Category Archives: Perverse Incentives

If health and social care funding is combined, the reality of a “quicksand” foundation will be faster..

Perhaps the public need to feel and see the unreality of the situation regarding social care. With so many of the population ignoring their possible future needs, and health care being free, whilst social care is means tested, there is a perverse incentive for those making the decisions (who also hold the purse strings) to class as much as possible as “social”, and as little as possible as “medical”. The actuary is founded in reality, but even their solution only applies to 33% of us!

No wonder the people “ignore their future costs” when they have been told they can have (in health) Everything for everyone for ever. 

I have had several families as patients who have deliberately given away property in plenty of time to avoid the state getting their hands on their cash, and to ensure it all passes on to the next generation. Since inheritance tax is a double tax I am in favour of abolishing it, but that does not mean lucky people who live into their late 90s should avoid payments. The system needs to be altered, and to face reality.

Despite the warnings, especially from “Community Care” the politicians will not grasp the nettle. Homes are going to close. There are many areas of the country where the privately funded are so few that there is only one payment schedule. In richer areas the wealthy often subsidise the state funded clients….. its one of the questions needing asking when being admitted to a home and in my view, in the interests of openness, needs to be publicised on their internal notices, literature and website.

‘Your insurance doesn’t cover acts of God, like age related illness and accidents.’

Nick Triggle for BBC News 26th June reports: Care cuts inevitable in ‘fragile and failing’ system

The Actuary 25th June 2019 (They really do know) reports: Social care reforms proposed for third of UK population – Around a third of the UK population could benefit from targeted government incentives that boost saving for social care, the Pension Policy Institute (PPI) has proposed.

The Mirror reports that the social care time bomb is set to explode as millions ignore future costs entirely. 

Luke Haynes in “Community Care” opines 26th |June 2019: Worsening social care funding position wreaking increased human cost, warn directors – Numbers affected by home care provider closures double as fragile care market and NHS cost shifts exacerbate financial woes for councils

Update 26th June 2019: Next PM should lift constraints on public spending to fund social care like the NHS – report finds

( A report equally in the clouds of unreality. If we cannot afford the one for free, we cannot afford both! ) The BMJ opinion from Anita Charlesworth is well intentioned but unrealistic.

Dominic Brady in Public Finance reports: “Social Care heads are unsure that they can provide minimum finance…”

Anita Charlesworth in the BMJ opines: We need a social care system that is as much a source of national pride as the NHS

The care of autistic children is a disgrace. Covert systems lead to perverse outcomes..

The Times analysis of the situation is summed up well by Oliver Wright but he fails to appreciate that if we need to ration health care covertly, there are fewer votes to be lost in dereliction of duty to those who cannot represent themselves.  Treatment of the mentally ill is a toxic mix of political and NHS failure

n the aftermath of the Winterbourne View care home scandal Jeremy Hunt pledged to make improving the care of vulnerable patients a central mission of his time as health secretary.

But despite speeches, policy documents, steering groups and delivery groups two reports next week will lay bare the continued failure of the system to protect those least able to help themselves. One of those reports was commissioned by Mr Hunt’s successor and Tory leadership rival, Matt Hancock. He won’t be thanking him for it.

Part of the problem is political. For example, despite introducing minimum standards for how adults on mental health wards should be treated in 2014, no such standards exist for children. For that, responsibility rests with ministers.

They are also responsible for a system that provides no incentives to minimise the use of expensive in-patient mental health beds. Those beds are paid for by the NHS whereas community care is paid for by stretched local authorities.

The NHS itself should not be absolved of blame. One former Conservative health minister said they had been shocked by just how unresponsive NHS leaders were to reform. It is certainly true that the NHS has jealously guarded its freedom to set spending priorities.

Finally, despite being the authors of one of the reports the Care Quality Commission, which inspects mental health units, bears some responsibility. That it took a minister, under pressure from the media, to uncover the continued failure of these units is shocking.



Oliver Wright and Greg Hurst report in the Times 18th May 2019: Autistic children are routinely restrained and drugged in care

Autistic children as young ten are being detained and subjected to chemical and physical restraint hundreds of times a month, two reports will say next week.

Ministers are braced for fresh revelations about the inappropriate treatment of children with learning disabilities more than six years after Jeremy Hunt, when health secretary, pledged to end the “normalisation of cruelty” in parts of the care system.

One report from the children’s commissioner reveals that in a single month last year 75 children were restrained 820 times, an average of 11 per child.

In another report the Care Quality Commission is expected to reveal children and adults being subjected to long periods of prolonged seclusion and segregation in secure and rehabilitation mental health wards.

