Category Archives: Perverse Incentives

Calls to cull failing managers… but the rules of the game dictate their failure…

Managers can only do their jobs within the rules of the game. The rules say they are not allowed to mention that all health care is rationed, that technology and new drugs cost more than we can afford, and that consultants are afraid to speak out and ask the right questions in a “culture of fear”. Critical Incidents are legion, and there are so many that juniors and their consultants have given up reporting the less significant ones, like unavailable notes are a common problem. Many are very personable, but without the tools, and honesty they cannot gain the trust of their staff. Compounding this, in Wales, is the lack of sufficient funding owing to the Welsh Synod. If we had no assembly we could have 10% more on health and education in Wales. The autumn elections here in Wales will be interesting, and the vote for the “Abolish the Welsh Assembly” party may rise significantly. No wonder there is invective thrown at managers, usually in private, because they are not allowed to speak the truth about what we cannot have.  Managers should be able to change the rules, and “win”, but such an outcome is impossible in a service where there is a pretence of “Everything for everyone for ever for free”.

The rules mean that there are perverse behaviours leading to perverse outcomes. Enoch Powell was right, and the managers know it:

BBC News 3rd July 2020 reports: Welsh NHS: Call for powers to strike off failing managers

A professional body able to hold Welsh NHS managers to account and strike them off for poor performance should be set up, a Plaid Cymru AM has said.

Helen Mary Jones has called for more scrutiny to prevent a repeat of the Cwm Taf maternity scandal.

A damning report earlier this year said the department was “dysfunctional” and mothers had “distressing experiences”.

But Health Minister Vaughan Gething told a debate such a new body could be complex.

Ms Jones said scandals at Cwm Taf, Tawel Fan mental health ward in Ysbyty Glan Clwyd and elsewhere “exposed consistent and systematic management failures across our Welsh NHS”.

Professional regulatory bodies already exist for doctors and nurses, but Ms Jones want a similar professional body for managers.

The Plaid health spokeswoman said senior staff should be registered, so they cannot fail in one local health board and get a job at another.

But unless it is taken on by ministers, Plaid’s proposals are not expected to reach the statute book.

The Welsh Government has its own new law planned to place a “duty of candour” on NHS organisations, requiring them to be open and honest when things go wrong.

Plaid Cymru wants ministers to go further, putting a “legal duty of candour” on health professionals to “empower” whistle-blowers.

Jon Restell, chief executive of trade union Mangers in Partnership, said: “This kind of rhetoric damages morale and effectiveness of management and has a chilling effect on recruitment to these posts, especially clinicians.”

He said he would “welcome any investment in professional standards and development for NHS managers”, but any regulatory process “would need to be fully independent of the political process”.

Ms Jones called for new legislation in a debate on Wednesday – with support from the Conservatives and Brexit Party.

Mr Gething did not support the idea of a new regulatory body for NHS managers, saying it “would introduce a level of cost and complexity, but of course that’s always the case when introducing new measures”.

One consideration, he said, would be defining “who or what a manager is to be called within the ambit of a new regulatory body”.

Cwm Taf’s maternity services were put into special measures after failings were uncovered at the Royal Glamorgan and Prince Charles hospitals, prompted by concerns about the deaths of a number of babies.

The Welsh Government said it wanted to “create a culture of continual learning and improvement in our NHS”, adding: “We have already introduced our Quality and Engagement Bill which will increase openness and transparency across the NHS and give a stronger voice to staff and patients.”

The government’s bill also proposes to replace Community Health Councils with a new body – there have been concerns about a lack of detail on what will replace

HSJ implies Managers and Directors are now at odds with Politicians over rationing..

The revolving door of health service managers….. mismanagement is nothing less than neglect.

How can the NHS offer fulfilling, lifelong careers? The managers have no idea why doctors quitting in droves…. Exit interviews?

Whistleblowing in the NHS – The need to regulate non-clinical hospital managers

Are there any administrators in the declining UK health services? We need more professionals, and we get managers.

Golden goodbyes for NHS managers soar to £39m

NHS managers still growing as GP posts fall

It’s falling apart, and it’s going to get worse… for everyone except the top managers and politicians.

GPs (Commissioning Groups in England) spend vast sums on temporary managers – no its not happening in Scotland

or Wales

NHS middle managers too comfortable to take top jobs “Kafkaesque regulation and rising patient expectations mean that managers and doctors opt for an easier life in less demanding roles”… political courage is needed.

