Category Archives: Perverse Incentives

We need more co-payments – not less. But “Stealth dentistry charges bring in millions for NHS”

Co-payments are an important principle in Insurance. They reduce claims. There is no incentive to reduce claiming on the 4 medical health services, except waiting lists/times and in England, prescription charges. In ophthalmology, and in dentistry there are big co-payments. Dental care is riddled with worrying incentives, and the contract with dental surgeons needs changing. But before it is changed we need to re-examine the whole ideology of the health services. With the poorest getting more obesity, and more sugar related dental decay, many in the professions are expecting a rise in streptococcal heart disease. Does the recent rise in scarlet fever (The Mirror) and scarletina reflect this risk increase? Rationing (restricting, prioritising, excluding)is usually reasonable, but it should not be covert. or unequal, or subject to a lottery of where one lives.

Chris Smyth reports for the Times 4th April 2018: Stealth dentistry charges bring in millions for NHS (Be sure to read his analysis at the end

Hundreds of thousands of patients are paying a “stealth tax” when they have an NHS dental checkup, making the government millions of pounds a year.

Within five years NHS patients at a third of surgeries will be paying more than their treatment costs as dental fees continue to rise, an analysis has shown. This will raise £20 million for the government, leading to claims of a “rip-off” tax on treatment.

Just over half of NHS patients pay for their dentistry, with children, pregnant women and those receiving low-income benefits exempt from the charges, which are considerably lower than private treatments.

After charges rose at the weekend, a checkup costs £21.60, fillings and teeth extractions cost £59.10 and complex work such as crowns and bridges costs £256.50. These fees go to the government. Dentists are paid through an arcane system for each “unit of dental activity” (UDA) that they perform.

An analysis of NHS payment data by The Times and the British Dental Association found 331 surgeries that are paid less than £21.60 for each UDA. This means that patients are paying subsidies to the NHS of up to £10 at each checkup, making the government £1.3 million over the next year.

Henrik Overgaard-Nielsen, the association’s chairman of dental practice, said: “When patients put in more towards their care than the government pays to provide it, NHS charges cease to be a ‘fair contribution’.”

The government pays most of the cost for fee-payers at 68 practices. Last year The Times revealed that half of dentists with data available were not taking on new NHS patients.

Charges have been rising by 5 per cent a year. If this continues until 2022, and payments to dentists increase at the previous rate of 1.5 per cent a year, then 2,128 of 6,300 high street practices will be charging patients more than their treatment costs, raising £20 million for the NHS.

Neel Kothari, a Cambridgeshire dentist, said: “For many patients, NHS dentistry has become a fixed price service largely funded by themselves. It raises the bigger question: how much should the government be contributing towards NHS dentistry?”

Dentists say that a fifth of patients have delayed treatments because of their cost, while the UDA system has led to concerns that dentists are incentivised to rush appointments to maximise their pay.

A Department of Health spokesman said that access to services was increasing. “Dental charges remain an important contribution to the overall costs of services and this increase will ensure there is no shortfall in the costs paid by users and those met by the NHS.”

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Analysis
Dentists rarely kill patients. While this is good, the low risk of toothache puts it way down the NHS priority list (Chris Smyth writes).

Ministers have delayed fixing the NHS payment system that rewards dentists for seeing more patients. The system as it is creates worrying incentives: Desmond D’Mello caused the largest recall in NHS history after secret filming showed him not changing gloves and equipment between patients. D’Mello, who earned £500,000 a year from the NHS, was struck off but not before five patients turned out to have hepatitis C.

For almost a decade the government has been saying that it wants to shift to a system that rewards dentists for preventing illness, but little has been done. At a time when the NHS needs money, increasing charges is an easy way of raising it. But the government profiting from this looks wrong. Ministers may claim that this is the least-worst option, but they should own up to what they are doing.

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

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Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

Short termism rules, and shames the politicians who have denied that the system needs long term solutions. In our first past the post system with 5 year time horizons, we can expect no more. Proportional Representation, and a depoliticised ideology is urgently needed. Suggestions that an extra 1% tax (Liberals and Labour) don’t win the votes of the caring professions, who know the four Health Systems are not founded on an ideological or financial rock. Caring for people needs humans, not robots, and plenty of them. Anyone would think there was a conspiracy to ruin the Health Services.