The CQC report was commissioned by Mr Hunt’s successor, Matt Hancock, after revelations of abuse in mental health institutions seven years after the Winterbourne View care home scandal in Gloucestershire which resulted in six workers jailed for abuse and neglect.….


Despite “run through” blackmail, a large majority of doctors are opting out and taking a career break.

Despite “run through” training blackmail, a large majority of doctors are opting out and taking a career break. The Foundation Programme was first proposed by England’s Chief Medical Officer, Professor Sir Liam Donaldson in 2002…. Some countries, (India) use financial measures to entice their doctors to work for the state for their first 5 years. Doctors can be posted to unpopular outlying areas, so they try to avoid this, and even borrow to pay their way out. The “Perverse outcomes” of the foundation programme could only have been avoided by overcapacity of doctors and it has been through many administrations that places have been rationed.

Since “run through” training (GMC)  was advanced, and the penalties for “uncoupled training” were made clear at the start of the “Foundation Programme”, the profession have felt bullied, and coerced into a narrow based training, rather than the broad based training of yesteryear.

Knock on effects mean that opening up an abdomen often needs several specialities present. The convention of Human Rights states that a person may elect to take his skills to anywhere that wants and allows him, and in Europe this is part of the free movement of people in the European Convention of Human Rights. SO blackmailing doctors to stay in the UK, for fear that they will not get posts on their return, has backfired. The profession as a whole has voted with it’s feet. There is a world market in doctors, and medics reserve the right to take their trade where they wish. A perverse outcome from the wrong incentive at the wrong time…

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The BMJ Editorial by Jennifer Cleland, John Simpson, and Peter Johnston “Doctors opt out of training after foundation years,” (BMJ 2019;365:l1509 )

The UK’s inflexible training system looks increasingly unsustainable

There has been an explicit assumption in the UK that doctors will seamlessly progress upwards through the postgraduate training pathway. This was perhaps the case in the early years of the UK’s foundation programme (the first two years of generic training following medical school)—in 2010, 83% of foundation year 2 (FY2) doctors progressed directly from foundation to specialty training, including primary care. By 2018, however, that figure had fallen to 38%.1 Nearly two thirds of UK medical graduates now opt out of the training pathway at the first natural opportunity.

Most doctors who opt out return to specialty training within three years.2 This suggests that the break from formal training is the postgraduate equivalent of gap year—a time to recuperate from intense educational experiences, resolve uncertainties about the next steps in life, and make a curriculum vitae more competitive.345 Qualitative research suggests these are common reasons for not entering specialty training after FY2.5

Taking dedicated time to plan a career that may last more than 40 years is sensible. That doing so does not align with our current training system suggests a need for change. This is already happening. Doctors are opting to work overseas for a year or two, or take a “service job” (a post which is not linked to a formal training programme) to gain experience. Academic or clinical fellowship posts are also proliferating.2 These posts are designed to support medical education and other areas of activity, such as quality improvement, usually combined with some clinical service—often supporting rota gaps. These posts work for individuals, and also work for the NHS by keeping early career doctors in the UK.

But they are an isolated solution that could cause ripple effects throughout a complex training system.6 Fellowship posts, for example, are largely funded with money saved from unfilled specialty training posts. The two options compete for funding and are at the mercy of shifting trends. Fellowships will be a sustainable option only if they attract independent funding as, in the current system, an increase in the uptake of specialty posts would decrease the funding available for fellowships.

More fundamental changes to postgraduate training should consider the following: the interactions between individuals and the system at different points in the pathway; how different elements of medical education and training relate to each other and to the wider social and political landscape; and how systemic changes may benefit training and, ultimately, healthcare. Research shows, for example, strong connections between admission decisions by medical schools and the choices made by FY2 doctors about both specialty and place of work.78

The relation between medical school admissions policies and medical workforce planning is not simple or linear.9 Shifting the focus of admissions, however, from a stifling emphasis on high academic achievement10 to a model better aligned with social accountability would be a good first step towards a better match between the two. Such a model would select a mix of students with the personal attributes and motivation to train and work in the NHS, across the full range of localities and specialties. To facilitate this change, selection policies should consider the views of a broader cross section of stakeholders, including representatives from community and hospital medicine, employers, patients and the public, and government.11

Similarly, medical education and training in the UK involves many separate systems, including medical schools, the Foundation Programme, postgraduate training providers such as Health Education England and NHS Education for Scotland, and the royal colleges. All must work together across boundaries to ensure a smooth transition between foundation and specialty training. Consider, for example, the potential value of aligning medical school admissions (such as dropping the high academic requirements) with increases in intake (through government reform) and royal colleges rethinking how training programmes are constructed, assessed, and regulated.

