Category Archives: Perverse Incentives

NHS Liabilities and negligence costs. Minister fails to answer the question from Mr Hunt. Lack of candour and honesty continues..

The perverse incentive for a current minister to think and act short term, because of the First Past the Post system is evident.

Asked by Lord Hunt of Kings Heath

Asked on: 17 March 2020 in Parliamentary Business Questions

NHS: Negligence:Written question – HL2693

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There are just not enough geese to lay enough golden eggs. The cupboard is bare. We cannot be cloned.

There is a National shortage of GPs across all the 4 health dispensations. When the Department of Health primes reporters such as Chris Smyth, in the Times 7th Feb 2020, I am surprised by his naïve acceptance, seemingly without question. The bribes will not work as there is a 10-15 year shortage…A GP might move for 20K but he will not wish to move to a deprived area, and that is where the doctors are needed. SO what sort of perverse behaviours can we think of? Changing practice repeatedly and, like Monopoly, collecting £20k whenever you become a partner? There could even be a mutually beneficial merry-go-round…. There are just not enough geese to lay enough golden eggs. The cupboard is bare. We cannot be cloned.

Image result for health merrygoround cartoon

We could make it an obligation for all new doctors to work in deprived areas at first. ( Breaking EU convention human rights?) but would that deter some from applying? There were 11 applicants for every place up to recently, so it’s worth a thought.

Just as we could move our MPs to the midlands or S Yorkshire, the change would sort out those with real commitment. How many MPs are in the house because of the opportunity in London? Moving either house will test its members. Committing doctors to deprived areas for say 2 years, would test their altruism.

Bribes belittle the profession. They encourage distorted and perverse behaviours. In the long term deprived areas are best addressed by overcapacity. There is another distortion, and that is the temptation to go abroad, and that is best addressed by cultural change, making the doctors and staff feel valued, and an honest language, And Exit Interviews: what are they? Why not obtain from GPs?

Doctors to be given £20,000 for taking over local surgeries. Chris Smyth in the Times 7th Feb 2020.

Family doctors will be given £20,000 golden hellos for taking over local surgeries as the NHS struggles to deal with a GP crisis.

Care home residents have been promised weekly visits from surgery staff as part of government efforts to boost local care and keep elderly people out of hospital.

Thousands more pharmacists, physiotherapists and dieticians will be recruited as the NHS plans to boost an “army” of support staff to 26,000.

A shortage of GPs is one of the most pressing problems facing the NHS, with numbers falling even as the government has repeatedly promised more. Recently Boris Johnson pledged to boost numbers by 6,000.

Efforts to hire more have been hampered by younger doctors’ reluctance to become full-time owners of surgeries but, in an effort to tie them in for the long term, all new GP partners will be eligible for £20,000 bonuses plus help with training.

Under a deal struck yesterday between NHS England and the British Medical Association, £1.5 billion of a £4.5 billion pot allocated for primary care will be allocated to encourage GPs to stay in the NHS.

Sir Simon Stevens, NHS chief executive, said that the agreement was a “vote of confidence” in the GP system. “This agreement funds a major increase in general practice staff — including GPs, therapists and pharmacists — so that patients can get quicker appointments with a wide range of health professionals at their local surgery,” he said.

“These extra staff will be offering expanded services, including regular health checks for people living in care homes, action to boost vaccination uptake, earlier cancer detection and better support for people with learning disabilities.”

Health checks for new mothers and consistent medication reviews are also promised under contracts that pay GPs for providing them. Doctors will be encouraged to prescribe exercise and arts groups to expand “social prescribing”.

Richard Vautrey, of the BMA’s GP committee, said: “The significant investment in and focus on recruitment and retention, including payments to incentivise doctors to take up partnership roles and work in under-doctored areas, is a vote of confidence in the partnership model and a much-needed first step if we are to reverse the trend of falling GP numbers.