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The Western Telegraph reports 19th Jan 2018: Extra funding to help NHS used for short term fixes, report finds

Additional funding aimed at helping the NHS get on a financially sustainable footing has instead been spent on coping with existing pressures, according to a report.

The National Audit Office (NAO) warned that “repeated short-term funding boosts could turn into the new normal” when funding with a long-term plan would be more effective.

Clinical commissioning groups and trusts are increasingly reliant on one-off measures to deliver savings, rather than recurrent savings that are realised each year, the report said.

The NHS was given an additional £1.8 billion Sustainability and Transformation Fund in 2016/17 ahead of the service having to survive on significantly less funding growth from 2017/18 onwards. It was also intended to give it stability to improve performance and transform services, to achieve a sustainable health system.

The report said this financial boost helped the NHS improve its financial position and overall the combined trust deficit reduced from £2,447 million in 2015/16 to £791 million in 2016/17.

But despite its overall financial position improving, the report said the NHS is struggling to manage increased activity and demand within its budget and has not met NHS access targets.

Furthermore, measures it took to rebalance its finances have restricted money available for longer-term transformation, which it said is essential for the NHS to meet demand, drive efficiencies and improve the service.

It said that, for example, the department transferred £1.2 billion of its £5.8 billion budget for capital projects to fund the day-to-day activities of NHS bodies.

On top of this funding, many trusts are receiving large levels of in-year cash injections, most of which are loans from the department, which have worsened rather than improved their financial performance. Extra cash support increased from £2.4 billion in 2015/16 to £3.1 billion in 2016/17.

It said progress has been made in setting up 44 new partnership arrangements across health and local government, which are laying the foundations for a more strategic approach to meeting the demand for health services within the resources available.

But the report added that, in reality, partnerships’ effectiveness varies and their tight financial positions make it difficult for them to shift focus from short-term day-to-day pressures to delivering transformation of services.

Amyas Morse, head of the National Audit Office, said: “The NHS has received extra funding, but this has mostly been used to cope with current pressures and has not provided the stable platform intended from which to transform services”

“Repeated short-term funding-boosts could turn into the new normal, when the public purse may be better served by a long-term funding settlement that provides a stable platform for sustained improvements.”

Chief executive of the King’s Fund, Chris Ham, said: “Across the country, there are encouraging examples of areas that are changing services so that they better meet the needs of local people. But transforming services requires investment, and the speed of progress in Greater Manchester, for example, has only been possible because of upfront investment.

“Yet, most of the Sustainability and Transformation Fund is being spent on addressing acute hospital deficits rather than being invested in new service models, which is holding back progress.”

British Medical Association council chairman, Dr Chaand Nagpaul, said: “This report provides clear evidence that investment designed to help the NHS transform and improve patient services is instead being used to firefight and meet existing pressures and deficits.

Financial sustainability of the NHS -The financial performance of NHS bodies worsened considerably in 2015-16, according to the National Audit Office.

New Statesman 18th Jan 2018: Patient care is key to a thriving health system

More nurses are leaving than joining and both the Times and the Guardian report that: we are ‘Haemorrhaging nurses’: one in 10 quit NHS England each year – Data showing 33,000 nurses left in 2016-17 triggers warning of ‘dangerous and downward spiral’

Two letters in The Times 17th Jan 2018 on remedies:

Sir, Rachel Sylvester argues for funding responsibility for social care to be given to the newly named Department of Health and Social Care (Comment, Jan 15). She is right. The barrier between the budgets for health and social care is unhelpful and the Barker Commission into the future of health and care recommended a single, ring-fenced budget covering both. We also agree that we need to increase the amount we spend on health and social care. The Barker Commission made the case for spending to rise as a proportion of GDP to bring us into line with countries such as France and Germany. This increase would be significant, but is affordable if we are prepared to make hard choices. We could means-test universal benefits such as winter fuel allowances and change national insurance so that better-off older people contribute more. Polling suggests that a clear majority of people are prepared to accept tax rises to fund the NHS. A cross-party consensus is now needed to make this happen.
Chris Ham

CEO, The King’s Fund

Sir, Rachel Sylvester is right about the need to increase NHS funding. This could be done without raising any new taxes by amending the NHS charging system. At present the government pays for everyone’s treatment. In France the elderly, unemployed, poor and children receive 100 per cent free treatment. Others have a proportion of their costs — usually 70 per cent — paid by the state. If they wish they can take out private insurance for the rest. My monthly insurance cost of €100 is less than my car insurance. In effect, this is an additional health tax on those who can afford to pay without all the complications of raising and hypothecating it.

