Category Archives: Perverse Incentives

The pressures on doctors, in and around an election… The social contract has been broken. This is why there is so much anger, and more to come.

Doctors should be able to say how they feel. In my own practice there was some comment when I put a poster showing my voting choice on my office door. There was no implication that the whole practice should support my choice, but several of the partners were uncomfortable. … Doctors are under great strains: overworked, gagged, humiliated (The suggestion that many GPs are corrupt) and there is more and more evidence of early burnout.

Purdah rules shouldn’t stop NHS doctors speaking out  (BMJ 2019;367:l6679  )

Charles Lamb (Psudonym)  for the BMJ talks about the “4 major errors in medicine” and asks: Please do not feed the lawyers

Tim Locke, Dr Rob Hicks | October 1, 2019 for Medscape opine: Sexual Harassment of Uk Doctors: report 2019

Thank goodness some do speak out, and even on video.

Patients are waiting twice as long for an ambulance if their GP asks for it at their surgery. Perverse outcomes are everywhere, and arise because of perverse incentives. ( Alex Matthews-King in the Independent 4th January 2019)

Emergency Beds are now used all the year round. Trolley waits are routine. But why is it that a child having his treatment on a perfectly safe mattress, gains more sympathy and publicity than multiple grannies on trolleys? At least treatment was being given.. In some emergency situations we could have two children to a bed. Better than refusing them..

We have rationing by delaying decisions – gaming, arbitrary rules, and bureaucracy  (Obfuscation of the truth) – as described by David Oliver ( BMJ 2019;367:l6620 ) 

No wonder the doctor patient relationship is being threatened. Without continuity of care and an ongoing trust relationship, we are going to get more burned out doctors. If it helps here is a good description from Jonathan Glass in “How not to be the heartsink doctor” ( BMJ 30th November 2019)

The social contract has been broken. Social care crisis wastes £½m of NHS money a day and is not free but means tested. (The Times 4th December) This was followed by Social care crisis wastes nearly £30000 of NHS money an hour by This is why there is so much anger..

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?

NHSreality is a “heretic”. The NHS has become the greatest cult of our time. As a “holy relic” it is granted immunity from meaningful change.. If social care is means tested, why not medical care?


The Election Horror Show, and denial… The political spin doctors are leading us into a health-less “black hole”. The Health services are too toxic for honesty…

The main reason for the problems with beds is that 80% would not be occupied at all if there were alternatives … Such as home or community Care.
The main reason there are too few staff, both diagnostic and caring, is that it takes decades to train them, and concern to retain sufficient. There have been 3 parties in power over the last two decades. Austerity has not helped, but the problems were incubated well before 2008.
There is no NHS where patients are concerned, but there is for staff, who often aspire to work and educate their children in better areas. The 4 dispensations are controlled by Westminster with regard to finding, but Scotland has more than Wales due to their different methods of funding. They all choose to spend their money differently with different outcomes. This experiment ,without honesty or the possibility of sustaining the 4 services, and done without the consent of the professions, is going to reveal serious differences in the next few years. (See WHO and IFS reports)
We need to ask why no other country has chosen to imitate us. We need to abandon the experiment of devolution in health. The media needs to stop using the abbreviation NHS.
Outside of health we need to review the rules of referenda, to change to PR, to have a constitution, to control false news, and to institute a fairer tax system, particularly addressing capital ( Land Rental Tax. ).

California and Ireland have addressed referenda well.

We need to bring back choice as a virtue and this election is making most of the professionals sick.

The political spin doctors are leading us into a health-less “black hole” because they can get away with it and the perverse incentives to fail to address the issues are too strong. The Health services are too toxic for honesty.

The Economist talks about the “nightmare” before Christmas and Endorses the Liberals despite their mistakes:

Economist endorses the Liberals Dec 5th 2019…

….Next week voters face their starkest choice yet, between Boris Johnson, whose Tories promise a hard Brexit, and Jeremy Corbyn, whose Labour Party plans to “rewrite the rules of the economy” along radical socialist lines. Mr Johnson runs the most unpopular new government on record; Mr Corbyn is the most unpopular leader of the opposition. On Friday the 13th, unlucky Britons will wake to find one of these horrors in charge.