“An expanded healthcare team working in GP practices as well as increasingly closely with community colleagues across groups of practices, will mean patients have access to a wider range of staff, allowing GPs to see those who need them most more quickly.”

Matt Hancock, the health secretary, said: “This new contract is the first step to delivering our manifesto commitment to make it easier to get a GP appointment when you need it by delivering 50 million more appointments a year in general practice.”

2019: To paraphrase Spike Milligan: “I told you the Health Services were all ill”.

2019: A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

2017: The decline of General Practice.. Bribes may be too late…

2017: The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

2016: The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

2015: Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

A new and very different type of NHS in England (BMJ 2011)

May 2011: BBC Panorama Report By Undercover Investigator

2012: Nuffield Trust Report on Rationing

2012 The Health and Social Care Bill 100 Voices on NHS Reforms

2013: Burnout forces almost 10% of GPs to take time off work as pressure on occupational health services grows

2013: Mid Staffs – Who, if Anyone, Will Be Accountable?

2013: The Demographic Time Bomb

The skill of “doing nothing” is valuable, and is what makes the GPs so efficient.

The UK trains many doctors, especially Scotland, and some of them go abroad. We import some 30% of the doctor labour force. Wales trains many GPs. But we then have too few. We export them to England, and places where they aspire to bring up their families. Better infrastructure and education plays a great part in where doctors choose to live. With 80% of medical school places being allocated to female candidates, there is more incentive to stay near their home. Inner city and suburban schools provide most doctors for training. Whatever plan the government comes up with it needs to reverse these trends.. Inducements for doctors to work in poorer areas could be a lot greater….

Meanwhile we are promised a new brand of fast track doctor, who might have been a pharmacist or a paramedic beforehand. Lets hope they cut the mustard, and are asked to pass the same exams. NHSreality predicts that these people will not be able to live with uncertainty. Doing nothing for a short period of time allows diseases to take a natural course… The skill of “doing nothing” is valuable, and is what makes the GPs so efficient. If they cannot do this, and we know consultants find it hard, they will elongate the waiting lists for investigations. This will cause adverse outcomes, and those right enough will go privately. The perverse outcome of well intentioned but ill thought through change.

Read the damning nature of this joint report.. GP shortages …. Our very own post-code lottery.

Welsh NHS has ‘nothing to hide’, says health minister. Listen to Mr Drakeford…

Wriggling on the hook of Dr under capacity. Any solution, ethical or not, will be considered. On the other hand anyone who passes the final exams, however they learned, should be allowed to be a doctor.

Nurses and pharmacists to replace GPs for 1 in 4 visits

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Teetering on the edge? Living with uncertainty… something consultants are never trained for.. General practice is not a retirement home for hospital physicians (Let alone pharmacists and paramedics)


Wriggleing on the hook of Dr under capacity. Any solution, ethical or not, will be considered. On the other hand anyone who passes the final exams, however they learned, should be allowed to be a doctor.

What an admission of 40 years of manpower mismanagement. NHSreality warned that politicians would be “wriggling on the hook of under capacity” in October 2018 when the news was that GPs would see patients in groups. The perverse incentive to risk standards is too strong. So much for personalised care as far as politicians are concerned, but it has not happened. The same outcome is likely for the suggestion that pharmacists could become doctors…. It will require extra training, then 2 “fellowship” years to register, and then 3 years to become a GP, or more for the other specialities. If the pharmacists are allowed to work after F2 years, then we may see come in 6 year’s time! Becoming a surgeon is an unlikely outcome.. and robots are more likely.

Image result for surgeon training cartoon

NHSreality advocates virtual medical school(s) and a unified national exam. As far as I am concerned anyone who passes the exam should be allowed to be a doctor. We need 500% more, so there is no room for rationing places any longer. The main problem once we are training enough will be practical experience… There will eventually be an over capacity, and then some will need to go abroad.

