Category Archives: Perverse Incentives

More votes could be lost if the politicians are honest? Ministers must admit that the health service can’t cope

The perverse incentives to deny the truth about the four UK Health Services is greater than the desire to be honest, have a long term view, and engage in the debate which Mr Stevens has asked for. But the pressures are getting bigger, and as more and more unnecessary deaths occur, and waiting lists become longer, and staff remain disengaged from the politics, but more and more angry, the penny may drop. We have to ration health care overtly. Only once this decision has been taken can we debate exactly how..

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Dennis Campbell reports 12th September 2017: Ministers must admit that the health service can’t cope

Is the NHS constitution still worth the paper it’s written on? It’s the nearest thing the health service has to tablets of stone. Its 15 pages enshrine the principles and values that should guide the conduct of the NHS in England. They say “the patient will be at the heart of everything the NHS does” and that, as a tax-funded service, decision-making should be transparent.

Sadly, on both counts, the deeds of a cash-strapped and understaffed service operating in a strange and volatile political environment are increasingly failing to match either the spirit or letter of those fine words.

That is closely linked to the document’s detailed description of key patients’ rights, including the NHS’s duty to treat those who need A&E care, an ambulance, non-urgent hospital treatment or cancer care within specified waiting times.

But the truth is that almost no part of the NHS can now cope with the demands on it. The decision to in effect shelve the referral to treatment (RTT) target – that 92% of patients should be treated in hospital within 18 weeks of referral, usually by their GP – tells us something profoundly worrying. The health service’s leaders such as NHS England boss Simon Stevens, ministers and the health secretary, Jeremy Hunt, know it can’t treat the required volume of patients within the agreed timeframes, but dare not say so in case their honesty triggers a media backlash or Theresa May’s displeasure.

Since the decision to relax the 18-week target in March, the total number of patients on the RTT waiting list has crept to more than 4 million people for the first time in a decade. But what really matters is the lack of honesty here. Neither NHS England nor the Department of Health has yet publicly acknowledged that a key target – unmet for 16 months – has now been downgraded or that patients are suffering pain, anxiety and distress as a result.

The same attempt to deny reality applies to the NHS budget. As NHS Providers, an organisation representing NHS trusts, says, hospitals face “mission impossible” trying to deliver the waiting time targets this year, the seventh of austerity funding. In a briefing last week on RTT, it said: “We should not maintain a fiction around what the NHS can deliver, given current demand increases, workforce shortages and sustained levels of funding increase that are well below historic averages. To do so carries several risks, including misleading the public.”

Faced with a government in denial on health and social care funding, the NHS is increasingly doing less for patients, despite rising demand – but again dare not admit that’s what’s happening. Jeremy Taylor, the chief executive of National Voices, a coalition of more than 100 health and care charities, is worried NHS England is increasingly making decisions that are bad for patients in a desperate attempt to make its sums add up. “We’ve seen a relaxation of the RTT target, a ‘budget impact test’ that could delay new drugs being available [for up to three years] if they cost more than a £20m threshold, an attempt to push the cost of pre-exposure prophylaxid drugs to local authorities, and a number of court cases where the NHS is seeking not to pay for certain treatments.” Taylor is also struck by the NHS’s “lack of meaningful engagement with the people who stand to gain or lose” from these decisions.

The NHS’s refusal to acknowledge that proposals to centralise many types of hospital care would inevitably generate controversy was judged a mistake by the King’s Fund, the British Medical Association and the Local Government Association – which is quite a feat. And NHS England has surrounded its bid to get 13 already cash-strapped areas to make £500m of extra savings this year, through the “capped expenditure process”, with almost total secrecy.

Such concealments, on all these difficult, politically charged issues, betray the service’s duty of transparency. But they also raise again a key question about Simon Stevens that won’t go away: is he the NHS’s voice in government or Whitehall’s man in the NHS?