December 9th in the Times Chris Hopson reports: We asked politicians to be straight on the NHS. They’ve not listened

The leading article on the same day: Election Promises – Times leader 9th December  accuses the politicians and by implication the media themselves, of denying voters the truth.

Shaun Lintern for the Independent reports 3rd December: Leaked NHS document reveals government plan to use cheaper staff to fill nurse vacancies

We even have the possibility of “foreign influence” demoralising the population with false truths.

Shanti Das and Andrew Gregory reveal the incompetence of the short term politicians: Amazon ready to cash in on free access to NHS data (The Sunday Times 8th December)


A toxic amalgam of 4 “health and social care” services

It seems that all the 4 health services are too toxic for any party to make a meaningful statement of how they, or social care, should be changed. The BMJ in a comparison of bribes describes the differences between the parties on Health and Social Care. Not one of them is suggesting that even with money, plant, people and cultural improvement, the system itself needs to change. It is not founded on a financial rock, and the result is a perverse incentive to deny or ration care covertly if possible, but overtly if the management cannot get away with it.

The ingredients for toxicity have been building up for years. Management, consultants, bullying, and culture etc.

Avoiding the issues Nowhere to go – The BMJ

2013 BBC News: Bullying ‘creates toxic NHS culture’ – BBC News

2013 The Independent: Watchdog warns of ‘toxic cocktail’ within the NHS

2013 Health Service Journal: NHS in-fighting is creating a toxic culture | Comment | Health …

2015 National Health Executive: ‘toxic’ bullying culture – National Health Executive

2019 HSJ: Surveillance of managers is ‘toxic’ says Don Berwick | News …

2019 The Guardian: Latest NHS maternity scandal is product of toxic ‘can’t happen …

2019 The NHS crisis of caring for staff | The King’s Fund

Miles Sibley in the BMJ: Changing the culture of learning from deaths

With the revelation that a “toxic culture” led to the deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, patient safety in maternity services is once again in the spotlight…..

Was there ever a better opportunity to promote Proportional Representation?




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

Ever since Mrs May tried to sell what the press deemed a “dementia tax”, all the parties have conspired to duck the hard truths of social care, and its linkage with medical care. the one is means tested, and the other is free. They should both be handled in the same way in order to avoid perverse incentives to classify in order to exclude. so either they are both free ( impossibly expensive ) or they are both means tested. The pragmatic solution…

David Aaronovitch opines in the Times 4th December 2019: ‘NHS for sale’ nonsense ignores a real crisis – Labour and the Tories are happy to keep distracting us from the fact that neither has grasped the nettle of social care

At what point does the repeated appearance of the surreal mean that it becomes the new real? Answer: when Donald Trump hits town.

In London for the Nato summit, the US president was taxed with the non-issue that has dominated election discourse for a week. Was the NHS on the table? Trump decided to interpret the question as though he was being asked whether he would like to buy the whole of the NHS, ship it back to America and re-erect it in the Arizona desert. “Never even thought about it,” he replied. Americans already had “private plans that they absolutely love. We wouldn’t want it even if you handed it to us on a silver platter; we want nothing to do with it.”

But Trump’s absurdity was really only a twist on the absurdity of our own discussion. The Corbyn slogan “Not for Sale!” gives the impression of the potential hiving off of A&E wards to predatory Yankees who will find some way of charging us ten bucks a swab and 20 for a suture.

All we actually have, despite the 450 pages of documents brandished by Labour last week, is the US side of preliminary trade talks in which they say they’d like to discuss drug prices and patents and British civil servants not responding.

The Conservative manifesto shut off any such possibility by slapping down a couple of red lines: “When we are negotiating trade deals,” it said, “the price the NHS pays for drugs will not be on the table. The services the NHS provides will not be on the table.”