Perverse behaviours by managers lead to covert and unfair systems for us all. Patients ‘bumped from cancer test waiting lists’

Trying to defuse some of the invective against NHS managers.

Patients and the professions are ready to ration health care strategically, without devolution. It’s the politicians and the managers who won’t hear of it because the strategy might mention rationing.

The NHS is a club for managers. Collect £200,000 every time they pass Go

Consulting professionals and managers about the NHS.

Pride is not a good reason to vote for poorer health and education.. Wales’ vote for AWA may well increase…

Meetings in the Regional Health Services – tarnished with the NHS managerial inactivity brush

Organisational failure, strategic failure, administrative failure, leadership failure, medical and nurse training failure, capacity planning failure, contract failure – where next?

What sort of evidence do Trust Boards and CCGs listen to? The Single Interest Pressure Group and levels of evidence. Do Commissioners and Trusts have policies to cope with them? Case studies are not valid evidence.

Poor Recruitment, Retention and Disengagement – no improvement for some years is inevitable, and Mr Hunt is “pissing into the wind”.

No freedom of speech for Welsh Regional Health service employees. The election campaign starts with a “general gagging order”.

Can the NHS be saved? Only with different local and global thinking, and changing the “rules of the game”.

Dementia cannot kill off any one UK Health Service if you exclude it, but understanding is essential to reconfigure..

It is so obvious that in a compassionate society we need to reconfigure the health services, and the social services. The perverse incentive to allocate all  possible conditions  to be classified as  social is so great. Fully funding the “Health Service” means that we don’t have enough money for the Social Service, which is means tested, but for which nobody prepares.

We could initiate laws that forced preparation, but they would be evaded.  Dementia cannot kill off any UK Health Service if you exclude it, but understanding is essential to reconfigure..  With a 40% rise predicted over the next 10 years, Belfast has led the way in this round of comment. But it will be quickly forgotten, as denial, especially by politicians, who will also suffer, becomes the norm, and the media move on again. If the odds are 30:1 we need to cover it..

The Alzheimers Society Jan 12th 2020: The Dementia Time Bomb

Victoria Ohara on 9th June in the Belfast Telegraph: Warning of dementia ‘time bomb’ as 60,000 people in Northern Ireland to suffer by 2051

James Ashworth in the Express says that the number of cases will double by 2050

The percentage of people suffering from dementia in Britain is set to increase from 1.6% to 2.7% by 2050, according to a report by Alzheimer Europe which reviewed 16 population studies

Giles Sheldrick reports 21st June in the Express: “Dementia crisis as £26bn “time bomb” threatens to sink the NHS. (As if it is not sicking already)

40% rise in Dementia cases in 10 years leads to “time bomb”. The Mail. 21st June.

A changing opportunity for the four UK health services.. Solution: avoiding paternalism, for rationing, and for financial probity.

Social care and the impact

of the pandemic – If social care and health care are to be funded the same way, then we can combine them.

Honest and pragmatic solutions to Social Care are ignored – by all parties. ( And the media )

The health of an intelligent democratic population deserves better. Yes to honest rationing…

There are perverse incentives in every health system. The secret is to expose them honestly. The Times leader is correct and refers to the disappointing response to Simon Steven’ request about 8 years ago. However it fails to look at the ethics of treating citizens paternally, and as if they would prefer NOT to know what is unavailable – this is not a virtuous or defendable method of working, and the health of an intelligent democratic population deserves better. The duty of candour which doctors have to comply with, should also apply to politicians. We are far from this in the disunited kingdom. 

Kat Lay reports in the Times 2nd June 2029: NHS will be forced to extend rationing, patients warned 

The public may have to accept previously unpalatable levels of rationing from the NHS until a vaccine against Covid-19 becomes available, a leading health expert has warned.

Patients could be barred from accident and emergency departments without a referral from a GP or the 111 NHS hotline, drop-in clinics will need to remain closed, and dental practices may become “unviable”, according to a report by the Nuffield Trust.

The health service must remain prepared for a potential second spike of the coronavirus, meaning it will need spare capacity. Before the pandemic hit, it was normal to have 92 per cent of hospital beds filled, but the NHS will need to aim for 75 to 80 per cent occupancy, the report says.

It will also be hampered by the need for increased infection control procedures, on top of existing challenges such as outdated buildings and a stretched and exhausted workforce.

