Category Archives: Perverse Incentives

The rising trend in fraud in the UK health services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When will the debate on rationing take place ?

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

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

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

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

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

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

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

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

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

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

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

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

Anticoagulants to prevent clotting diseases.

Orkambi rationed for Cystic Fibrosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Brexit catastrophe is only just beginning

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

The Times letters 22nd June 2018: 

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

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

President, Association for Palliative Medicine of Great Britain & Ireland

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

Hendon Chambers, London NW4

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

Cowes, Isle of Wight

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

St Helens, Merseyside

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

National guardian for the NHS

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

 

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”

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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