Fine. But it means, of course, that something else will be. Back in the summer when this matter came up Theresa May (remember her? Prime minister for a bit. Strong and stable.) stated the bleeding obvious in saying “the point about making trade deals is that, of course, both sides negotiate.” We set red lines, they set red lines. We say no to X, they say, then give us Y. That, and not the NHS being crated up for dispatch to the New World, is the issue.

This, of course, is just one element of Labour’s charge, going back to the days when Andy Burnham claimed the Tories were “privatising” the NHS. Nearly six years ago the shadow health secretary, serving in the catastrophic Ed Miliband team and deprived of the right to promise limitless billions for the NHS, began accusing the Conservatives of having “a privatisation agenda” that would mean the end of universal healthcare, free at the point of use.

If that was so, the Conservatives have manifestly failed. Not only has the basis of the service survived unchanged but, according to the independent health charity The King’s Fund, the share of revenue spent on services delivered by the private sector has stayed more or less static over the past few years. Not, incidentally, that people would be too bothered if it rose. As The King’s Fund puts it, “provided that patients receive care that is timely and free at the point of use, our view is that the provider of a service is less important than the quality and efficiency of the care they deliver.”

Amen. But these days not even Tories dare express such a view, leading to some pitiful denials of past opinions by Conservative spokesmen. Yet this sensible belief, once held by Labour but alas no longer, also turns out to be the conclusion reached by the substantial majority of our 100-voters panel after having the expenditure of the NHS explained to them.

So instead of any sensible discussion about how to improve healthcare in England, all we’ve had in this terrible election is the fraudulent “for sale” row and a bidding war. £20.5 billion in real terms plays £26 billion plays £7 billion per annum. 6,000 more doctors, 50,000 more nurses, 27 million more appointments and on it goes.

The figures are made to stand alone and no one gets to find out what they mean in the context of the real world. We have an ageing population. We need to shift resources into helping the population to age more healthily and to look after those who need care. That takes more money, more carers and new forms of delivery.

But the parties’ bidding war fails to take account even of the impact of their own policies on the requirements of the NHS. The Nuffield Trust think tank published a report this week on how, with NHS job vacancies at over 100,000 and social care worker vacancies at 122,000 and rising, both Conservative and Labour immigration policies to end freedom of movement from the EU are likely to exacerbate chronic staff shortages.

That’s just one. In addition Labour has promised a 5 per cent pay increase for all NHS staff in 2020 and “year on year above inflation increases” after that. This may help ease the recruitment problem a little, of course, but at huge additional cost.

And as if that wasn’t enough Labour has stated its ambition of moving workers, including all of those in the public sector, to a statutory four-day week. When the shadow health secretary, Jonathan Ashworth, attempted to exempt NHS staff from this promise he was effectively repudiated by John McDonnell.

There is a word for having a policy to significantly reduce staff hours at a time of chronic staff shortage. And it isn’t “clever”.

But above all Labour’s concentration of fire on the Conservatives over the false “NHS for Sale” controversy means that it fails to make the true accusation which should really damage the Tories.

For two decades the problem of inadequate social care has grown, and over time become a fug enveloping almost everything we might want to do to make our society that bit better. For almost the whole of the last decade the Conservatives have been in government.

Three years ago the Tories promised a green paper in the summer of 2018. Then in the autumn of 2018. Then April this year. Then as soon as possible.

And here in December 2019, in the manifesto of the great “Just Get It Done” Johnson, is his proposal on arguably the third biggest issue facing the country: “We will build a cross-party consensus to bring forward an answer that solves the problem”. And that is pretty much that.

Now ask yourself these two questions whenever the two prime ministerial candidates declaim on the subject of leadership: first, why have the Tories so cravenly dodged this issue? And then, why has Labour been so happy to let them do it?

Dementia Tax & Theresa May | The King’s Fund‎

What is the “dementia tax”? – Full Fact


England follows Scotland in funding CF drug. Wales and NI cant afford it.