The report concludes: “Without a vaccine or a reliable test, the issues outlined here may mean that the UK will be operating a health system with the capacity of a middle-income country — but with the expectations, regulatory standards, inspection regimes and governance of a high-income one.”

Health bosses face “tensions it will be difficult to manage”, it adds, with waiting lists potentially doubling in the next six months “even allowing for reductions in referrals, continued use of the independent sector, some increased reluctance of patients to come to hospital and less follow-up”.

The warning came after Cancer Research UK said around 2.4 million people in the UK were waiting for screening, further tests or treatment.

The charity said regular Covid-19 testing for cancer patients and healthcare staff would be vital, whether showing symptoms or not. This would mean between 21,000 and 37,000 tests a day.

Nigel Edwards, chief executive of the Nuffield Trust, said: “The implications of living with the virus are profound and will dramatically change the relationship between the public and the NHS.

“Hospitals will need to remain in a state of readiness for a potential second spike in Covid-19 cases — which means there will be no return to business as usual as the service gears up now to begin to restart routine work and address a growing backlog of unmet need.

“Even before the pandemic, the NHS already had many outdated hospital buildings, extremely high bed occupancy, serious workforce problems, overcrowded A&Es and rising waiting lists. These problems, coupled with the challenge of containing infection and tackling the ongoing coronavirus crisis, will mean a profound change in the way we deliver services for the foreseeable.”

Last month NHS England said that patients needing planned procedures including surgery would be required to isolate themselves for a fortnight before admission, and not be displaying any coronavirus symptoms.

This is likely to continue, the Nuffield report says, adding that the health service will also require a larger amount of personal protective equipment (PPE) as it takes on more work. Government plans for new hospitals will need to include more single rooms and wider corridors, increasing costs, it adds.

Services such as dentistry that require face-to-face interaction will face “severe constraints”, and be hit financially by the need to clean rooms between patients and invest in more PPE. This “has the potential to make NHS dentistry unviable in its current form”, the report warns, despite plans for services to reopen next Monday.

The report also highlights potential solutions. Some trusts are considering sending medics out with a driver to patients’ homes in place of one-stop clinics for conditions such as diabetes, where people can have tests on their eyes and feet during the same visit.

An NHS spokesman said: “Each part of the NHS has been asked to begin bringing back other services safely, balanced against maintaining enough flexible critical care capacity should it again be needed, and expanding community and rehab care.”

The Times view on the future of the NHS: Underlying Conditions – The coronavirus crisis has highlighted fundamental problems in Britain’s system of healthcare. Now is the time to confront them

ritain’s well-documented love for its National Health Service is about to be tested. A report by the Nuffield Trust warns that patients are soon to face previously unthinkable levels of healthcare rationing and that the NHS will need to run a reduced service for the foreseeable future. That is a consequence not only of the challenge of containing the virus, the paper says, but of existing problems in the health service. Politicians have in the past been reluctant to confront the deep flaws of the NHS for fear of offending popular sentiment. Yet it can only return to health if they do.

Particularly severe constraints will fall on services where physical contact between patient and doctor is essential. Dental practices, which will need to clean rooms between patients and invest in personal protective equipment, will come under financial pressures which some may not survive. Patients may be barred from A&E without a referral from a GP or the NHS 111 service. Drop-in mother and baby clinics and diabetes clinics could remain closed. Meanwhile hospitals will need to continue to separate those suffering from the coronavirus from everyone else. That will limit the number of beds available. There is also a large backlog to work through, since thousands of planned procedures have been postponed. Cancer charities estimate that some 2.4 million patients have missed out on cancer tests and treatments.

NHS staff deserve praise for their work and sacrifices. Yet the crisis highlights a truth rarely acknowledged, which is that rationing already takes place in the health service because resources are scarce. Those shortages are felt particularly in areas such as mental health, where often only the most severe cases are given prompt treatment. Hip and knee replacements are rationed, as are speech therapy and operations to remove varicose veins. The criteria for accessing fertility treatment have tightened too. In some areas clinics are denying IVF to women older than 35.

The pandemic has focused attention on the NHS’s underlying conditions. Many of its buildings are outdated, with narrow corridors and shared accommodation. Waiting rooms are small, so patients must crowd together. That poses a risk to those trying to observe social distancing. Even before the pandemic the NHS had overflowing wards and overcrowded A&Es. In November, those waiting for treatment numbered more than 4.5 million. These cases add to the large backlog. Staff in high-risk categories may need to be removed from front-line duties, as will, temporarily, those who test positive for the virus. Those who remain have the task of changing in and out of PPE and administering tests, as well as their daily duties. That will only exacerbate existing staff shortages.

