Category Archives: Perverse Incentives

With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness.


Don’t kid yourself. You could get mentally ill. This is why so many GPs and consultants are looking to go part time. The result is less continuity of care, and especially in GP land, lack of the doctor patient relationship which stopped complaints and led to understanding. I used to look after mild anorexics myself, and there is evidence that they do worse in the hands of the “experts”, but then of course only the worst get to the experts. Now a new NICE guideline means they will all go into the mental health system.. Without continuity of care perhaps this is just as well.

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With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness. It is so sad that with no votes in it, no large party is really interested in mental health.

40 % of primary care is mental health, and yet GPs do not all get mental health training.

In the Times 23rd May 2017 Kat Lay reports: Police investigate up to 20 deaths at mental health unit

Police are investigating the deaths of “up to 20 patients” at a mental health facility in Essex.

Last week an inquest ruled that the authorities had failed to protect Richard Wade, 30, who died in May 2015 after staff at the Linden Centre in Chelmsford failed to confiscate the item he used to hang himself when he was admitted.

Matthew Leahy, 20, died at the centre on November 15, 2012. The inquest into his death concluded there had been “multiple failures”.

The court heard that observation slots were missed, the ward was short staffed and no care plan was put in place for Mr Leahy after he was sectioned on November 7.

The two men were among seven inpatients known to have died at the centre since 2001, all of whom had attached a ligature to fixtures or furniture. Mr Leahy’s mother, Melanie, said that Essex police had told her they were “still investigating my son’s death but are also looking at . . . up to 20 patients, who all died by the same means”.

A Care Quality Commission report in 2016 on the Essex Partnership Trust, which runs the Linden Centre, found improvement was required at the trust and said that there were too many places where patients could hang themselves.

It warned: “Over the past five years, CQC inspectors, along with Mental Health Act reviewers, have inspected this trust several times. Each time we have identified problems that the trust needed to address; for example regarding safety at both the Linden Centre and the Lakes locations. Each time the trust had given assurances and then has not done so.”

Ms Leahy welcomed the fresh investigation and said: “I have worked tirelessly to collect evidence going back to 2001, which proves the trust knew about the ligature points on the ward.

“As proved by the Care Quality Commission inspection in 2015, the wards were not up to the standard required to ensure patient safety.

“The trust had been advised to change things after other patient deaths.”

One nurse, who left the trust in mid-2016 after a decade, speaking anonymously to the BBC, said that ligature points had been identified “many years before” Mr Leahy’s death but had not been resolved.

“If you asked too many questions you were deemed as a troublemaker and things made difficult for you,” he said.

A spokesman for Essex police said that the force was “conducting initial inquiries into a number of deaths which have occurred at the Linden Centre since 2000”.

He added: “This work follows further allegations surrounding the death of Matthew Leahy at the facility in Chelmsford on November 15, 2012.

“We would not put specific links to specific deaths, the research phase will look at the circumstances of a number and then identify those that may have a link due to the circumstances of how the individuals died.”

A spokesman for the Essex trust said the serious incidents were of “great concern” and the trust was “improving systems to ensure that investigations are carried out rigorously. The trust will co-operate with any police inquiries.”

Greg Hurst in The Times 24th May: Refer anorexia cases immediately, GPs told

Mental health now area of most public concern within NHS

No place but cells for those having mental breakdowns

The cost of poor mental health

The production line mentality of government. They are behaving like the worst employers..

Plan your hospital advocate…. NHSreality warned you that it was happening near you. The problems of Mid Staffs and Sussex Mental Health services are endemic, and Christmas is not a time to be ill..

1 in 5 mentally ill children turned away by the NHS. The “random walk” of health care decision making…

There is no money – and now there are no beds! Mental Health is a jungle…

Despite the crisis in child and adult mental health – The (depressing!) message that most politicians give us is that there are no votes in it.

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The Hacking reveals a collusion of anonymity for responsibility for rationing…

Update 13th May 2017: Mark Bridge May 13th in the Times: Outdated technology offers easy pickings

As readers know NHSreality says there is no NHS, but a regional system. The rationing of services, and this includes IT, is the responsibility of the Trust Boards, and commissioning groups in England. An inability to provide the requisite upgrades to computer systems is a decision made at a higher level. IT managers, paid much less than those in the private world, are rewarded by job security (never get sacked), but they have failed to use their leverage and knowledge to force the changes needed. The debate would have been puerile, if it ever happened at all. On December 8th NHSreality posted: Hackers get easy route to patient data – still on Windows XP but we have no sense of sangfroid, only sadness. The Hacking reveals a collusion of anonymity for responsibility for rationing…

“The first duty of government is to keep the nation safe”. (Amber Rudd on Radio 4 this am) The Health Services are part of this safety, but the net has been holed in so many places, and the responsibility for errors leading to potential disasters such as this is missing. NHSreality predicts that no heads will roll, and the media will fail to find a scapegoat.