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It is essential to look into health staff claims and be aware of fraud and exaggeration. It’s our money being spent…

Insurance companies are right to be “doubtful” about many claims in todays world. Since the Health Services insure themselves (doctors are covered by Medical Liability), there is an interest in justifying and confirming claims. It is essential that a jaundiced manager does acquire evidence by video and surveillance. He is protecting our money. It is not outrageous, and it would still be necessary if we had “no fault compensation”. Its just that in the latter instance settlements would be lower and calculated on a formulaic basis. There are perverse incentives to exaggerate especially if there is no due diligence.

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Jon Ungoed-Thoms in the Sunday Times 3rs September reports: NHS spying on negligence ‘victims’ hits record level

The NHS is mounting more than 50 surveillance operations a year on alleged victims of medical negligence or accidents in its hospitals.
NHS Resolution, which deals with clinical negligence claims in hospitals, says it is launching an offensive against exaggerated claims and fraud. The operations include the use of private detectives to follow patients who sue for compensation.
A record high of 55 surveillance operations were authorised in 2016-17, up from 24 in 2013-14.
In one case a 42-year-old patient claimed more than £2.5m in damages after alleged negligent surgery. The woman was put under surveillance and it was noted she could undertake most daily activities. She was awarded £115,000 and the judge found her case had been “in part dishonest and in part grossly exaggerated”.

In about half of the cases — 23 in 2016-17 — evidence of exaggeration was detected. It means in some cases victims of NHS blunders who are not exaggerating their claims are being put under surveillance.

Peter Walsh, chief executive of Action Against Medical Accidents, said: “This is outrageous. This is an invasion of the privacy of patients who have already suffered untold misery through negligent treatment.”
The surveillance is described as “non-obtrusive” — which can include private investigators filming patients or researching social media.
The investigations extend to NHS staff who sue. Lorna Hayden, a former cardiac physiologist at Kent and Sussex Hospital in Tunbridge Wells, was awarded £425,000 in a High Court judgment in December over an injury she sustained moving a 16-stone patient in March 2007.
It emerged during the case that she had been filmed by investigators.
Jacqueline Hardaway, a lawyer at Dawson Hart, said: “The NHS trust seriously injured one of their hard-working employees, through negligence, then subjected her to years of heartache, filming her and calling her a fraud, until, after a nine-year battle, a High Court judge awarded her substantial compensation . . . clearing her of any dishonesty.”
NHS Resolution said it always considered privacy before proceeding. “While it is very rarely used, surveillance helps to protect the public purse from paying unreasonable or unjustified levels of compensation.”

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Stroke survivors ‘are dumped by the NHS’. Dead patients don’t vote, and those near death don’t appear to count…

If you have a stroke on your way to the hereafter, your life expectancy is short, demand for services is high, and nobody listens to you, even if you can be understood.  Dumped is the right political word. Congratulations to the reporter on his understatement however, The real word, especially with regard to intensive physiotherapy, is abandoned. Dead patients don’t vote, and those near death don’t appear to count. Commissioners have a perverse incentive to save money, richer areas can have more physio as more patients go privately, and the post-coded, covert rationing lottery continues..

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Jon Ungoed-Thomas in the Sunday Times reports: Stroke survivors ‘are dumped by the NHS’

Sufferers feel abandoned after leaving hospital and face waiting up to a year for the right treatment — or paying for it themselves

Stroke survivors are being left to languish at home with a “shocking” lack of support. Many say they feel abandoned by the NHS.
Juliet Bouverie, chief executive of the Stroke Association, said a new national plan was required to help the 1.2m stroke survivors in the UK. Some have to wait up to 12 months for psychological help.
“As a stroke survivor, your life and the life of your family is turned upside down,” she said. “Many stroke survivors say they feel abandoned, as if they have dropped off a cliff. The provision in some areas is shocking.”
About 100,000 people suffer a stroke every year in the UK; it is one of the country’s leading causes of death.
Andrew Marr, the broadcaster and journalist, who suffered a stroke in January 2013, said better support for stroke survivors — many of whom are of working age — could help them return more quickly to employment. He was back at work within six months, but largely because he paid for additional physiotherapy.