Part of the problem could be solved with more money. Yet the rest is a consequence of the institution’s structure, which is largely the same as it was when it was founded in 1948. It is ill-equipped to deal with the growing population of chronically ill elderly people who nowadays take up most of its bed space. Healthcare is separate from social care. Yet fusing the two would be sensible, as elderly people could be sent home with extra help.

Such a plan was once proposed by Sir Simon Stevens, head of NHS England, but has not come to fruition. Neither is the NHS’s top-down bureaucracy adequate to the task. Badly distributed resources have often meant that patients face a postcode lottery, including for rates of cancer referrals, hip replacements and mental health treatment. Inefficiencies meanwhile waste large sums every year. During the coronavirus crisis there have been about four times the usual number of empty hospital beds. A nimbler health service might have been able to fill that spare capacity.

It may seem harsh to think of reforming the NHS while in the midst of a pandemic, but that is vital if it is to be equipped to deal with the next one.

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

A dishonest and covert dialogue is all that is happenning at present.. Simon Stevens says he would like to change this.

Treat the public honestly and as adults, so they buy in to rationing…

The Cygnus report.. How can the politicians expect doctors and nurses to display candour if they don’t themselves??

The “N”HS is a lie. Politicians have a duty of candour.

NHS Liabilities and negligence costs. Minister fails to answer the question from Mr Hunt. Lack of candour and honesty continues..

Reports commissioned by Government and others – but not acted on. A shame on all politicians for their short termism.

Updates 16th July: The pandemic report – Exercise Cygnus. Pandemic exercise predicted problems and in the Guardian  David Pegg, Robert Booth and David Conn report similarly.

The OPCW (Organisation for the Prohibition of Chemical Weapons) executive summary of the findings of its ‘technical assistance visit’ to Salisbury and subsequent analysis of the toxin is now available and can be downloaded below.

The document is carefully worded not to say that the substance analysed was a ‘Novichok’, in spite of media spin to the contrary – because the government’s Porton Down chemical weapons research facility also did not say it’s a Novichok.

Update 12th May: The Cygnus Report

David Pegg in the Guardian 7th May reports: What was Exercise Cygnus, and what did it find? The 2016 simulation of a pandemic found holes in the UK’s readiness for such a crisis.

…The Cygnus report was frank about the state of the UK’s readiness. “The UK’s preparedness and response, in terms of its plans, policies and capability, is currently not sufficient to cope with the extreme demands of a severe pandemic that will have a nationwide impact across all sectors,” it found.

One problem was that while each government body participating in the exercise had its own bespoke plans, enabling a flexible and decentralised response, nobody in the centre had oversight over everyone else.

In the absence of any “overview of pandemic response plans and procedures”, participants found it much harder to shift resources between one another so as react to unexpected rises and falls in demand for services such social care beds….

There is a list of reports which have been ignored by our politicians. The perverse incentive to act in the short term, and not to put the population ahead of individuals is to blame. The least harm to the most people is another way to interpret utilitarianism. The political neglect has led to great long term harm. 

The most recent is the Dilnot report “Caring for our future”, a briefing is offered by the Kings Fund:

The Dilnot Commission Report on social care: Briefing 13 July 2011

The current social care system is widely regarded as inadequate, unfair and unsustainable. The Dilnot Commission was established to report on how to deliver a fair, affordable and sustainable funding system for social care in England.

In this briefing we reflect on the Dilnot Commission’s report and consider the recommendations it suggests…. (None of which have been acceptable it seems.)


 The Committee found that the administration of antibiotics to farm livestock poses certain hazards to human and animal health since it has led to the emergence of strains of bacteria which are resistant to antibiotics. The committee was satisfied that these hazards can largely be avoided and has put forward a number of recommendations to that end.

We accept, in general, the committee’s proposals for the control of antibiotics.

It is important to recognise what are the hazards presented by antimicrobial resistance in animals to human health. The first is the transfer of resistant zoonotic pathogens. The second is the selection of antimicrobial-resistant bacteria which are not pathogenic for man, but which may transfer their resistance via plasmids to human commensal and pathogenic bacteria, which may later cause resistant disease….