Change may be unpalatable, but the alternative is to continue with the current state of affairs—an inflexible training pipeline that fails to supply enough doctors to meet growing demand and fails to meet the needs of doctors in training. Acknowledging that systemic and structural problems exist is the first step towards developing effective, system-wide solutions.

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Overseas staff are desperately needed. Why can’t we provide them ourselves? The populism and emergence of “fascist” tendencies will make things worse..

Lets start with the answer to the question first. There is rationing of training places in all specialities, in nursing and in paramedical training. We need to aim at providing an overcapacity, especially now that the work-life-years of the average health service staff is declining. All 4 health services are dependent on overseas staff… The same pressures from “populism” are on governments worldwide. We know about the USA and Mexico, which needs the Mexicans badly. In Australia the Human Resources Directorate reports that “Labour plans to tighten skilled worker visa laws”.

The post code lottery of our devolved administrations makes shortages worse in deprived areas. This encourages more populism and fascist tendencies ….

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The fascist tendencies in populism worldwide are worrying. This talk from Israeli Yuval Noah Hurari explains how to understand what is happening...

David Oliver in the BMJ 2nd Jan 2019 opines: Falling immigration could destroy the NHS  BMJ 2019;364:k5308

Workforce gaps currently pose a major threat to the viability of our health services, as noted in a joint 2018 report by the King’s Fund, Nuffield Trust, and Health Foundation.1

One in 11 NHS clinical posts is currently unfilled, rising to one in eight nursing posts.2 The report estimates that, without concerted action, the current shortage of NHS staff employed by trusts in England—already around 100 000—will grow to an estimated 250 000 by 2030.

Some of the proposed solutions have been put forward before, by organisations including NHS Providers3 and the Royal College of Physicians.4 These centre on training more staff at home and doing more to look after staff so that more of them stay in the workforce. But this will take years, so let’s get real……

Chris Smyth in the Times 24nd April opines: New migration plan puts hospital services at risk

NHS chiefs have warned the government that “destructive” post-Brexit immigrant plans could force some hospitals to close a quarter of services, leaked minutes suggest.

Health bosses have told senior civil servants that a strategy involving a £30,000 salary threshold for any workers moving to Britain would be “the most destructive policy for NHS recruitment” because of the service’s reliance on overseas staff.

The proposals are under attack from NHS and social care services, which are short of 100,000 staff. In a white paper published last year, ministers proposed that when freedom of movement ends, all workers wanting to take up jobs must earn more than £30,000.

According to minutes of a meeting in January seen by The Daily Telegraph, one NHS director told officials that the “£30,000 limit is the most destructive policy proposal for NHS recruitment I’ve heard of”, to which another person present added “and the entire UK”. The minutes also say that the policy will be particularly “awful for social care”.

The health service relies on overseas staff, with one in ten doctors and one in 15 nurses coming from other EU countries, and there are concerns that tighter immigration controls could worsen staff shortages.

A nurse’s starting salary is £23,000 and social care workers earn even less. Health think tanks have urged the sector to be exempt from post-Brexit salary controls as 90 per cent of staff earn less than the £30,000 threshold.

Caroline Nokes, the immigration minister, has acknowledged the problem, telling MPs last month that there is a “lot of concern” about social care in particular. She promised further discussion with unions and other bodies.

• Heather Blake, a director at Prostate Cancer UK, has warned that the charity estimates “thousands of men will miss out on the support they need because there are not enough clinical nurse specialists to support them”.

Doubling NHS surcharge “punishes” international doctors for working …

The BMJ9 Jan 2019


You can’t get no satisfaction – and its going to get worse….

The 4 health services need money, especially if they are “free at the point of access”, and cradle to grave, without reference to means etc. Unfortunately we in the profession know this is unsustainable and hence the problems at Chester – refusing Welsh Patients. The money moves with the patient all around the 4 Health Services, so no wonder the commissioners refuse second opinions from outside their trust (These are the only ones that matter), and refuse inter trust transfers and referrals whenever possible. Just like in Dentistry, private services are going to thrive, whether GP advertising is banned or not… Cutting referrals means more private care.. 

The fines for long waiting lists have to be more than the cost of extra contractual referrals! Commissioners will coolly calculate the difference and lives will not be considered. 

We shame Aneurin Bevan’s ideal and even Stephen Hawking realised this.

Nick Triggle for BBC news 7th March reports: Satisfaction with NHS ‘hits 11-year low’

and this is particularly true in the Walsh border area around Chester.#

The Chester Chronicle reports: Satisfaction with NHS “at lowest since 2007”.