Stroke survivors can wait up to four months for speech therapy and up to a year for psychological support, according to data from the Royal College of Physicians. Stroke survivors say there is insufficient physiotherapy, a treatment which would ensure the best recovery.

Andrew Marr, who had a stroke in 2013, paid for physiotherapy to help him get back to work sooner<img class=”Media-img” src=”//″ alt=”Andrew Marr, who had a stroke in 2013, paid for physiotherapy to help him get back to work sooner”>
Andrew Marr, who had a stroke in 2013, paid for physiotherapy to help him get back to work soonerDavid Cheskin/PA

A stroke strategy, launched in 2007, outlined a 10-year plan to overhaul stroke services and has seen significant improvement in acute treatment. The Stroke Association is calling for a new action plan to build on improvements and outline a new strategy for the rehabilitation of stroke victims.

Nathan Ridgard, 40, a self-employed businessman and a father-of-two from Harrogate, North Yorkshire, suffered a stroke on New Year’s Eve 2012. After being discharged from hospital, he said he was given some leaflets by the NHS on coping with a stroke, but struggled to read them because of his poor vision.

“I just felt I had been dumped out in the world,” he said. He received some NHS physiotherapy, but also paid for private sessions to supplement them. He has since made a good recovery.

Professor Tony Rudd, National Clinical Director for stroke at NHS England, said: “The quality of care and survival rates for stroke are now at record highs. We are working with the Royal College of Physicians and others local health service leaders to improve rehabilitation care for everyone who suffers a stroke.”

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A fundamental dishonesty is behind almost all the Health Services System news… and our failure to respond appropriately and improve.

There are many signs that the rivets have popped (The NHS: have the rivets popped? ) and those of us in the professions know this. The reasons include poverty, perverse incentives for commissioners and trusts, covert rationing, and lack of choice. These can all be covered by “dishonesty” in the language of health and the way information is given to the public. We all need to know what is not available in our particular health care cohort. A lack of honesty is behind almost all the Health Services System news… It is similar to the lack of open honesty in London after the Grenfell Tower. The Independent 29th June 2017: Grenfell fire: Kensington council cancels meeting after High Court lets journalists attend. It is the same with Trust and Commissioner Boards: all the important decisions are taken in private. Even the National Health Executive is at odds over integration of Health and Social Care… (NHS and council bosses at odds over divisive Better Care Fund targets

If silence is dishonesty, then dishonest politicians and administrators have resulted in dishonest doctors and nurses.

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The small amount of “good news” is in “Learning from Scotland’s NHS” – from the Nuffield Trust (particularly mental health) but does not comment on the financial state of their health service, or choice limitation. May needs to put young people’s mental health at the centre of policy.

This report looks at Scotland’s unique health care system, and explores how other parts of the UK might be able to learn from it. But remember what is lost in Scotland: Analysis: Why is Scotland not doing more to offer stem cell treatment … Herald Scotland30 Jun 2017

and on 6th July: BMJ investigation: NHS ‘postcode rationing’ on the rise

Clinical Commissioning Groups (CCGs) in England are increasingly rationing treatments amid growing financial pressure, an investigation by the BMJ reveals.

Freedom of Information data from 169 CCGs shows a 47% rise in the overall number of individual funding requests (IFRs) submitted to CCGs by doctors over the past 4 years, with substantial variation across the country.

Cataract removal, hip and knee replacements, and mental health care are among the top 10 most commonly requested treatment areas….


Chris Smyth in the Times 5th July 2017:  Patients forced to beg for routine operations

( and Council revolt over NHS chief Simon Stevens’s ‘secretive’ social care reforms – see below)

Patients are having to beg for treatment that was once routine as the NHS rations procedures ranging from hip replacements to cataract removal.

Requests by doctors for exceptional funding have surged by almost 50 per cent in four years as health trusts restrict what they will automatically pay for, an investigation has found.

