Category Archives: Perverse Incentives

In a celestial world as outlined by the old NHS, there was universal, cradle to grave cover, with no barriers to access, free at the point of delivery, and without reference to means. Funny that we have so many medical charities then. And the greatest number of these charities is in the Hospice (Palliative and Terminal care) sector. These charities are mostly run from physical buildings, and hospices, but in the poorer areas of the country they are “Hospices at Home”. The idea to help elderly at home is a good one, BUT it overlaps so much with charitable providers. The perverse incentive for Trusts and Commissioners to offload as much as possible to these charities will inevitable mean there are large post code voids in cover. NHS reality does not object to this IF it is honestly discussed. The solution is a means based insurance based system, and since most of the assets in the UK are held by the elderly this would be more progressive.

Chris Smyth reports November 22nd in the Times: Rapid response teams will help elderly at home

NHS “rapid response teams” will be on call 24 hours a day, seven days a week to help frail and elderly patients who fall or suffer infections, Theresa May will say today as she promises to use extra health service cash to keep people out of hospital.

GPs will also get to know care home residents personally in an effort to keep them well at home. Such services will get an extra £3.5 billion a year by 2024 as part of a £20 billion boost promised to the NHS in the summer

Experts welcomed the ambition but questioned whether the NHS would have the staff to provide the services, and warned that such top-down initiatives often backfired…..

…Simon Stevens, chief executive of NHS England, said that guaranteeing the money for local services would help to make the plans a reality.

“Everyone can see that to future-proof the NHS we need to radically redesign how primary and community health services work together,” he said. “For community health services this means quick response to help people who don’t need to be in hospital.”

Sally Gainsbury, of the Nuffield Trust think tank, said: “This money will simply allow GPs and community services to keep up with demand over the next five years. That’s important but it means the new money announced today is not going to lead to a significant change.”

She added that there were “serious questions about whether the NHS has the right staff in the right places to carry this out”. She warned: “We would agree the NHS needs to focus on helping people more outside hospital and getting them home more quickly. But the idea of telling every local area to do the exact same thing has often backfired in the NHS, as it is bound to be less well-suited to certain places.”


Advances in Diabetic care are rolled out at different speeds in different post codes.

There is a history of rationing new advances in medical care differently in different post codes and regions. Some things are too important for this type of random care. If it was open and honest, and announced in advance, for some cheap services rationing is appropriate: but of course it is not allowed to be talked about. The perverse incentive for commissioners to get away with what they can is too great..

Judy Hobson in the Mail in 2010: The alarm that can save diabetics’ lives (so why is the NHS rationing them?)

Faith Eckersall reports in the Daily (Dorchester) Echo 12th October: Diabetics to confront councillors over postcode lottery DORSET diabetics – including some children- will be part of a delegation at the county council on Wednesday to campaign for new testing technology free on the NHS.

Currently people with Type 1 diabetes must use the painful and inconvenient pin-prick method to check their blood sugar levels but Flash, which must be paid for in Dorset, works on a pain-free patch and scanning device.

The protestors are angry that despite the government’s NICE drugs and medicine rationing committee approving the use of Flash Glucose Monitoring on the NHS, Dorset Clinical Commissioning Group has not made it freely available, as has happened in adjoining health areas.

The CCG is running a six-month pilot of the Freestyle Libre blood glucose monitoring device for 200 people in three specific groups of diabetic patients in the county. But protestors point out there are 5,000 diabetics in Dorset who could potentially benefit and say no further testing or pilot is needed.

Diabetes UK south west regional head, Phaedra Perry, said: “The Dorset Clinical Commissioning group should make Flash available immediately to all people with diabetes in the area who can benefit, and not to just a very limited group of 200 patients for six months.

“Commissioners here are out of step with neighbouring CCGs which have agreed to prescribe it. Dorset is one of very few areas in the south west where Flash is not available and is effectively imposing a postcode lottery on diabetes technology.”

The rising trend in fraud in the UK health services.