The drug for CF does not cure, but slows down the decline. It cost far more (normally)m than NICE recommends for each year of life gained (QALY) but presumably the “deal” struck means it is much cheaper. Since the price is secret, it is covert, and we cannot judge. What does seem to have occurred is that one Single Interest Pressure Group (SIPG) has succeeded where many others are unsuccessful. All trusts and regions should have policies on how they deal with SIPGs. Such policies will make the need for rationing clearer. We can afford the low volume and expensive items if we ration the high volume and cheaper items. Once again, although reported as a national decision, this is only for |England. Wales and NI cannot afford it, but then politically perhaps they cannot afford to refuse it. The perverse outcome if the situation remains the same, should be that CF patients move to England and Scotland.

October 25th in the Times: NHS agrees deal to fund cystic fibrosis lifeline drug

A life-saving cystic fibrosis drug is to be made available on the NHS after a deal with a private health company.

The drug Orkambi, which improves lung function, reduces breathing difficulties and can be given to children as young as two, should be available to patients on prescription within 30 days.

NHS England reached a deal with Vertex Pharmaceuticals, the drug’s manufacturer, after a row over the cost, which dragged on for more than three years. The company wanted to charge £100,000 per patient per year but a compromise was reached in a confidential deal. It is, according to the BBC, understood to involve significantly less than the sum originally asked for.

Two other drugs made by Vertex — Symkevi and Kalydeco — will also be made available as part of the deal, meaning that about 5,000 NHS patients will have full access to the drugs. Symkevi is restricted to over 12-year-olds, while Kalydeco can be used from 12 months.

Simon Stevens, the NHS chief executive, said that the deal was a “long hoped-for moment”. He added: “The UK has the second highest prevalence of cystic fibrosis of any country in the world, so today is an important and long hoped-for moment for children and adults living with cystic fibrosis.

“That fact also means that any drug company wanting to succeed commercially in this field needs to work constructively with the NHS.”

Matt Hancock, the health secretary, said that the decision was “great value for money for the NHS”.

Gemma Weir, 35, from Portsmouth, has campaigned to get the drug on the NHS for her six-year-old daughter Ivy for the past four years. She told The Times: “I’m completely ecstatic, as I can’t believe the government agreed to it. My daughter’s life expectancy has just doubled and she will no longer have to live with a horrible life expectancy hanging over her head.”

The drug is said to slow decline in lung function — the most common cause of death for people with cystic fibrosis, a life-shortening genetic condition that can cause fatal lung damage. Only about half of those with the condition live to the age of 32.

NHS England said that the deal was made possible by the company agreeing confidential commercial terms that constituted good value for British taxpayers.


Ambulances use unproven scoring system to ration their service…

As a recent sufferer from sepsis, and having had much pain as a result, and from a hand operation (for which I am most grateful) I am interested in this new form of rationing. Since ambulances are “free” and since many calls are for relatively trivial issues, triage has to occur. However, when a GP rings, rather like when a doctor appears in A&E, lights should alert the telephonist that this needs to be taken seriously. A&E, and Emergency, and Urgent Care centres, have sepsis warnings all over their walls…  It made little difference to my care..

The ambulance service regards being in a GP practice as a place of safety, with medical care to hand, although GPs are being systematically deskilled in emergency care. This reduces their “points” score and the perverse action of the GP whose surgery has been “arrested” by this, is to send the patient outside and ask them to ring the ambulance!

Yes, the ambulance service is underfunded, especially if it remains free for all. The Air Ambulance is a charity, and like many others it too has to prioritise its service. Waiting times for ambulance calls are generally getting worse, and it wont be long before private contractors compete. But in West Wales it would be very expensive as the journey to a competent hospital is 1.25 hours at Swansea, or 2 hours to Cardiff.

Hiba Mohamadi reports for Pulse 27th September 2019: GPs requesting ambulance will have to provide a score for level of emergency.

In the BMJ Elizabeth Mahase reports: GPs warn against use of scoring system.  BMJ 2019;367:l5814

…..The system is based on six physiological measures: respiratory rate, temperature, oxygen saturation, systolic blood pressure, pulse rate, and level of consciousness. Despite not being validated for primary care, NHS England has “encouraged” its use. Last year its was made mandatory in ambulance trusts. NHS England said the score should be used “for all pre-hospital patients who are ill or at risk of deteriorating” and to “support colleagues to identify deterioration early and prioritise resources in times of surge.”…..