Image result for surgeon training cartoon

Chris Smyth reports 31st Jan 2020: Pharmacists could retrain as doctors to boost NHS

Pharmacists and paramedics will be helped to become doctors through a fast-track conversion course as ministers seek to use Brexit to loosen medical training rules, The Times has learnt.

EU rules requiring doctors to do a five or six-year medical degree could be scrapped as Britain seeks to resolve an NHS workforce crisis by making it easier for experienced staff to retrain.

The move is likely to be controversial, with medical leaders warning against a “quick fix” that lowers standards……

Why has it been left too late to be honest about health provision?

Doctors to see groups of patients – is probably madness. The fox is waiting..

Wriggleing on the hook of rationing health care in different ways, means that we will see many experiments until the numbers of diagnosticians increases. if a GP is needed for a 2 hour group surgery he could have seen 12 new 10 minute appointments in that time, along with the opportunity to examine and personalise the consultation.

Any GP you want: so long as you’re healthy

Sir, No one wants their operation done by a “have-a-go” surgeon. Nor do they want their medicines reviewed by an amateur pharmacist. In their desperation to plug workforce gaps, the spin doctors at No 10 have seized on the idea of putting pharmacists to work as hospital doctors (“Pharmacists could retrain as doctors to boost NHS”, Jan 31). However, since there is no surplus in either profession, the idea amounts to robbing Peter to pay Paul. Existing rules require surgeons to spend six years obtaining a medical degree. Specialist surgical exams follow, with practical training working alongside experienced colleagues, before anyone is let loose transplanting a heart, or removing a cancer. Those of us who develop surgical training programmes are wholly focused on making surgery ever safer for patients. Although we do need more trainees entering surgery, we cannot raid other equally hard-pressed professions to fill posts.
Professor Derek Alderson

President, Royal College of Surgeons England

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

Image result for surgeon training cartoon

Image result for surgeon training cartoon

Perverse incentives and results will mean new antibiotic development is slower than it need be..

The perverse incentives in the Pharma Industry extend to what they spend their money researching. In search of profit lifestyle drugs dominate, as these are long term prescriptions. Short term drug regimes for antibiotics are not high on their priority list.

SO new antibiotics will be led by the Welcome Trust, and the former Medical Research Institute which is now the Crick Institute. The Bill Gates foundation is also altruistic at the expense of profit, as is shown by their focus on population health and new vaccines for the developing world.

This is an opposing perverse incentive to that of the government, who restrict cancer drugs.

Times letters 30th Jan 2020: ANTIBIOTICS CRISIS
Sir, Tim Jinks (Thunderer, Jan 27 and letter, Jan 28) makes very clear the urgency of developing new classes of antibiotics. One factor determining Big Pharma’s attitude in this respect is that a successful antibiotic cures the condition for which it is prescribed, often in a matter of days. Thus the income from its prescription is limited. In contrast, common chronic diseases, such as Alzheimer’s and cancers, involve long-term prescription, and are more profitable. It is probable that only significant amounts of taxpayers’ money will adequately fund antibiotics research.
John Drewe

Former adviser to Ciba-Geigy Pharmaceuticals; London NW2

Two waiting lists for cancer patients needing new drugs. The insured and the uninsured….


Two waiting lists for cancer patients needing new drugs. The insured and the uninsured….

NHSreality has warned readers that there is a perverse incentive to delay the release of newly patented drugs; even for cancer. The pace of technological advance is faster than any government can afford. Hence France has decided to ration out dementia drugs, and to spend the money saved on looking after demented patients. Overt rationing of this type is sorely needed, and extends to other areas of health care. We can afford all the newest proven treatments IF we ration out the high volume low cost treatments, and encourage autonomy. There are now two waiting lists for cancer patients needing new drugs; the insured and the uninsured.

‘Your insurance doesn’t cover acts of God, like age related illness and accidents.’

Governments need to address the needs of populations ahead of those of individuals. They are right to ration, and all dispensations do this, BUT surely it is more ethical to ration overtly, so that people can plan for what is excluded, for them.