My calculation for a population of 70 million is that this “fraud” costs us all around £16 each. The known parts are £5 loss to staff, £1 loss to patients, and £10 the professionals.  How can an organisation be run by administrators and leaders so much in the dark? We know purchasing power is reduced in smaller Health Services (Wales, Scotland and N Ireland), and now we know more about what they have been unable to correct due to the perverse incentives in the system. How many families have crutches, walking sticks and other accessories no longer needed? A small co-payment, is needed, with partial refund when returned undamaged. The managers need a breakdown at the touch of a button, of all missing items. Can you imagine a company like Screwfix or Argos not knowing what was where? Whilst the figures are not high, the rising trend shows it might become a real problem in future. 

Fraud is also a concern in other countries, especially the USA. Some comfort…

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Kat Lay reports 8th October 2018 in the Times: Fraud in the NHS could have paid for 40,000 nurses

Fraud costs the NHS £1.29 billion every year, according to the health service’s anti-corruption watchdog.

The money would be enough to pay for more than 40,000 staff nurses or buy more than 5,000 frontline ambulances, the NHS Counter Fraud Authority said in its annual report.

The organisation was established on November 1 last year. The new figure is higher than the £1.25 billion identified at its launch. The estimated total loss includes £341.7 million from fraud by patients and £94.2 million by staff.

Fraud by dentists adds up to about £126.1 million, the watchdog said, and opticians £79 million. Fraud in community pharmacies is estimated at about £111 million and in GP surgeries it is worth £88 million. People accessing NHS care in England to which they are not entitled is thought to cost the health service £35 million. The rest included fraud involving NHS pensions, bursaries and legal claims.

Simon Hughes, the authority’s interim chairman, said: “Ensuring public money pays for services the public needs and doesn’t line the pockets of criminals means we all benefit from securing NHS resources.”

Sue Frith, its interim chief executive, said: “Fraud always undermines the NHS, with every penny lost to fraud impacting on the delivery of vital patient services. If fraud is left unchecked, we believe losses will increase.”

The report said there was “no such thing as a ‘typical’ NHS fraudster”. It noted that there were barriers to tackling the issue, including a lack of understanding of the problem in many NHS services. It added: “There is also sometimes a mistaken assumption that reporting fraud casts the organisation involved in an unfavourable light.”

At the end of March there were 45 criminal investigations in progress, the report said. In July a neurology nurse from London was jailed for 16 months for fraud by false representation. Vivian Coker, 53, from Camberwell, took sick leave from August 2014 to May 2016. During this time she received pay of £32,000 from St George’s University Hospitals NHS Foundation Trust, but had also registered with two agencies and worked shifts. Coker initially denied the charges but changed her plea at Kingston crown court.

In March the authority helped to jail Andrew Taylor, a locksmith employed by Guy’s and St Thomas’ NHS Foundation Trust. He was sentenced to six years for defrauding his employer of £598,000. He had charged the NHS mark-ups of up to 1,200 per cent.

Taylor, 55, from Dulwich, was found guilty at Inner London crown court of fraud by abuse of position. Financial investigators “established that Taylor was leading a cash-rich lifestyle beyond his legitimate means, which included paying for his son to attend a private school whose fees were £1,340 a month and purchasing a brand new Mitsubishi L200 vehicle at a cost of £27,400”, the report said.

It also described the case of Paula Vasco-Knight, 53, chief executive of South Devon NHS Trust, who made fraudulent payments of more than £11,000 to her husband, Stephen. She admitted fraud by abuse of position in March 2017 and was given a 16-month prison sentence, suspended for two years, and ordered to do 250 hours of unpaid work by Exeter crown court.

The couple said that they did not have sufficient assets to repay the money but investigators found that they had access to personal pensions that could be surrendered.

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

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Orkambi and Yescarta are merely illustrating an ethical problem that will get bigger into the future… Political dishonesty and denial stall a solution.

It is self evident that we cannot afford everything. In health we only find this out when we need a non-funded treatment, such as Orkambi. There are other examples, such as Yescarta, Anticoagulant monitors etc. With drugs the perverse incentive is for authorities to decline them for as long as possible, so that they get as near to their patent expiry (12 years) as possible. Usually media pressure brings the state funding forward by a few years.. But in the intervening period the “health divide” means that only those who can afford it will get the new treatments. We could afford all these treatments once they were proven, if we agreed to ration out high volume low cost treatments. Indeed, for a disease like CF, the advent of CRISPR could ensure that fewer and fewer people need the drugs. This is the longer term solution, but shorter term our politicians need to ration honestly and overtly, large volume low cost products, so that those unfortunate enough to have an expensive disease can be treated. Even America is not covering Orkambi…

When will the debate on rationing take place ?