The good that may arise is that computer systems may be updated. GPs in Wales were in charge of their own systems and backup until 5 years ago. The Welsh Government took over the computers, put all the data in one central server, and connected to the periphery by BT lines . ( Virtual Private Networks ) I recommended to my own practice that we had our own independent back up system which would ensure that, if the government server failed, or the lines were sabotaged, that we could perform our daily work. My recommendation was rejected but the idea needs re-visiting, even though Wales was unaffected on this occasion.

There is so much evidence for rationing, not prioritisation when it is “all or none” as in IT. Here are some articles/news from the last 24 hours:

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Laura Donelly in the Telegraph: Thousands of children and teenagers with anorexia forced to wait months for help

Chris Smyth in the Times: Hospital backlog is worst for decade – A&E units had their worst year since 2003, with one in ten patients not being seen within four hours and Patients wait longer as GP jobs lie vacant and, initially reported in the Shropshire Star: Nurses ‘forced to buy pillows for patients’

and because of the rising anger even a cancer sufferer is standing against the Minister for Health: The Deathbed Candidate. Getting nearer and nearer to “posthumous voting” isn’t it?

Paul Gallagher opines in the Independent: General election 2017: what role will the NHS play among voters? and implies Theresa May is more trusted than the others…. but this was written before the latest Hacking.

NHSreality trusts none of the parties. They are all lying. It is only going to get worse. Patients are going to wait longer. (Personnel Today) More and more, those who can afford it, will go privately.

Health Reform – Rationing for rare and complex conditions is wrong, and against the concept of a “mutual”.

The debate is puerile. There is no addressing the real issues..

NHSreality on IT systems

Hackers get easy route to patient data – still on Windows XP December 8th 2016

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Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

We all know that the one on one confidential consultation is the bedrock of primary care. We have been taught that confidentiality is paramount, and as a profession we have honoured this. However, being a GP (or any type of Dr) means complaints and possibly litigation at some time in your career. These problems are much less if the Dr is a) female and b) British trained.

False claims against doctors are not yet commonplace, but to keep the confidentiality and the confessional nature of the GOP consultation will need audio-visual recordings in every room. The patient can undress behind a screen, but the acoustics should remain even when the video is missing.

An alternative, accepted in many hospitals and most dental practices, is to have a “chaperone” or another person (assistant) present at all times with patients. GPs could move in this direction, as could teachers. Male teachers in particular know about “false claims” against them. More and more teachers and doctors are female ….. the adverse selection processes, the timing of recruitment, and the behaviour of  students/patients/clients is excluding men.

The Yorkshire Post 11th May 2017 reported: Growing GP recruitment problem ‘staggering’ as vacancies hit new … ITV News reported 12th May 2017: ‘Staggering’ GP recruitment problem hits new high – ITV News – and the Standard followed it up with a report by Eleanor Rose: GP recruitment problem “staggering” as vacancies hit new high, research shows.   for Pulse reports 12th May: One in five practices abandon recruitment due to ‘staggering’ shortage of GPs

Almost one in five practices has had to abandon searching for a new GP as vacancy rates have hit their highest ever, a shocking Pulse survey has revealed.

Pulse’s annual practice vacanies survey was answered by 860 GPs and reveals that 12.2% of all positions are currently vacant – an increase from the 11.7% reported at the same time last year.

More worryingly, 158 said they had to give up recruiting a GP in the past 12 months after unsuccessful attempts.

The survey – the only longitudinal data available on this subject – also reveals that the average time taken to recruit a GP partner has lengthened by almost a month over the past year….

Dr Richard Vautrey, deputy chair of the BMA’s GP Committee, said: ‘The high number of positions vacant and one in five practices abandoning their search) is another sign of the recruitment crisis with many practices struggling to find GPs.

‘This is adding to the pressure of the remaining staff. Some practices are looking to recruit therapists, pharmacists and other health professionals but of course they are not a replacement for a GP. There needs to be a real step-change in recruitment initiatives to ease the pressure on GPs.’

Professor Helen Stokes-Lampard, chair of the RCGP, said: ’We know that practices across the country are finding it really difficult to recruit GPs to fill vacant posts, and the degree to which this problem has increased over the last six years is staggering. In the most severe cases, not being able to recruit has forced practices to close, and this can be a devastating experience for the patients and staff affected, and the wider NHS.’

Abi Rimmer in GP careers warns: Workload pressure would not be a defence against clinical negligence, barrister warns

Rosemary Bennett The Times May 11th 2017: False claims ‘have made teaching a lottery for men’ and False claims ‘have made teaching a lottery for men’ : ukpolitics – Reddit

What kind of person makes false rape accusations?



Let us charge patients for extra services, GPs urge – is this “decommissioning”?