..animal antibiotics are implicated in the rise of resistance in some strains of Salmonella, Campylobacter, Enterococcus, and E. coli;…

The Marmot Report: Fair Society Healthy lives.

Marmot Review report – ‘Fair Society, Healthy Lives. Local Government review

The Marmot Review into health inequalities in England was published on 11 February 2010. It proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work and age and which can lead to health inequalities.

It draws further attention to the evidence that most people in England aren’t living as long as the best off in society and spend longer in ill-health. Premature illness and death affects everyone below the top.

The report, titled ‘Fair Society, Healthy Lives’, proposes a new way to reduce health inequalities in England post-2010. It argues that, traditionally, government policies have focused resources only on some segments of society. To improve health for all of us and to reduce unfair and unjust inequalities in health, action is needed across the social gradient.

The Health Foundation Marmot Review: Launching 2020: the Marmot Review 10 Years On

…The report highlighted the need to take action across the social determinants of health, and called for progress to be made on a clear set of policy objectives. However, life expectancy is stalling, after steady increases for the past 100 years, and health inequalities are widening…..

The Pearson Report on No Fault Compensation in 1979 is reviewed by R A Hasson in the British Journal of Law and Society.

And also by J M Collinson in the British Journal of Industrial Medicine: The Pearson Report-compromise or step towards effective and just compensation for disability?

And in The Modern Law Review

And in the Annals of the Royal College of Surgeons: Person and the Patient

And in the Journal of Social Policy review: Journal of Social Policy

And 8 years later in Hansard

And Margaret Thatcher in the House of Commons and PEARSON COMMISSION (Hansard, 28 June 1979)

Mr. Alfred Morris

asked the Prime Minister, what consideration she has given to the recommendations of the report of the Pearson Commission; what action the Government will be taking; and if she will make a statement.

The Prime Minister My colleagues will be examining those aspects of this wide ranging and important report for which they are responsible. In particular, consideration is being given to the implications of the Pearson Commission’s recommendations for the industrial injuries scheme. The Government are also studying the recommendations for the introduction of strict liability for defective products, having particular regard to the proposals by the EEC Commission.

As far back as 1982 Prof Robert Duthrie (1925-2005) of Oxford University produced a report for the Government of the day: Orthopaedic services : waiting time for out-patient appointments and in-patient treatment ; report. (Robert B DuthieGreat Britain. Department of Health and Social Security. Working Party on Orthopaedic Services.1981. The full report has been scanned  for NHSreality and is below) Duthrie was deeply involved in the Nuffield Orthopaedic Centre. As we all live longer most of us will need some sort of Orthopaedic operation during our lives..

Duthie 1981 Orthopaedics 1

Duthie 1981 Orthopaedics 2

Duthie 1981 Orthopaedics 3

Duthie 1981 Orthopaedics 4

Duthie 1981 Orthopaedics 5 (summary)

The Wass report 2017: Supporting medical students towards careers in general practice

RCGP: GP recruitment: political drivers and the role of medical schools ( 3 years on 2020) The Wass report 3 years on

Stop med school GP ‘banter’ to boost recruitment, says RCGP

Workforce figures are a huge blow (2017) – RCGP response to 5000 more GPs needed

Medical Generalism – a report from The RCGP, in partnership with the Health Foundation 2013

BMA response to Wass report on GP training at medical school

Responding to the Wass report from Health Education England looking at reforms to GP training at medical schools, Harrison Carter, BMA medical school committee co-chair, said:

“General practice is under unprecedented strain from a combination of factors including rising patient demand, falling resources and, crucially, staff shortages. As many as a third of GPs told a recent BMA survey they were considering retiring early and just as importantly there is an endemic problem of too few medical graduates choosing general practice as a career option.

“A key problem is that General Practice is not given adequate prominence in the medical curriculum and it is encouraging that this report recommends that this problem is addressed.  However, it is also right not hide the fact that one of the solutions to this problem is to address the funding crisis which many GPs say is having a real impact on the service that they can provide for their patients. A comprehensive approach to solving the current crisis is the only way that more medical graduates will be encouraged into general practice.”

Other reports on shortages:

Radiologists: RCR’s annual workforce report highlights UK’s radiologist shortfall and escalating millions spent on scan outsourcing 2018

Anaesthetists: RCoA responds to the government agreeing to place anaesthesia on the Shortage Occupation List 2018

Physiotherapists: The health care workforce in England: make or break?  2018 – Three health think tanks have today issued advice to NHS England on the future workforce.