George Herd for BBC Wales: Cystic fibrosis mothers’ plea over ‘life-changing’ drug

Kimberly Roberts is the mum of three-year-old Ivy, who has cystic fibrosis – or CF – which is a genetic lung disease with no cure.

Along with her friend Alison Fare, who has two daughters with the condition, they want access to one of the most advanced treatments – the drug Orkambi.

But the manufacturer and NHS bosses have been locked in arguments over its £100,000-a-year price tag since 2015.

“Our children deserve to have it – deserve to live a healthy long life. Without that drug they won’t have one,” said Mrs Roberts, who lives near Conwy in north Wales.

Nice – the body which recommends whether a drug or treatment is available on the NHS – has said that the ongoing bills for the drug would be “considerably higher than what is normally considered a cost-effective use of NHS resources“….

Nice has said the cost for the drug would be “considerably higher than what is normally considered a cost-effective use of NHS resources“.

In July, NHS England made an offer of £500m for five years to have the treatment, with £1bn over 10 years.

But while that offer remains on the table – the deal has not been done.

Good News: Deal to freeze prices will allow NHS to use new drugs

First stem-cell therapy (for corneal epithelium) approved for medical use in Europe

Drug trails: how much obligation ha the state to support unproven treatments?

Anticoagulants to prevent clotting diseases.

Orkambi rationed for Cystic Fibrosis

Big pharma is taking the NHS to court this week – research is not “nationalised” for a reason..

More money needed… lets pour a little more into the holed bucket – and reduce the quality of care by rationing new treatments

Key cancer drugs to be axed from NHS fund – ITV News is updated by the Mail and Wales makes sensible decision..

The Times 29th August 2018: Yescarta cancer therapy ‘is too costly for NHS’

Kate Thomas for the NY Times 24th June 2018: A Drug Costs $272,000 a Year. Not So Fast, Says New York State. – New York’s Medicaid program says Orkambi, a new drug to treat cystic fibrosis, is not worth the price. The case is being closely watched around the country.

In PharmaTimes, Selina McKee, online 9th July 2018: Vertex, NHS England no closer to Orkambi settlement

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

The safety net of the 4 health services is “free, comprehensive, cradle to grave, without reference to means”, but the safety net of social care is means tested, and only available in extreme poverty and with multiple conditions, and after a long delay in assessment, by which time the patient is often dead. The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care? Brexit costs can only make this worse… If we are going to ration lets do it  honestly. Commissioners should be allowed to alert their populations to what is not available in their post code.

William Eishler in Local Government news reported 17th Jan 2018: Funding system for continuing healthcare needs failing patients.

The system for funding health and care services is overly ‘complex’ and is ‘failing’ people with continuing healthcare needs, such as Alzheimer’s and multiple sclerosis, MPs say.

A new report by the Public Accounts Committee (PAC) warns that many people have their care compromised because no one makes them aware of the funding available or helps them to navigate the funding system……

Mark SMith for WalesonLine 23rd August 2018 reports: Families facing ‘excessive delays’ in reclaiming thousands for healthcare costs they should never have paid – Public Ombudsman for Wales has says 330 claims still need to be reviewed

Patients and their families who have incorrectly paid up to hundreds of thousands of pounds in healthcare costs are facing “excessive delays” in getting their money back, it has been revealed.

A new report from the Public Ombudsman for Wales has found that as many as 330 claims still need to be reviewed from people who feel they may entitled to a reimbursement.

The NHS has set up a funding programme, known as NHS Continuing Healthcare, which means people with a complex, ongoing illness can apply for an assessment.

For those eligible, all care needs outside hospital – including nursing home costs or help from a community nurse – are met by the NHS.

But for years, many families have been unaware about this programme and have resorted to selling their homes and making other major sacrifices to make ends meet….

Continuing Health Care funding needs to be rationed honestly, universally, and overtly. The only fair way is by a third party without the Perverce Incentive to refuse..

Continuing Health Care – the Lottery of how you die and how determined and educated your relatives are: Healthcare system is in need of a cure

Untrustworthy staff – continuing saga of data collection failure blights the Health Services potential. GPs cannot have had enough say and power in planning…

What models of funding are best for a healthy and just society? No other country has chosen our system, even after 70 years and our Olympic boasting. The public need to be led into realising why not.