Should there be any “Extra” services in a cradle to grave health service as devised in 1948?. More and more services can be seen as “extra” depending on the political whim/philosophy of the day. Perverse incentive need to be made overt, and if minor surgery on warty lesions becomes the norm, then patients could be conned. The doctor-patient relationship has been a clean one to now…is this “decommissioning”?

Chris Smyth reports in the Times May 5th: Let us charge patients for extra services, GPs urge

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GPs are demanding to be allowed to charge patients for extra services to ease an NHS cash crisis and evade rationing.

Doctors want to offer vaccinations and minor surgery not available on the NHS, saying it will be more convenient for patients and cut down on bureaucracy.

Nine local medical committees representing GPs from Northumberland to Cornwall have asked the British Medical Association to support a change in the rules, saying they are hopelessly out of date and constitute restraint of trade. Some say the change could allow general practice to develop as a “truly commercial entity”….

Ben Molyneux, vice-chairman of the City and Hackney local medical committee in London, who will present the proposal at a conference in Edinburgh this month, said it was about “allowing patients to get the non-NHS services they want to receive from the GP they know, at a surgery near to their home”. Some patients are not covered for vaccines such as shingles or the HPV anti-cancer jab on the NHS and Dr Molyneux said it would be easier if they could pay their own GP, rather than going to another surgery. At present patients can pay other GPs, but not their own, for such procedures. The rules are said to exist to prevent distortion of the patient-doctor relationship.

Dr Molyneux said: “This adds to the pressure on short-handed GP surgeries as one patient ends up requiring multiple appointments and a new set of medical notes taking for a vaccine which is usually medically advisable.”

Prit Buttar, a GP in Oxfordshire, said allowing more private work would attract new doctors and raise money, but conceded: “It may well be more contentious when you have something like evening opening, [if] a practice could earn more opening privately in the evening than it could from the NHS.”

If the plan is backed, it will become a policy of the BMA’s GP committee, which negotiates contracts. NHS England has rejected similar requests in the past.



Cancer sufferer urges patients to stop suing NHS – No fault compensation is the answer.

NHSreality has long supported No-Fault compensation. The concept of all of us owing £1000 each in medical negligence and litigation costs is daunting. Add to this the fact that 0ver 50% of the costs go to the lawyers and the logic of no-fault compensation is evident. The trouble is the timescale for savings: this is not within one term of office. Perverse Incentives conspire to ensure that all the parties reject the prospect, as it will not save money over even 10 years: but it will in the end. Ask the citizens of NZ or Sweden. Post code differences in wealth mean that litigation is more common in richer areas, but this is reduced by “no-fault: no fee” lawyers deals.

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James Gillespie in the Sunday Times 16th April 2017 reports: Cancer sufferer urges patients to stop suing NHS

A woman dying of cancer has started a campaign to curb the compensation culture in the NHS despite suffering two cases of medical negligence herself.

Susanne Cameron-Blackie, 68, from Norfolk, has been given three months to live after being diagnosed with leiomyosarcoma, a soft tissue cancer, six years ago. It has spread through her body, leaving her virtually paralysed.

She is determined to spend her final weeks battling to cut the spiralling costs of litigation against the NHS. Last year, settlements and costs took £1.5bn out of the NHS budget.

NHS Resolution (formerly known as the NHS Litigation Authority) estimates that £56bn could be needed to deal with all cases arising from failures and mistakes made up to March 2016.

“That is the equivalent of half the annual budget of the NHS,” said Cameron-Blackie. She suffered in her early twenties when her womb was removed without permission as she was undergoing a dilation and curettage procedure. During recent treatment she was given another patient’s medication, leaving her in agony.

“But I didn’t sue,” Cameron-Blackie said. “The money from the original operation would have made no difference, I just got on with my life. The second time, I would not have got anything — the money would have gone to my husband in a few years’ time. What good would that do?

“Even the valid claims where somebody gets £6m and it’s entirely justified, that money goes into the court of protection and all their needs are met by the NHS.

“It is whether there is a fault that matters. If you can’t prove a fault, then you can have a patient with exactly the same damage, exactly the same needs and they are met in exactly the same way, but there is no payout.”

Cameron-Blackie, who formerly worked for the lord chancellor’s office, has returned home after her latest hospital treatment. The NHS has installed a bed and oxygen in her home on the Norfolk Broads.

“When the chips are down and you are left like this, the NHS provides everything and more that you need without a penny piece going anywhere near lawyers,” she said.

Cameron-Blackie is likely to find widespread support for her campaign.

Rob Hendry, medical director at the Medical Protection Society, which represents healthcare professionals, said: “A package of legal reforms is required to control the spiralling cost of clinical negligence, including a fixed cap on the legal fees that can be charged.”