Nurses: Lack of nurses ‘most concerning’ shortage in NHS, report finds 2019 commenting on ‘The state of the NHS Provider sector’, The NHS is in the middle of the longest and deepest funding squeeze in its history. While the extra funding promised in the Conservative manifesto is welcome, spending on health will still fall as a percentage of our national wealth until 2022/23.

Maternity: State of Maternity Services Report 2018 (England) – Its just as bad or worse in the other 3 dispensations.

Royal College of midwives comments: NHS gains just one extra midwife for every 30 trained

The state of medical education and practice in the UK: the Workforce Report 2019

Royal College of Emergency Medicine: The first publication of data from the Royal College of Emergency Medicine’s 2019-20 Winter Flow Project shows that existing data does not reflect the true scale of the problem of 12 hour stays in A&E.

The Pathology Workforce – Shortfall June 2017


If this is the model for the post covid world, it is not a good omen for human development.

For all our sakes, governments need to work together. Unfortunately, owing to the recent trend to populism, and neglect of the “slave society” and increased inequalities and reduced social justice, cooperation is being replaced by competition. If this is the model for the post covid world, it is not a good omen for human development. The perverse incentive for politicians in the G8 to see profit for their companies has proved too great…

Chris Whitty’s recent Gresham College lecture on CV19

Theresa May – Avois Nationalism is no ally in this battle without borders. The Times 6th May 2020.

…The effectiveness of co-ordinated global action was in doubt. Nations with no allegiance to democratic values displayed a growing assertiveness, just as the western alliance seemed to be in decline. A stronger China flexed its muscles as a US president was elected on a mandate of America First. Little wonder that the theme of this year’s Munich Security Conference was the concept of Westlessness — the idea that not only is the world as a whole becoming less western, but the West itself may become less western too….

Medical Nationalism The Times Leader 6th May 2020.

highly infectious new virus that has already caused hundreds of thousands of deaths and wreaked havoc on the global economy ought to be a reason for nations to co-operate. Instead, as Theresa May writes in The Times today, “it risks exacerbating the drift towards nationalism and absolutism in global politics”. This drift threatens extending to the quest for a vaccine, which until now had been seen as an example of global co-operation. At a summit on Monday organised by the European Union, global leaders pledged some $8 billion to help to develop one. Yet the event was overshadowed by America’s decision not to participate and China’s last-minute choice to send an ambassador rather than Li Keqiang, the prime minister, who had been scheduled to speak. Neither the US nor China made a pledge.

The world cannot afford for the race to find a vaccine to become politicised. It is understandable that nations are jostling for the honour of making a scientific breakthrough. …

…it is in the interests of all nations to help each other in the race. That is because each team in each country is testing a different vaccine, any one of which could turn out to be effective. If countries fall out with their neighbours or obstruct international funding efforts, everyone stands to lose out. Besides, trials will be quicker if they can be conducted in countries with large outbreaks whose citizens are more likely to be exposed to the virus. That means that if nations collaborate on testing their vaccines, progress will be faster.

Letters to the Editor: Don’t clap for the NHS — change it May 3rd NHSreality

Cloud cuckoo land….. The poor will remain slaves in a GIG economy. Nov 2019 NHSreality.

Poverty and Wealth, and pregnancy rates. Will the slave society mean that Middlesborough et al supply the future low paid workforce? April 2019 NHSreality


In a long war liberty has to be reduced. Tracking apps are the same. ID cards should follow.

The new Apps designed to track new cases and their contacts as they arise is designed in London. It is available to Wales, but they may, or may not, use it.. And in Wales the BBC reports that “Coronavirus: Key workers to trial NHS tracing app”, rather than in Isle of Wight, where it will be the population. So much for a National Health Service. The Political perverse incentive: to show that a region is independent, against the interests of the whole of the UK, is evident. We need one app for the whole country, and in this emergency it needs to be understood that its worth losing a little individual freedom in order to track all cases down as soon as possible. In wartime liberty is reduced.

New app created to track coronavirus in Wales

The Welsh Government sets Health and Wellbeing policy for Wales.

In BBC Scotland: Coronavirus: Scottish test, trace and isolate system ‘in place by end of May’

Lisa Summers opines for BBC Scotland:

Scotland needs to recruit a small army of “contact tracers”.

Around 2,000 need to be in place for the end of May as Scotland gears up to move out of lockdown.