Patients are left in pain because of long delays even when permission is granted, in the latest sign of the impact of cost-cutting. In Buckinghamshire, every patient referred for hip and knee surgery must have their request scrutinised by a panel. The local health trusts that pay for care have been ordered to make savings in order to help the NHS balance the books after years of hospitals running deficits. An investigation by the BMJ has found that doctors seeking common treatments for their patients are increasingly forced into individual funding requests — pleas for discretionary approval for procedures.

In 2016-17, doctors made 73,900 such requests, up 20 per cent from the year before and 47 per cent from 2013-14, when 50,200 were made, according to data gathered under Freedom of Information laws. About half the requests are granted, often after months of delay.

The requests are most commonly used for fertility treatment or cosmetic procedures but an increasing proportion are now for treatment that was once routine. Three years ago just 49 such requests were for hip and knee surgery. This rose to 899 in 2016-17.

The Times also reported July 5th: Doctors send scans by social media to bypass ‘backward’ NHS systems

Georgie Keate, Fariha Karim report6th May 2017: Bosses knew about groping surgeon for years

and Chris Smyth: Antibiotic factory waste water was as toxic as drugs

Council revolt over NHS chief Simon Stevens’s ‘secretive’ social care reforms

Councils have turned on the NHS over “secretive, opaque and top-down” reforms that they say will fail patients.
Simon Stevens, chief executive of NHS England, has staked his tenure on co-ordinating care more effectively and has said that local authorities are crucial to the process because they oversee public health and social care for the elderly.
However, only a fifth of councils think the plans will succeed amid widespread complaints that they have been shut out of the process by the NHS, according to a survey by the Local Government Association.
Not one councillor who responded said they had been very involved in drawing up plans and nine out of ten said the process had been driven from Whitehall rather than locally. Cultural clashes with a “command and control” NHS that did not trust elected councillors meant that more local authorities believed the process was harming social care than helping it.
Mr Stevens has created 44 “sustainability and transformation partnerships” (STPs) where hospitals and GPs are meant to plan with councils on how to improve care and help close a £22 billion black hole in the NHS budget. However, four out of five councillors said the system was not fit for purpose and criticised the NHS for prioritising cost-cutting and closing hospital units over preventing illness.

Izzi Seccombe of the Local Government Association said: “Many councillors have been disappointed by the unilateral top-down approach of the NHS in some of the STP areas. As our survey results show, the majority of local politicians who responded feel excluded from the planning process. If local politicians and communities are not engaged then we have serious doubt over whether STPs will deliver.”
Half the 152 councils with social care responsibilities responded to the survey and 81 councillors with responsibility for health contributed. “The way in which the STP has been handled (top down, secretive, lack of engagement) has harmed relationships between the council and some NHS colleagues,” one said.

Another said: “It is entirely driven from the top, via budget pressures. The process has been overly secretive and opaque. It has got in the way of closer working between councils and health.”
Councillors criticised STPs as “complex and full of jargon”, saying “the NHS simply does not understand the decision-making of local government”.
Ms Seccombe said that in a centralised NHS, managers often did not want to share information with party political councils accountable to local voters, saying that the process was “trying to mix oil and water”.
Chris Ham, chief executive of the King’s Fund think tank, said: “This survey suggests worrying numbers of council leaders are still frustrated by the process and lacking in confidence in their local plan. A huge effort is now needed to make up lost ground.”
A spokesman for NHS England said: “By creating STPs we have issued a massive open invitation to those parts of local government willing to join forces, while recognising that local politics can sometimes make this harder. The fact that public satisfaction is more than twice as high for the NHS as it is for social care underlines the real pressure on councils. It should serve as a wake-up call to every part of the country about the importance of joint working.”