Prostate cancer has overtaken breast cancer to become the third deadliest type of the disease in Britain, but is it appropriate that less money goes into this disease as the victims are older? Most men with advancer prostate cancer do not receive chemotherapy: why not? (only one in four men with metastatic disease gets recommended chemotherapy BMJ 2020;368:m120 ) 

The only reason has to be RATIONING.

4th December 2019 in Science Business: Despite rapid innovation, UK patients wait up to 14 years for new cancer drugs.

Dennis Campbell in the Guardian 10th Jan 2019: Record 20,000 patients a month are suffering delays in seeing a consultant or starting therapies

Kaya Burgess reports in the Times 29th Jan 2020: Patients wait 14 years for groundbreaking cancer drugs.

Cancer patients are having to wait years for groundbreaking drugs because the approvals process has not fast-tracked them, a report has found.

Innovative drugs licensed between 2000 and 2016 took an average of 14.3 years to be available to NHS patients after patenting, according to a study by the Institute for Cancer Research (ICR). Conventional cancer drugs took 11.1 years.

The charity said the approvals process was too “risk averse”. Paul Workman, chief executive of the ICR, said the system was not keeping pace with advances in science. “Alarmingly, delays are longest for the most exciting, innovative treatments,” he added.

The government said the system had improved substantially since 2016.

Once a drug is licensed, the National Institute for Health and Care Excellence (Nice) assesses whether it is cost-effective for the NHS.

The ICR found that Nice had shortened the time between approval and the start of appraisal from 21 to 6.5 months but the appraisal process itself had sped up only from 16.7 to 16 months. “There was evidence that Nice had not been prioritising the most innovative treatments,” the ICR said.

Nice said it had worked with NHS England to “accelerate the evaluation and adoption” of cancer drugs since 2016 and had approved 75 per cent of cancer drugs since then, up from 47 per cent in 2012-13.

The Department of Health and Social Care said: “Three years ago we introduced the Cancer Drugs Fund, which is already delivering faster access to the most promising medicines.”

If you had CF would you think health and drugs were rationed, or not?

Call to end NHS rationing of HIV prevention drug PrEP

Drugs giants challenge NHS rationing plans in court. If the government wins the case should be appealed to the European Court before it no longer has the right to judge – after Brexit.

Fast-track plan cuts wait for newest drugs by years… will cost more in an unrationed service

Increasing the “Heath divide”? – Dementia victims to have drugs rationed. The “affordability test” is reasonable and sets a precedent at the high cost end..

Sensible rationing of dementia drugs – a lead from France

The cost of curing just one congenital disease…. The pace of advance of technology is faster than any government can afford

See the source image

Ways of reducing the bill for NHS negligence – The perverse incentives and outcomes …

Every doctor and student of medical systems needs to understand the perverse incentive. I define this as a “driver within a system that works against the overall objective of the system”. Claims for medical Negligence in our tort driven system are necessary to arrest or slow down the continuing decline in standards. Unfortunately Dr Barton is correct: the 4 health services have lawyers who are salaried and paid win or lose, and 80% of claims result in success! The argument for no fault compensation has been addressed properly in NZ and several other countries, and Australia appears to have found a half way house…

Image result for medical litigation cartoon

Times letters 24th Jan 2020: Ways of reducing the bill for NHS negligence

Sir, Your article “£4bn budget for legal fees in NHS negligence claims” (Jan 22) points out that the health service faces legal costs of £4.3 billion as part of a compensation bill for clinical negligence claims of £83 billion. The extent of this crisis cannot be overemphasised, as over the past three years the bill appears to have risen from £54 billion, according to the Department of Health. Apart from the usual platitudes about being careful, no one appears to be interested in addressing this parlous situation.