This is a skilled job. It requires speed to track down potentially infectious people before they pass on the virus, and sensitivity – posing personal questions about health and who people have met.

Who will they be?

It’s my understanding that these contract tracing teams will likely draw on existing public and environmental health professionals. For example, those people who currently trace sexual health infections such as HIV.

There could also be a tiered approach, with a place for returning retired medical professionals and newly graduating students to supplement the core teams.

The scale of challenge is immense. The paper sets out that 15,500 tests a day could be needed in Scotland – and would clearly involve significant parts of the population being asked to stay at home for 14 days at time, perhaps on multiple occasions.

Test, trace, isolate, support will need understanding from employers and – most importantly – widespread cooperation from the public if it’s going to work.

Update 6th May. Apps are different in different diverged dispensations. How can it be “National”? Philip Hayward for Walesonline 11th April reports: New app created to track coronavirus in Wales and Philip Sim in BBC Scotland  5th May asks “Will Scotland have its own coronavirus app?”

How can we still call this a National System? Just like the EU, and the World, our different “countries” are acting differently to each other, and in an uncoordinated way. Tribalism at it’s worst.


Deny, Delay, Defer and Defend.. The Perverse Incentives within the law related to Health..

The Times letters 5th May 2020. Deny, Delay, ( Defer ) and Defend..  A letter from Dr Barton of the Medical Negligence Team tells us how justice is being distorted by “no win no fee”, and perverse incentives. A free health service tempts people not to look after themselves. A free legal service has similar downsides. At present only the very rich, and the very poor, are accessing the legal system in the UK. Polarisation is regressive…

See the source image

Sir, Litigation provides robust independent clinical scrutiny according to professional norms. The health service cannot objectively investigate itself. The test of legal liability is flexible to adjust for the pandemic. The prevalent privatisation of access to justice by no win, no fee (like the National Health Service) is free at the point of need. It is a virtuous circle: the NHS pays damages only on proven negligence, when claimant lawyers get paid. The vast majority of scrutinised cases are not pursued. By contrast, state funding of legal fees creates perverse incentives: the lamentably low success rate of legally aided healthcare claims in which too often the only winners were lawyers; and the inflation of NHS defendant legal fees by self-serving “deny delay defend” behaviour.
Dr Anthony Barton

Solicitor, Medical Negligence Team


See the source image

Social care and the impact of the pandemic – If social care and health care are to be funded the same way, then we can combine them.

There is a discussion which is absent from most households as we conspire between us to deny our mortality. None of us know how it is going to end. Talking to an old friend who I last saw 45 years ago at my wedding, on Zoom, we exchanged our medical histories, and life’s chances. He, like me, has had a nasty malignancy, and in addition has had two heart attacks and stents. We have both survived, and are likely to live past 70. The problem in USA, where he lives, is that there is no pension, and he is still working when I have retired some years back. The safety nets provided by the state and other means are significant. One such is the safety net whereby, if one has assets less that £17,000 in the UK, all social care is provided for free by the state. Add to that the free health care for over 65s who don’t even pay prescription charges (even though they own most of the country’s assets) and this seems patently “unfair” to those working. Add to that the state pension scheme, which is a glorified and very large Ponzi scheme, and we can all see that the elderly are cared for better in the UK than in the US.

We do this by under paying, and under funding the care homes. When I qualified they were almost all owned by the state (1974) but since then they have been privatised. There is a large incentive for the social care authorities to deny funding for demented people, even though they may need full care ( feeding, changing, drinking, incontinence ) such as my mother. There is also a large incentive for affluent and informed families to persuade their elderly to pass on capital, as they know that basic funding will be provided by the state. We have to find a compromise; a way that satisfices both parties, but is not seen as penal to either. An honest discussion of our basic values would be a start. In my case the death of my mother, a 95 year old “veggie” could never be seen as a disaster, but as the Times leader says “the scale of deaths in our care homes shames us all”.  If health is free should social care be free? OR, If social care is means tested, should health care be means tested? In the former system we will have an enormous social divide. In the latter system we will have more equity, and justice. The second system rations openly, the first rations covertly. Which do we want?