France spends a higher proportion of GDP on its health service, with the top-up coming through health insurance. A recent analysis by the Nuffield Trust, published in the BMJ, estimated that if Britain were to spend the same as France the NHS would have another £24 billion a year — substantially more than the Brexit bus’s promised £350 million a week.
Paul Barnes

L’Horte, Languedoc-Roussillon

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

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

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

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

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

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

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

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

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

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

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

extract:

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

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

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

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

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

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

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

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

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

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

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

Axact denies all wrongdoing.

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

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

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

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

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

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

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

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

Declining training standards prompt rescue action

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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How to give the NHS extra billions it needs –

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hypothecated taxation and the NHS – CentreForum (2014)

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

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

LibDems suggest hypothecated taxation – without examining the ideology

Hypothecated taxation? A separate NHS tax would rein in spending

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

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

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

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

Pithed Politicians?

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

When I was a new GP in 1979, patients called for “home visits” as if they were a “right”, and doctors rarely triaged their request calls. There were no “targets” to meet until I believe 1998 when smear and vaccination targets were begun. The day was structured by two surgeries (sometimes three in occasional practices) with visits in between the surgeries. The evening surgery ended around 18.00 officially, and if the doctor was on his own he would have visits after evening surgery, and then be on call until the following day. We knew most of our patients. 

One day a particularly nervous lady was on the visit list for headaches and I put her last out of 8 visits. I can still remember the house address, and the time of day (4.30 and before my lunch) when I arrived at the gate of the terraced house. I was met by an irate husband as I went through the gate. “You’re too late Doctor!”. Oh dear, I thought, with mental images of the GMC, and the MDU phone calls that I might have to make if the patient had died of, say, a sub arachnoid haemorrhage. “What’s happened?” I asked. “She’s better now came the reply”. I don’t remember whether I entered the house or not…

The perverse incentive to overuse a service when it is entirely free, and when patients regard the service as a right, has led to just a few families like this one all over the country. West Wales had one in Pembroke Dock, and during our co-operative out-of-hours days (The best teamwork of my GP career) we were warned about the family and dealt with them accordingly. Calls reduced. The cost of these families is enormous, and New Zealand type co-payments, are the way forward. However, Nationally, most GP consultations are appropriate, and it is only 25% in total that might be managed by others. Since we cannot charge, perhaps insisting on an unpleasant examination would work on the few..

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Fariha Karim on Jan 4th 2018 reports in the Times: Household made 3,600 ambulance calls in one year

Paramedics were called more than 10,000 times in a year to only ten households, despite few calls resulting in a hospital visit, figures suggest.

Frequent callers cost the NHS about £18.8 million a year, and the London Ambulance Service £4.4 million a year.

One household in Barnet, north London, called paramedics 3,594 times in 2016 to 2017, equivalent to more than ten times a day. An ambulance was sent 715 times, and a patient was taken to hospital 37 times, according to The Sun, which obtained the figures under a freedom of information request.

The NHS spends about £8 on average to answer a 999 call. Dispatching an ambulance to an address costs about £155, and taking a patient to hospital costs more than £250. This means that the calls from Barnet could have cost the NHS about £150,000.

Experts say that frequent callers often have numerous issues and phone “as a last resort”, or are isolated or have needs that are not being met elsewhere.

A spokeswoman for the London Ambulance Service said that around 1,600 callers dialled an ambulance nearly 50,000 times in total. “Although relatively small in number, these patients make it harder for us to reach others with more serious or potentially life-threatening conditions,” she said. “We recognise they will often have complex health and social circumstances which require us to work closely with other health and social care organisations.”

Understanding pressures in general practice – The King’s Fund

General Practice Workload Survey (NHSdigital, last done on 2006-7_

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Image result for total UK GP workload

Image result for total UK GP workload