I previously worked for seven years in Australia, where this became a big problem and was addressed by an act of parliament transferring the liability risk away from the provider, unless it was ruled criminal negligence. This has led to a year-on-year fall of medical protection and indemnity fees for colleagues in Australia, while those in the UK have risen inexorably, providing yet another reason why doctors are giving up in droves and taking early retirement.

The start of a new government offers an ideal moment to address this festering sore on the NHS’s future.
Professor Angus Dalgleish

Foundation professor of oncology, University of London

Sir, As medical litigation costs spiral and threaten the future of the NHS, the case for a no-fault compensation system becomes overwhelming. At present, if a patient cannot prove medical negligence, they will receive no financial compensation — the decision sometimes having more to do with inadequate record-keeping than true clinical incompetence or negligence. As a result, two patients may have identical medical injuries but one will receive nothing whereas the other may be well compensated after perhaps years of litigation.

New Zealand has had a successful no-fault compensation scheme since 1974, with changes in 2005 ironing out some of its early anomalies, resulting in most claims being resolved in weeks rather than years. Litigation lawyers are the only people benefiting from the system in the UK.
Dr Andrew Quayle

Retired GP, Martock, Somerset

Sir, The cost of medical negligence (or accidents) is indeed high, but the possibility that the size of a giant claim might be reduced means that many cases end up in court because the legal fees justify an expensive defence. However, with court and legal costs of about £2,800 per day on top of barristers’ and solicitors’ fees it is often cheaper for an NHS Trust to settle a little case for a small sum than to defend it. While this is often done without an admission of liability it is open to abuse, because once word gets around it may generate frivolous or spurious “me too” claims that result in a payment of a few hundred pounds without many questions being asked. The system needs to address this as well as the top-end settlements.
Dr Andrew Bamji

Rye, E Sussex

Sir, NHS legal costs are inflated partly because of perverse incentives. NHS lawyers are paid win or lose, which encourages “deny, delay, defend” behaviour and promotes speculative defences. By contrast, claimant lawyers are generally paid “no win, no fee”; payment is by result, which imposes commercial prudence. This is amply borne out by NHS Resolution figures which show that compensation is paid in 80 per cent of cases where proceedings are issued. NHS lawyers should be paid by result and not rewarded for failure.
Dr Anthony Barton
Solicitor, Medical Negligence Team

Professional Liability Insurance : Market Global Report Jan 2020 – Fusion Science Academy

New York Telecast: Global Liability Insurance Market Status (2015-2019) and Forecast (2020-2024)

Image result for medical litigation cartoon

Lexicology: Wright Hassall LLP The most notable medical liability case in 2019

United Kingdom August 27 2019

The NHS is facing an existential crisis. The negotiations over junior doctors’ pay and conditions and widespread dissatisfaction among GPs, combined with a £2.45bn overspend by NHS Trusts, is impacting on patient care. The NHS is treating more patients than ever before, including a rapidly growing number of elderly people whose care, in many cases, is caught in a Mexican stand-off between the NHS and social services.

The NHS announced it has paid out more than £1.63 billion in damages for medical negligence in 2017/18; this is an increase from £1.08 billion in 2016/17 with the highest number of claims coming from emergency medicine. The number of claims made as a whole has decreased slightly (0.12%), but the cost to the NHS continues to increase.

The cases outlined below are some of our most notable and an indication of what can go wrong when the caring services come under pressure – and these are just the tip of the iceberg……

Image result for iceberg under water

Update 29th Jan Times letters 2020:

Sir, I would be delighted to accept the challenge from Dr Anthony Barton that NHS lawyers should be paid by results (letter, Jan 24) so long as in return he accepts that claimant lawyers should pay NHS costs when they lose. This should include the more than 80 per cent of cases that never reach court, often because they were frivolous claims which were pursued regardless of commercial prudence. These nevertheless incur NHS legal costs and waste vast amounts of NHS staff time, which often leaves them inadequate time to care for their patients.
Martin Sheppard

Retired NHS consultant
Haverfordwest, Pembrokeshire