer members of society. In some areas it does produce impressive aggregated results (for example, on cancer survival rates) but given that the Americans spend an enormous 16 per cent of national income on health, it is disappointing that their results aren’t considerably better.

If we approach the debate in this way, we may well conclude that the schemes used by most countries on the Continent are preferable to the NHS model. Although systems vary, the basic idea is that each individual has an insurance package that pays out when they need treatment. Those with the means to do so would have to pay for this insurance themselves — in the same way that drivers are obliged to take out motor insurance. Those on tighter budgets would have their premium topped up, or wholly paid for, by the taxpayer. We could insist, through the law, that pre-existing conditions are not considered in the premium charged, so the system is equitable and the risks shared across society. The question as to how much we should spend on healthcare overall is an important argument, but a separate one.

When winter comes in Germany, the Netherlands, Switzerland or Belgium, it is not typically accompanied by their health systems plunging into crisis. They appear to be able to deal with a change in the seasons effortlessly and without spending a great deal more money than we do in Britain.

This year marks the 70th anniversary of the National Health Service, which seems a good time to ask ourselves whether we have a monopoly on wisdom in how to provide healthcare. If we wrongly conclude that we do, we should brace ourselves for many more winters like this one.

Mark Littlewood is director-general of the Institute of Economic Affairs.

Compared with 11 other countries UK ranked first – for it’s system and not for it’s outcomes

As the 4 state systems fail, more taxpayers go private. A two tier approach to rationing by default rather than by design means no fairness for anyone.

The Commonwealth Fund compares health systems. Unreality of MPs. ..

Mark Britnell “In search of the perfect health system”, (published by Macmillan Education and Palgrave ISBN 978-1-137-49661-4)  2015 – Reviewed on NHSreality

 

We must avoid the mistake of a hypothecated health tax – unless the tax takes income and capital into account.

Mistakes are all part of medicine. We make small mistakes all the time, and the pressures of work are part of this lack of perfection. Medical students have always helped out on teaching hospital wards, and it is fake news to suggest this is new. What is new is if their work is unsupervised, and if patients have no choice to opt out. There are some people who will take 17 stabs at a vein, and some patients will have PTSD as a result… Choice is part of Liberal philosophy, as is a progressive tax system whereby inequalities are reduced, and the tax system enhances choices. Hypothecated taxation could well be regressive rather than progressive, it could increase post-code rationing, and unless it is applied allied with an identity card, and fees are related to wealth as well as income, it may come to be regarded as grossly “unfair”. The German two tier insurance system would be better, as it is only a small percentage of high earners who get the extras, and these are not related to medical outcomes: rather to choice, comfort and convenience.. Pithed Politicians have an invidious choice: they have to choose what is less divisive, less regressive, and less unequal. Whatever they choose will be “unfair” to some, but they need to avoid the mistake of introducing a new system and of it being unsupervised. Even Iran has studied this more openly than the UK. 

In a deserts based system where co-payments are related to means, infrequent attenders who kept healthy and looked after their own needs would pay more, but less frequently.. Impoverished frequent attenders would pay less, but more often. There could be a rewards system for reducing attendance, and there could be increasing fees for multiple attendees/families. There could be tax exempt savings (Health ISAs) to encourage thrift, with tax relief on health related savings accounts.

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How to give the NHS extra billions it needs –

The PM and health secretary should be bold and support the emerging political appetite for a levy to fund social care

Another winter, another NHS crisis. With operations cancelled and ambulances queueing outside hospitals, the prime minister has already been forced to apologise to patients. Last week 68 consultants in charge of accident and emergency departments warned that people were dying “prematurely” in corridors because beds are full. Medical students are being asked to fill the staffing gaps. This is not just “shroud-waving” by health professionals or scaremongering by opposition MPs, but the result of a genuine demographic change.

The NHS crisis is really a social care crisis, created by an ageing population and exacerbated by government cuts. Although health service budgets have been ring-fenced since 2010, there has been a £6 billion reduction in spending on social care and an entirely related 50 per cent rise in the numbers of elderly people stuck in hospital because there is nowhere for them to go in the community.

Over the past decade, 929 care homes have closed and more than 30,000 places have been lost because providers can no longer afford to operate on the money they receive from the state. On average, local authorities pay £486 per week for residential care, while the typical private user is charged £700. At least one council pays a shocking £2.31 an hour to providers. Care blackspots have developed in poor areas where there are not enough wealthier “self-funders” to cross-subsidise the places paid for by the government. This is a market that is being broken by its state users at a time when the Conservative Party is calling for a more responsible capitalism.