Dr Rachel Marsden RCGP Clinical Support Fellow for Sepsis, is on the RGP website: The updated National Early Warning Score and its use with suspected Sepsis

Image result for ambulance cartoon

Its easy to say you will fund a treatment, but much harder to say what you won’t fund. How long will the English and Welsh hold out against the media led pressures? Emergency loans for Trusts merely delays the inevitable.

In the National Institute for Health and Care Excellence (NICE) website:

One QALY is equal to 1 year of life in perfect health. QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality-of-life score (on a 0 to 1 scale).

In Wikipedia a QALY year is defined: Quality-adjusted Life Year


Quality-adjusted Life Year
The quality-adjusted life year or quality-adjusted life-year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value for money of medical interventions. One QALY equates to one year in perfect health. If an individual’s health is below this maximum, QALYs are accrued at a rate of less than 1 per year. To be dead is associated with 0 QALYs. QALYs can be used to inform personal decisions, to evaluate programs, and to set priorities for future programs.

In “Carrying NICE over the threshold” ( 19th Feb 2015 ), Professor Karl Claxton suggests that paying more than £13,000 per QALY for technologies “does more harm than good” by displacing other more effective healthcare from the NHS.

In Scotland it appears that they are taking a lead in commissioning treatment that is very expensive, but effective in prolonging life, for Cystic Fibrosis sufferers. This induces perverse behaviour in families of sufferers, and, in addition, fails to point out what services will be weakened, or not funded, since the resources are limited.  . Cystic fibrosis: Father considers Scotland move to access new drug. BBC News 20th September 2019.  In the end it has to be politicians, with public consent, who agree how to ration. We can afford the CF treatment, but only if we ration high volume low cost treatments, or other more expensive treatments, out. Decisions like that in Scotland, without equivalent saving decisions will make the Health Service (s) worse, and the differences between the haves and the have nots worse. The main expense in the health services is spent on its greatest asset: staff. These are no longer feeling valued, and those that can are making hay as locums. This is an even greater burden to their health services than expensive treatments. Add to this the cost of infections (longer stays and expensive treatments) and litigation, and it is evident that England is correct in putting its population before its CF individuals. How long will they hold out against the media I wonder? Sepsis and Litigation are much larger problems. Emergency loans for Trusts merely defers the inevitable…

A father has spoken of his agonising dilemma about whether to leave England and move to Scotland so his daughter can access life-prolonging medication.

Dave Louden’s four-year-old daughter Ayda was diagnosed with cystic fibrosis shortly after she was born.

The family live in Carlisle, 10 miles (16km) from the Scottish border, where a new drug has become available.

However, despite the position in Scotland, NHS England said the drugs were not cost-effective.

Costing £100,000 per person per year, Orkambi and Symkevi improves lung health and life expectancy for sufferers of cystic fibrosis.

Patients in Scotland can access the drugs after the Scottish government agreed a “confidential discount” with the pharmaceutical company Vertex.

Cystic fibrosis affects about 10,400 people in the UK and causes fatal lung damage, with only around half of sufferers living to the age of 40.

Mr Louden said it was “heartbreaking” that his daughter could not get the treatment…..

‘Life-changing’ cystic fibrosis drug deal for Scotland is welcomed BBC 20th September

BBC News 16th September: Review launched into Aberdeen hospital project costs

BBC News 20th September: Hospitals relying on ’emergency’ loans

Huw Pym 19th September: How much does diabetes cost the NHS?

Jonathan Ames 14th September in the Times: Locum ruling will cost NHS millions

NHS long term plan to reduce toll of NHS Long Term Plan to reduce toll of “hidden killer” sepsis

Sarah Neville in the FT 7th September 2017:  Cost of NHS negligence claims quadruples to £1.6bn in decade – Soaring bill affects quality of care and increases financial pressure on trusts