Personal, continuing care….. is going the way of the dodo. Basingstoke represents the rest of the country.

Trials of personal budgets will have long term perverse outcomes in an ageing society. Health costs are rising, and geographic variations will become greater….

The “State of health and care in England” – is declining and worryingly underfunded…

A loss of personal continuing care. 700 practices in 5 years. Is the GP going the way of the Dodo in the past, or the Salmon in the future? We need to rediscover it’s value.

The Brexit catastrophe is only just beginning

Potentially talented sports teenagers need protection – for their own health. Legislation is needed…

We have been reading about disgraced sportsmen for years, but politicians must remember that these people are “role models” for youngsters, whether we like it or not. The risk involved in becoming a professional sportsman, often involving parents signing a contract for a child in their teens, is invidious. Many of us feel this is tantamount to abuse.

Potentially talented sports teenagers need protection – for their own health. It is time for the state to do this – now. The chances of success at teenage level are VERY small, and a sensible family will discuss this and have other irons in the fire. A degree, or a professional qualification, or some HNDs seems essential, and since 95% of aspirants will drop out, protects their future.

What is the average IQ of professional sportsmen I wonder? No need to quote anecdotes of intelligent and degreed players (Steve Highway of Liverpool), but how about a study? Is the level of responsibility for average IQ (100) enough not to need a minder when off duty but at a meeting or during a test match?

The list of players who have made it but led themselves into trouble is a long one, but the list of those who never made it,  and then underperformed in the rest of their lives, is even longer.

We need new legislation to replace the current rules, and it needs to be with informed consent that a short contract is signed at 18y at the earliest. In the 4 health services, which are falling apart, the last thing we need to produce is mentally fragile youngsters. It is as disappointing to a potential professional footballer to be rejected as it is for a potential doctor. We need the doctors but 9:11 of applicants have been rejected up to now.

Sport is recreation, and that is how it should be for most of us. The tendency for young people to give up team sports if they are not in the top echelon is not healthy. Individual activities are taking over, such as surfing, and golf, but when professionals recruit to their “youth training programmes” parents need to give “informed consent”, and NHSreality feels this cannot be before age 18y. Before that age it should be a gentleman’s agreement between clubs and families, but a second string should always be available,

In addition to the problems of professional abuse, new youths are tempted and threatened by social media. At school level social media can do great harm, and parents face a minefield in trying to get access to on line bullying and other abuse. Sportsmen are no different, and many of them need minders both physically, and for their social media.

The student grant and loan, and fee payment schemes are leading to poverty and perverse behaviours. Although I suspect he overstates the case, it is worrying when a Councillor claims: Bristol is “full of perverts and disease riddles prostitutes from the local universities” claims local UKIP councillor on Ben Stokes case”,  (BristolLive)

The mental strain and the temptations are enormous, but the services are not there, either preventative or for treatment. 

Bearing in mind that this is a parenting problem, surely the law needs to be changed to help those families unable to protect themselves?  Following this an educational program on TV and radio similar to the AIDs programme might be much better value than having to treat the problems that arise from our denial.

You might argue that in a “robotic” age, when work is almost voluntary for many, that sport will be a natural outlet. I would agree, but the professional v amateur argument still holds. Sports that aim deliberately at damaging the brain are anathema to most doctors, (Boxing), and those that accidentally risk damage to the brain are becoming less and less acceptable (Rugby, American Football) to many sensible families. Should the longer term problems caused by these “games” be covered by insurance rather than the Health Services?

The Perverse Incentives of professional athletics led Flo Jo to take steroids, and she died young, and the combination of a cycle industry, a TV channel team, and professionalism was too much for Lance Armstrong.

Ben Stokes trial LIVE updates: England all rounder found not guilty of affray after late night bust up The Mirror 4 days ago

The list of rugby players includes:
Danny Cipriani,
Lawrence Daliagio
Mike Tindall
Jason Leonard
Manu Tuilagi
Olly Barclay
In the cricket world there has been:
Ian Botham
Mohammed Amir
Salman Butt
In Football:
George Best
and there are many more. In cycling and athletics, in Baseball and Ice Hockey.

Self-harming up by 70% among young teenage girls. Is social media responsible?