Jeremy Hunt, the health secretary, has persuaded the prime minister to add “social care” to his job title, but the money to pay for this essential service remains at the Ministry for Housing, Communities and Local Government, which is absurd. If the rebranding is to be more than a change to the headed paper, then the budget must also be transferred to Mr Hunt. The NHS, rather than councils, should then be put in charge of commissioning social care. In Greater Manchester, where this has already happened, the service has improved dramatically while money has been saved. Delayed discharges have almost halved and A&E visits are stable, with GPs visiting care homes to reduce the number of ambulances called. The partnership has approved a pay rise for care workers to avert a recruitment crisis, but is still running a surplus.

It costs about £250 a day for someone to be on a hospital ward and £100 for a domiciliary care package, so there is a motive for the NHS to help elderly people to go home. If local authorities are funding social care, they have a perverse incentive to transfer the cost to hospitals.

Whatever happens, the Treasury will have to find more money. Care homes should be paid the true cost of the service they provide, rather than having to rely on private self-funders to top up the public sector contribution through what is in effect a stealth tax on those who are unlucky enough to need expensive residential care.

Most importantly, the government needs to address the complete unpredictability of the cost for families. Although half of us will end up spending less than £20,000 on our care, one in ten will have care costs of more than £100,000. The Tories like to say that they support those who “work hard and do the right thing” but old age is quite literally a condition lottery in which those with cancer have their treatment funded by the NHS while those with Alzheimer’s have to pay for the cost of their care.

In her first conference speech as prime minister, Theresa May argued: “The state exists to provide what individual people, communities and markets cannot.” It’s hard to think of a more perfect example than social care. The only fair solution is to pool the risk between as great a number of people as possible so that everybody loses something but nobody loses everything.

The prime minister is nervous of championing reform after her disastrous manifesto pledge, dubbed the “dementia tax”. But the problem with the policy drawn up by Nick Timothy was that it raised the prospect of higher charges while failing to pool the risk. That was why Mr Hunt emailed No 10 as soon as he saw the plan (the day before the manifesto launch) to warn it was a “disaster”. With the health secretary now in charge of the green paper, due out this summer, the government will surely return to the idea of a cap on care costs, with anything above the agreed level funded by the state. Indeed, Sir Andrew Dilnot, whose commission first proposed such a scheme in 2011, has been appointed to an expert panel advising on the future of social care.

It will then be a political decision how to pay for the change. One option is to take the money out of people’s estates after they die, but this looks dangerously like the Labour plan condemned by Tories as a “death tax”. The government could raise some of the cash by means-testing pensioner benefits such as the winter fuel allowance and ending the pension triple lock but this has been ruled out by the power-sharing agreement with the DUP.

Mr Hunt is among a growing number of Tories attracted to the idea of a hypothecated health and social care levy as a way of making tax rises more palatable to the public. Last week Nick Boles, the former planning minister, proposed turning national insurance into a ring-fenced health tax. Oliver Letwin is a fan of the plan and Lord Macpherson of Earl’s Court, the former permanent secretary to the Treasury, which traditionally opposes hypothecation, has been won round to the idea.

Sarah Wollaston, the Conservative chairwoman of the health select committee, believes national insurance should also be extended to those beyond retirement age, who are presently exempt, in order to increase the money raised for health and social care. There could be a higher rate for older workers, as in Japan, which has an additional levy paid by those over 40.

Although sources say Mr Hunt is not “wedded” to the idea, he is “open to all the options”, including a dedicated tax, because he knows more money needs to be found. There would be widespread support for it on the Labour and Liberal Democrat benches.

With the number of people over 85 set to double by 2039, social care is now a much more pressing spending priority than reducing university tuition fees. There is no time for another royal commission, nor is there any need for one. A political consensus is emerging about what has to be done. It just needs courage and leadership to see it through. With nothing to lose after his reshuffle showdown, Mr Hunt is willing to be brave. The only question is whether the prime minister has the authority to back him up.

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Medical students are asked to help out in crisis-hit hospitals

Medical students have been asked to help out in overstretched hospital wards to deal with the winter backlog. The request came as leaders of Britain’s 220,000 doctors warned of a crisis in the NHS, which they said would get…

The NHS is already in crisis – Brexit could finish it off – New Statesman

Hypothecated taxation and the NHS – CentreForum (2014)

Hypothecated taxation is not the answer, and Brexit may “finish off” the UK Health services.

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

LibDems suggest hypothecated taxation – without examining the ideology

Hypothecated taxation? A separate NHS tax would rein in spending

The NHS can no longer provide everything to everyone, and we should “Look abroad for serious solutions to the NHS crisis”.

Inequity in Health Care Financing in Iran: Progressive or Regressive Mechanism?

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

Laura Kuensberg comments for the BBC News 11th Jan 2018: Time for an answer on the NHS?

Pithed Politicians?

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