So if  we are to devise a system that makes sense we need to combine the funding as well as the systems. In the Times letters 15th April: Social care and the impact of the pandemic, there are two letters which expose the problem:

Sir, Your leading article “Who Cares?” (Apr 13) is welcome. Governments of different complexions have struggled with how to organise and fund adult social care, including “elder care”, for more than two decades. There is an urgent need for a long-term, cross-party settlement for social care once the pandemic is over. Your otherwise excellent editorial overlooked one crucial dimension: the contribution of unpaid carers, the family and friends looking after loved ones in their own homes. Research that Carers UK undertook last year suggests that there could now be as many as 8.8 million adult carers. The number is rising rapidly with the ageing population, and more than half of these carers are looking after someone for more than 35 hours a week.

Even in 2015, independent research for Carers UK put the value of these unpaid carers at £132 billion a year — almost a second NHS budget. Hence the government should indeed “be bold” in joining up health and social care more effectively once coronavirus is defeated. It must also ensure that all the critical parts are linked in, including family and friend carers.
Professor David Grayson

Chairman, Carers UK

Sir, Your article “Cancer, heart and stroke patients pay the price of war on virus” (Apr 11) (and also in todays paper by Alice Thompson) highlights the problems that patients with non-communicable diseases are facing during the Covid-19 pandemic. However, you omit to mention diabetes, one of the commonest non-communicable diseases in the UK, with almost five million Britons affected; the disease affects up to 500 million people globally.

Routine diabetes appointments are understandably being cancelled. Many patients can be advised by telephone/video consultations but this is not the case for some with late complications. Transplant surgery, including kidney and combined pancreas/kidney transplants, is virtually at a halt, as is non-urgent surgery. This means that, for example, patients awaiting arterial bypass surgery to improve their circulation to the lower limbs will probably have to wait several months.
Professor Andrew JM Boulton

President, International Diabetes Federation; Manchester Royal Infirmary

the day before Prof Mayur Lakhani opined:

Sir, Further to your report “NHS will use scores to decide if over-65s need intensive care” (Apr 13), doctors do not want to offer false hope. We must be honest. Cardiopulmonary resuscitation (CPR) and/or ventilation have a very small chance of success in patients who, a priori, have a poor prognosis. Functional status and not age alone is the key consideration.

Discussions at the end of life are tough, but necessary conversations for doctors to have. Doctors are trained to cure: seeing so many deaths from Covid-19 makes us feel as if we have failed. But we must engage the public with difficult conversations about the reality of the process of dying. Instead of offering futile invasive treatments, providing palliative care to keep the patient comfortable and allowing them to die a naturally dignified death in their home is the best thing to do. Admission to hospitals for severely frail patients with incurable diseases is usually unhelpful and may even be harmful and is not what most people want.

Evidence shows that care planning in advance improves outcomes that are important to patients and their families. We must dispel the idea that advance care plans are a way of denying treatment. Doctors must address this understandable and significant concern by communicating sensitively and observing strict ethical, legal, and professional codes of practice. There must never be any blanket policies; all decisions must be made with individuals, involving their families and carers.

The aftermath of the Covid-19 world will see a lot of grieving families and communities who will need help and support. Dame Cicely Saunders, the founder of the hospice movement, said: “How people die remains in the memory of those who live on.” There is no doubt that, even at the best of times, considering our mortality is a taboo subject. Although it is a gruesome topic, now more than ever, people need to think ahead and plan their future care in the event of severe infection with Covid-19.
Professor Mayur Lakhani

President of the Royal College of General Practitioners, 2017-19, and chairman of the National Council of Palliative Care, 2008-15

Alice Thompson 13th April: Cancer treatment will be the next NHS crisis – While attention is focused on coronavirus patients, those with other potentially fatal conditions are being neglected

The Times leader 15th April 2020: Duty of Care – The problem in care homes is quite possibly worse than we know

…The David Cameron government commissioned Sir Andrew Dilnot to devise a solution in 2011 but then abandoned his proposals. Theresa May threatened to act but fears about inheritance ruined her election campaign in 2017 and social care returned to the box marked “Don’t open. Too difficult”.

And on 13th: The Times view on the impact of coronavirus on care homes: Who Cares? – Care homes have been neglected and are now bearing the brunt of the pandemic. They need urgent help


NHS Liabilities and negligence costs. Minister fails to answer the question from Mr Hunt. Lack of candour and honesty continues..

The perverse incentive for a current minister to think and act short term, because of the First Past the Post system is evident.

Asked by Lord Hunt of Kings Heath

Asked on: 17 March 2020 in Parliamentary Business Questions

NHS: Negligence:Written question – HL2693

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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.

Image result for health merrygoround cartoon

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