(NHS and council bosses at odds over divisive Better Care Fund targets)

St Albans Advertiser 7th July: St Albans patients could have to pay for hearing aids and IVF under new NHS cost-cutting proposals

Walesonline 14th May 2017: Shortage of GPs causing waiting times ‘crisis’ for patients in Wales …      

Sarah Marsh in the Guardian 6th July 2017 reports: More patients waiting longer than a week for GP appointments – Annual survey shows that in England 20% must wait at least seven days and many are unable to get an appointment at all

In Chester the Jez Hemming for Daily Post 4th July 2017 reports Health council slams system delaying new GPs coming to work in Wales – Geoff Ryall-Harvey, chief officer of North Wales Community Health Council, says GPs wait up to 12 weeks to get on Welsh NHS Performance List

Dishonesty about open government is not restricted to London:  Labour revolt spreads as councillors barred (The Times May 19th 2017)

Governments can do a great deal of harm in health… Aneurin Bevan’s dream is being replaced by a greater fear…

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Government managed DNA testing is not risk free for individuals.

Do I really trust the government with my genetic information?

The answer is yes when I am over 65, and if the information obtained might help my children or grandchildren. Will I be thinking of the population as a whole? No. Will I be reluctant if I might carry a psychiatric gene? Yes. This might prejudice the employment prospects for my descendants if leaked… and it will leak. The ethics and the perverse incentives and perverse outcomes of a genetic data base need frank and full and open discussion before we go down the route proposed by the Chief Medical Officer. What could be the effect on your Private Medical Insurance premium, or your children’s life insurance premium? Whilst the health service argues about exclusions and co-payments it will fail to discuss these options openly, and it will be the same with a genetic database. NHSreality appreciates that governments are concerned with populations, and not individuals, but they will need to prove this concern in not distorted, and model any system in advance for genetic testing. The possible exclusion of paracetamol is cheap and risk free for each one of us. DNA testing is not… But it is good news that the option is coming..

Michelle Roberts for BBC news reports today: Chief medical officer calls for gene testing revolution

In the Times Chris Smyth reports: Give every cancer patient a DNA test, says health chief Dame Sally Davies


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Every cancer patient must have genetic testing on the NHS to bring an end to “one-size-fits-all” treatment, the chief medical officer has ruled.
Professor Dame Sally Davies demanded that DNA testing become a routine part of treatment within five years to allow for individually tailored care. Two thirds of cancer patients could receive more effective drugs or be spared side-effects by the testing, she predicted, adding that those with rarer diseases could be diagnosed faster.
The NHS must make a centralised DNA testing service to ensure patients have results within weeks and end the “cottage industry” where different hospitals use data differently, she said.
The potential of such medicine has excited doctors since the human genome was sequenced two decades ago. The NHS began a test programme three years ago, with tens of thousands of patients in 11 hospitals given routine DNA testing to determine treatment.
In her annual report, published today, Dame Sally said it was time for this to become the standard across the country, demanding that the NHS make Britain the first country to test the DNA of every patient with certain diseases. “I want it to be considered part of normal care, indeed an expected part of care,” Dame Sally said. She said that data from the test showed that 60 per cent of cancer patients have “actionable genes which either said ‘don’t treat with standard treatment that would be unsafe’ or ‘try that’, so we know that for two thirds it can impact on personalising treatment. That is going to go up.”

About three million people in Britain have one of 7,000 rare diseases and at present it takes an average of five doctors, four years and three misdiagnoses before they find out what is wrong. Genetic testing can give an immediate answer and Dame Sally said this should be routine within a couple of years.

Routine testing would also start quickly in patients with some types of cancer before being expanded, she said. “My dream is that in the end every patient has their genome done if they’ve got cancer,” Dame Sally said.

Jeremy Hunt, the health secretary, has backed Dame Sally’s vision.

Tests have already established the principle that cancer can be treated according to its genetic signature rather than where in the body a tumour is.

Professor Sir John Savill, chief executive of the Medical Research Council, said the plans were “a landmark report of great national importance”.

The names for tumours — breast cancer, skin cancer and the like could soon be seen as relics of the pre-genomic era. It is increasingly apparent the genetic make-up of the patient and their tumour are often more important than where it is found.