Public satisfaction with the NHS has fallen to its lowest level in more than a decade, despite the Government’s announcement of a funding boost, new research suggests.

Just over half of people (53%) in 2018 said they were very or quite satisfied with the way the health service is run, the British Social Attitudes (BSA) survey found.

This is down three percentage points from 2017 and the lowest proportion since 2007, according to analysis by the King’s Fund and Nuffield Trust.

In 2016, 63% of people were satisfied, compared to 65% in 2014.

Satisfaction with how the NHS is run is at its lowest since 2007 (PA Graphics)


(PA Graphics)

Ruth Robertson, senior fellow at the King’s Fund, said she was “surprised” by the results of the survey, in the year the NHS celebrated its 70th anniversary and was promised an additional £20.5 billion per year.

“We didn’t see this ‘birthday bounce’ that you might have expected in satisfaction,” she said.

The survey of almost 3,000 people in England, Scotland and Wales was carried out between July and October, after the funding announcement.

The main reasons people gave for being dissatisfied with the NHS overall were long waits for GP and hospital appointments (53%), not enough staff (52%), a lack of funding (49%) and money being wasted (33%).

More than two-thirds (71%) of those who were satisfied with the health service said it was because of the high quality of care, while 62% said it was the fact it is free at the point of use.

Older people were happier with how the NHS is run than younger people, with 61% of those aged 65 and over satisfied compared to 51% of those aged 18 to 64.

“Despite the outpouring of public affection around the NHS’s 70th birthday and the Prime Minister’s ‘gift’ of a funding boost, public satisfaction with how the NHS is run now stands at its lowest level in over a decade,” Ms Robertson said:

“In the short term at least, the promise of more money doesn’t appear to buy satisfaction.

“The public identified long-standing issues such as staff shortages and waiting times amongst the main reasons for their dissatisfaction and cash alone will not solve these.”

Satisfaction with GPs has hit its lowest level since the survey began (PA Graphics)

Satisfaction with GPs has also dropped two percentage points to 63%, the lowest level since the survey was first carried out in 1983.

Professor John Appleby, director of research and chief economist at The Nuffield Trust, said: “This may reflect continued strain on general practice, with mounting workloads and staff shortages and the evidence shows that people are finding it harder to get appointments than before.

“The NHS long-term plan expects even more of general practice – these problems will need to be addressed quickly if that vision is to be made possible.”

The analysts cautioned that there may be a “lag” before the money pledged by Theresa May has an impact on satisfaction levels.

However Ms Robertson added: “Two of the factors that people are telling us are big drivers of their dissatisfaction – waiting times and a lack of staff – are things that aren’t actually addressed in the long-term plan.

“We are waiting for the workforce strategy to come out to deal with the crisis we’ve got around workforce, and a review of waiting times as well.”

A spokesman for the NHS said: “For the third year in a row, public satisfaction with the quality of NHS care has improved and satisfaction with inpatient services is now at its highest level since 1993, however the results as a whole understandably reflect a health service still under pressure.

“The Long Term Plan sets out an effective blueprint for making the NHS fit for the future as funding comes on stream and does so on the back of the public’s enduring support for NHS services, with increasing satisfaction scores in the survey for both outpatients and inpatients.”

The Health Service is no longer National, and there is blatant finacial rationing because Wales has not paid up!

April 5th Chester Chronicle: English health trust accused of using Welsh patients as ‘bargaining …

BMJ 3rd April: David Oliver: The revolving door to the NHS lobby

The Guardian 31st Jan 2019: NHS England to ban GPs from advertising private services

The Herald Scotland 1st April: Margaret Taylor: It’s unforgivable for MPs to fiddle while our NHS burns

26th March 2019: CCGs continue to offer cash rewards for GPs to cut referrals

The Independent 15th February 2019: Tens of thousands of cancer patients left waiting months to start …



Covert and post coded randomised rationing of dementia care..

The daily mail claims there is a deliberate bureaucratic block on spending money on dementia. The implication is that these citizens, at the end of their lives, don’t matter. After all they often don’t have the mental capacity to vote, and they don’t have the life expectancy, so the combination means their votes don’t matter. The votes of their relatives do matter, but somehow relatives learn to live with this post code random rationing. It will be even more random in the other jurisdictions: these figures apply only to England.

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On Tuesday April 2nd the Times published: Dementia Care is not good enough across half of NHS but it was not on line (It referred to the Daily Mail):

“Dementia care is not good enough in half of NHS local healthcare groups according to official ratings.