The potential risk for blackmail – think about your medical records when you are young. Are you ambitious to be famous?

Rugby and Dementia pugilistica…. an unfair cost on the health service

Should dementia from sports injuries and concusion be subject to “deserts based rationing”?

Should sports injuries all be covered by the UK Health Services? The brain damaging season of international rugby is about to begin.


Hospital opiate deaths scandal at Gosport. Relatives should remember that they can also ask for a PM (Post Mortem) if they have any concerns.

“Between Shipman’s conviction and 2019 around 9 million deaths will have been handled through procedures known to be unreliable”, ( BMJ 2018: 361:k2668 )

The BBC has reported on Gosport Hospital: Gosport hospital deaths: Prescribed painkillers ‘shortened 456 lives’ 

Ever since Dr Shipman murdered so many people, we have mostly assumed that unexpected deaths, especially if in large numbers, are investigated. Unfortunately there is  perverse incentive for coroners, who have a budget from the  government, to reduce costs. Post mortems have reduced in number steadily since the 1970s. BMA fees for post mortems …. you can always ask for one as a family.  Commissioners have to cover these fees, and therefore they try to get the coroner to ration post mortems. In addition it will be an interesting dilemma for the Lord Chief Justice. Whether to sue for murder or manslaughter…. In England ( BMJ 2018: 361:k2668 ) New medical examiners will eventually scrutinise all deaths. Tom Luce chair of the fundamental review of death certification and investigation, and Janet Smith, chair of Shipman Enquiry.

The Times letters 22nd June 2018: 

Sir, The findings of the Gosport Independent Panel are shocking and will raise further concerns for patients, carers and the public about the use of opioid medication (News, June 21). We would like to reiterate the comments by the Right Rev James Jones that the deaths were related to the administration of “dangerous doses of a hazardous combination of medication not clinically indicated or justified”.

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Opioids are widely used within palliative care, and are uniquely effective in managing pain and other symptoms associated with cancer and non-malignant diseases. Side effects can occur but these are usually manageable. Furthermore, appropriate prescribing and continued monitoring can usually prevent serious issues such as breathing problems and drug addiction. Importantly, research has shown that opioid medication does not shorten lives, and may even prolong lives through good pain relief.
Dr Andrew Davies, FRCP

President, Association for Palliative Medicine of Great Britain & Ireland

Sir, Prosecutions resulting from iatrogenic deaths are usually for manslaughter, based on the gross negligence of those responsible for treatment. However, the independent panel has reported that deaths resulted from a practice of “shortening lives through administering opioids without medical justification”. Arguably that meets the legal definition of murder. Since Harold Shipman there has not been a case of large-scale killing by medical personnel. One would hope that, after investigating the facts in full detail, the CPS will have the courage to bring charges of the most serious kind.
Jeffrey Littman

Hendon Chambers, London NW4

Sir, The events in Gosport will have been facilitated by our unreliable coroner system. As part of her inquiry into how Harold Shipman murdered some of his patients, Dame Janet Smith recommended that there be an independent coroner service “at arm’s length” from the government. This is not what we have ended up with, and the public cannot have any faith in anything short of a truly national coroner service.
Veronica Cowan

Cowes, Isle of Wight

Sir, Minh Alexander is correct to cast doubt on how whistleblowers would be treated in today’s NHS, even with the “freedom to speak up” guardians that exist. Whistleblowers tend to be, at best, discredited and at worst forced out of their jobs, often on spurious disciplinary charges. Since it is often senior managers who collude to suppress whistleblowers, surely there has to be a role for a new independent organisation outside the NHS to handle whistleblowers’ concerns?
Mark Roberts

St Helens, Merseyside

Sir, If our new system of “freedom to speak up” guardians had been in place when the nurses at Gosport spoke up they would have been listened to and the right actions would have been taken. The “freedom to speak up” guardian can escalate matters directly to the chief executive and the board, and if necessary to the National Guardian’s Office and in turn the regulators. In the past year more than 6,700 cases have been raised with guardians by NHS staff in England to keep patients safe, support staff and start the culture change that we want to see in the NHS.
Dr Henrietta Hughes

National guardian for the NHS

Dame Janet Smith The Shipman Enquiry: Death Certification and the Investigation of Death by Coroners.