A spokesman for NHS Resolution said it aimed to settle claims fairly and quickly. “We also have a responsibility to defend unjustified claims robustly. We received 10,965 new clinical negligence claims in 2015-16 [and] resolved 4,935 (46%) of clinical negligence claims without the payment of damages.”

NHSreality has long supported No Fault compensation.

Harmonising Compensation in NZ


A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.

A general practitioner is trying to follow the dentists into private practice. NHSreality has warned that this was likely, and that when patients demand a choice from their ambulance – (private or public A&E?) that will herald the end of Aneurin Bevan’s dream. The perverse incentives in private care need to be exposed.. but even if we get an honest debate I think rationing by price and access may be acceptable in Bournemouth, but not away from the retired rich, and the tooth fairies… It will be interesting to see if Dorset tries to stop/discipline this Dr… watch this space. If it is allowed it will spread…

Laura Bennett reported in the Sun 14th Feb 2017: WANT TO SEE A DOC? THAT’LL BE £145 – GP warns general practice ‘on brink of collapse’ as he launches private service in NHS surgery – Patients can cough up to see a doc or pay £40 for a phone chat – Dr Tim Alder ( Poole Road Medical Practice – Bournemouth ) has launched a new private service at his NHS surgery so patients can pay to skip the four-week wait for an appointment

AN NHS GP surgery has told patients they can skip waiting lists to see their doctor – if they cough up £145.

The surgery has launched a private service – operated by exactly the same NHS doctors – to run alongside its NHS services.

But patients have to fork out £40 for a 10-minute phone consultation, £80 for a 20 minute face-to-face appointment and £145 for a 40-minute consultation.

Dr Tim Alder warned general practice was on “the brink of collapse” and “heading for privatisation” as he decided to launch the controversial Dorset Private GP Service at Poole Road Medical Centre in Bournemouth, Dorset.
NHS patients at the surgery have to wait four weeks for a seven-minute appointment with one of the practice’s four doctors if they are not eligible for its same-day walk-in service.
But critics have slated the move as a “kick in the teeth” for the NHS and patients, claiming it creates a two-tier health system and goes against the principle of reducing inequalities in healthcare.

Dr Alder said increasing demand, a recruitment crisis and lack of funding as well as private provider Virgin Care taking over practices across the country meant the new service was the only way to safeguard the surgery’s future.

He said: “The Government is not trying to save general practice and now it is on the brink of collapse. But when it’s gone, they’ll realise how good we have been at blocking access to the hospitals. By then, it will be too late.
“We have to try something different now to make ourselves stronger in anticipation NHS primary care will be even worse.
“The worry is that Virgin Care, who are already buying up practices, are going to come in and would then just take us over.
“I suppose we’d rather be in charge of our own destiny.”

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

The risks of private care… overstated?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

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The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Dental care for children is still free in the UK Health Services. Despite this, many parents don’t know this and assume that because they can only get private care locally, that their children are under the same “rules of the game”. I am told that the most common operation on UK children is now dental extraction or clearance. It used to be grommets, or tonsillectomy… These are still common in the privately driven health services such as the US. But in UK medicine all children for non dental operations are seen and assessed by someone else prior to surgery. Dentistry is different. The same person assesses as operates – and this is a matter of legalised perverse incentives. Having a Dental Hygienist make the diagnoses, and the dental surgeon operate would remove this perverse incentive, probably reduce the need for surgery, and save money by rationing sensibly. The way to control the dental profession is the same as the medical profession – overcapacity.

Tonsillectomy and grommets are now part of the “proven unnecessary” operations in 90% of the cases performed when they topped the list in the UK. Good dental care prevents heart valve disease and many other problems. It is a disgrace that there is no education campaign to help parents be aware of their free dental service.

Ross Lydall in the Evening Standard 6th March 2017 reports: Parents ‘must make sure their children visit a dentist by the age of one’

Nine of the 10 boroughs with the UK’s worst rates for dental care are in the capital — with two-thirds of children aged up to 17 in Kensington and Chelsea, Hackney and Tower Hamlets not having seen a dentist last year.

Professor Nigel Hunt, dean of the Royal College of Surgeons’ faculty of dental surgery, said: “The number of children in London who did not see a dentist in 2016 is unacceptable…..

A toddler in Texas dies after unnecessary dental work. Reported in the Mail 29th March 2016.

Tonsillectomy the most common operation for kids in the USA.

THE most common operation being performed on children today is the insertion of tubes into the ears to combat the effects of middle-ear infections. 1986 New York Times

Public Health England survey: New PHE survey finds 12% of 3 year olds (In England – it will be worse in Wales) have tooth decay 30th September 2014

Who is entitled to free dental care in England? Health England

How could your teeth look after 10 years of sweetened soft drinks – The Mail

Why were doctors treated differently to dentists? Perverse…

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…

Dentistry now outside the Health Services for most of the nation

Five million children failed to see a dentist in past year..