One in three patients does not have a diagnosis with large variations across the country..

Experts have accused the government of losing focus on dementia as the number of patients continues to rise. About 850,000 Brtions have dementia… Analysis on the Daily Mail website shows  19 clinical commissioning groups that fund care locally are rated “inadequate”, and 66 as “requires improvement”. This compares with 43 rated “good” and 52 “outstanding”.

Clive Ballard, a dementia specialist at the University of Exeter, told the newspaper: “In 2012David Cameron made a commitment to takle dementia. The current figures show no subsequent progress. It feels very much like these pledges have been kicked into the long grass.”…..

In Camden (London) 91% are estimated to have a diagnosis, whereas in Cornwall on 52%…..

Fiona Carragher , of the Alzheimer’s Society, said: “It’s deeply worrying that the postcode lottery of care is continuing. People tell us they have to wait years for a diagnosis and have to fight the system to access support, advice and treatments.

“Some say their care plan is little more than a tick box exercise”.

Alistair Burns , National Clinical Director for dementia at NHS England said: “The long term plan prioritises further improvement, with GPs being given additional support to spot the tell-tale signs”.


December 17th 2018. Chris Smyth in the Times: Dementia patients have to move hundreds of miles for good care

A million older people live in places where most dementia beds are rated poor, forcing vulnerable patients to move hundreds of miles for decent care, The Times has learnt.

Large swathes of the country have fewer than one satisfactory dementia care home bed for every 100 people aged over 65, according to analysis. One in 14 older people has dementia and diagnoses are rising.

In Kensington and Chelsea, only 19 per cent of dementia beds assessed by inspectors have been rated good or outstanding, the lowest in the country. Campaigners have warned of a “broken system” for coping with dementia, which is the country’s biggest killer….

and in 2016: Dementia patients marooned in hospital

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Universal (NHS Scotland) telephone triage… a way to foster private practice

If the Scots do decide to telephone triage all callers to GPs, they will create a monster. The perverse outcome could well be an expansion of private practice. This is already happening in consultant care, and needs only this sort of small push to apply equally to General Practice. It is only by co-payments that the system can be saved now.. The gap between rich and poor is widening….. (Philip Aldrick 27th Feb 2019: Gap between rich and poor at five-year high)

Jo Carlowe in Onmedica reports 27th March 2019: Online triage ‘not a solution’ to GP workload pressures

Online triage will not solve GP workload pressures, a lead GP warns.

Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners, acknowledges that online triage systems are convenient for some patients, but points to the fact that they do not always reduce GP workload.

Her comments come in a response to a study* in the British Journal of General Practice about online triage systems.

Abi Eccles and colleagues at the University of Warwick studied information from over 5,000 patients using online triage systems. Two-thirds of users were female and almost a quarter were aged between 25 and 34.

Highest levels of use were between 8am and 10am on weekdays (at their highest on Mondays and Tuesdays) and 8pm and 10pm at weekends. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list. Less than one in 20 contacts were for mental health problems.

Many patients found the system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting. The authors comment that the pattern of use of online triage is very similar to that of telephone contact with practices and a clear understanding of their needs is required to capture the potential benefits of this technology.

Commenting to the findings, Professor Stokes-Lampard said: “GPs and our teams have always made the most of technology as part of our ongoing commitment to provide the best possible care to patients.

“We were the first NHS sector to implement both electronic patient records and electronic prescribing, and we will continue to explore how using new technology in practice can benefit our patients, including through online consultations, which many practices across the country are already using in some form.

“There’s no denying that online triage systems are convenient for some patients, particularly people who are generally fit and well and work full-time, or for people uncertain if their problem is significant or not, but as this study shows, they do not always reduce GP workload – a major pressure currently facing general practice.

“The goal of adopting any new technology is to not only make sure it is safe and effective, but that it actively complements the work we already do. It is good to see robust research emerging about online triage systems in action.”

2013: Caroline White in OnMedica: Increasing workload boosts use of telephone triage in GP practices

Methods of rationing in the news… Telephone triage, scrutiny of referrals, larger practices, reducing standards, reducing access, excluding treatments. So many different and covert methods of rationing. No political party offers the honest option. No wonder we are disengaged.

Primary care telephone triage does not save money or reduce practice workload

GP A&E Triage – would be a good idea if we had planned for the numbers needed. We have not.. and GP partnership and continuity of care is in decline

The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse.

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

Back to the future: Look again at what we used to do well – before it’s too late.

Having the same GP halves chance of early death. Seeing the same GP will help older people… An association is not however a cause..

Household made 3,600 ambulance calls in one year….

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

See the source image