Personalised genetic treatment has been hyped for two decades but we may be on the cusp of making it a reality. One key reason is that the cost of sequencing has fallen from billions in the 1990s to £700 today. The main barrier may be attitudes. Will people be happy with a database of their genetics? Insurance companies will not be allowed to see it but researchers may.

Professor Dame Sally Davies is blunt: if you don’t allow genetic data to be gathered, your treatment will be worse as doctors will not understand the best way to treat you. After the debacle of the attempt to centralise GP records to boost research, she is banking on self-interest being more effective than altruism.


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What happens when targets (and standards) change (decline)?

The Nuffield Trust has published a paper after John Appleby did so in the BMJ. If targets decline so do standards, and inequality increases as more citizens are tempted to pay privately. Did NHSreality ever say that we would eventually get a two tier (overall) service?

What happens when targets for waiting times change?

BMJ 2017; 357 doi: (Published 01 June 2017) Cite this as: BMJ 2017;357:j2584

In Soviet era Russia Pyotr Petrov, manager of the state run ball bearing factory on the outskirts of Magnitogorsk studied the new production target. The target came from the chief department for ball bearing production, part of the Ministry of Automobile and Tractor Industries. From now on the Magnitogorsk factory was to produce 200 tons of ball bearings a month. “200 tons! That’s a huge increase in the number of ball bearings,” Petrov thought, “… or is it?” At the end of the month the factory had managed to meet its target: one, 3.7 m diameter, 200 ton, ball bearing.

Poorly designed or badly policed targets can create perverse incentives (a giant ball bearing), but they can also provide the right motivation to improve performance. So what has been the real life experience of the NHS and its use of targets, particularly to improve waiting times?

Two targets become somewhat iconic: one arising from the Labour Party’s 2007 manifesto pledge that “by the end of 2008, no NHS patient will have to wait longer than a maximum of 18 weeks from the time they are referred for a hospital operation by their GP until the time they have that operation” and the other, a maximum wait in accident and emergency departments for patients of four hours (before being admitted, discharged, or treated).

The referral to treatment target covered two separate standards—that a minimum of 90% of patients admitted to hospital should wait less than 18 weeks from referral by their GP, and that 95% of those seen in outpatients (“non-admitted”) should have waited no longer than 18 weeks. In April 2012, a third overarching target was added covering patients still waiting for treatment—that 92% of what were called “incomplete pathway” patients should not wait longer than 18 weeks.

But in October 2015 a review of what had now become quite a complicated set of targets recommended dropping the two earlier standards1 as the new target essentially did the job—covering patients’ total waiting experience from referral to treatment and included all patients waiting, not just those seen in outpatients or admitted as inpatients. It also avoided the perverse incentive that once a patient still waiting had tripped over the 18 week limit, as soon as they were seen in outpatients or admitted into hospital, a trust would then automatically fail on the old targets as well.

As figures 1 and 2 show, by the time these targets were dropped, the percentage of patients who waited more than 18 weeks before being admitted or seen in outpatients had been on a rising trend since 2012, leading to breaches of the targets in 2014 and 2015. Since then, perhaps unsurprisingly as the targets have been dropped, the percentages of patients who waited more than 18 weeks for admission or being seen in outpatients have continued to rise—and now stand at 22.6% and 9.7% and respectively.

Fig 1 Percentage of admitted patients who waited more than 18 weeks from referral by their GP (English NHS).5 Estimated performance from October 2015 is author’s calculation based on historical relation between adjusted (not published since October 2015) and unadjusted statistics (which continue to be published). Adjusted figures allow for various waiting time clock stops and starts due, for example, to patients refusing offered admission dates


Fig 1 Percentage of admitted patients who waited more than 18 weeks from referral by their GP (English NHS).5 Estimated performance from October 2015 is author’s calculation based on historical relation between adjusted (not published since October 2015) and unadjusted statistics (which continue to be published). Adjusted figures allow for various waiting time clock stops and starts due, for example, to patients refusing offered admission dates

Fig 2 Percentage of patients seen in outpatients who waited more than 18 weeks from referral by their GP (English NHS)