Category Archives: Perverse Incentives

Cancer sufferer urges patients to stop suing NHS – No fault compensation is the answer.

NHSreality has long supported No-Fault compensation. The concept of all of us owing £1000 each in medical negligence and litigation costs is daunting. Add to this the fact that 0ver 50% of the costs go to the lawyers and the logic of no-fault compensation is evident. The trouble is the timescale for savings: this is not within one term of office. Perverse Incentives conspire to ensure that all the parties reject the prospect, as it will not save money over even 10 years: but it will in the end. Ask the citizens of NZ or Sweden. Post code differences in wealth mean that litigation is more common in richer areas, but this is reduced by “no-fault: no fee” lawyers deals.

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James Gillespie in the Sunday Times 16th April 2017 reports: Cancer sufferer urges patients to stop suing NHS

A woman dying of cancer has started a campaign to curb the compensation culture in the NHS despite suffering two cases of medical negligence herself.

Susanne Cameron-Blackie, 68, from Norfolk, has been given three months to live after being diagnosed with leiomyosarcoma, a soft tissue cancer, six years ago. It has spread through her body, leaving her virtually paralysed.

She is determined to spend her final weeks battling to cut the spiralling costs of litigation against the NHS. Last year, settlements and costs took £1.5bn out of the NHS budget.

NHS Resolution (formerly known as the NHS Litigation Authority) estimates that £56bn could be needed to deal with all cases arising from failures and mistakes made up to March 2016.

“That is the equivalent of half the annual budget of the NHS,” said Cameron-Blackie. She suffered in her early twenties when her womb was removed without permission as she was undergoing a dilation and curettage procedure. During recent treatment she was given another patient’s medication, leaving her in agony.

“But I didn’t sue,” Cameron-Blackie said. “The money from the original operation would have made no difference, I just got on with my life. The second time, I would not have got anything — the money would have gone to my husband in a few years’ time. What good would that do?

“Even the valid claims where somebody gets £6m and it’s entirely justified, that money goes into the court of protection and all their needs are met by the NHS.

“It is whether there is a fault that matters. If you can’t prove a fault, then you can have a patient with exactly the same damage, exactly the same needs and they are met in exactly the same way, but there is no payout.”

Cameron-Blackie, who formerly worked for the lord chancellor’s office, has returned home after her latest hospital treatment. The NHS has installed a bed and oxygen in her home on the Norfolk Broads.

“When the chips are down and you are left like this, the NHS provides everything and more that you need without a penny piece going anywhere near lawyers,” she said.

Cameron-Blackie is likely to find widespread support for her campaign.

Rob Hendry, medical director at the Medical Protection Society, which represents healthcare professionals, said: “A package of legal reforms is required to control the spiralling cost of clinical negligence, including a fixed cap on the legal fees that can be charged.”

A spokesman for NHS Resolution said it aimed to settle claims fairly and quickly. “We also have a responsibility to defend unjustified claims robustly. We received 10,965 new clinical negligence claims in 2015-16 [and] resolved 4,935 (46%) of clinical negligence claims without the payment of damages.”

NHSreality has long supported No Fault compensation.

Harmonising Compensation in NZ

NO-FAULT MEDICAL LIABILITY COMPENSATION SYSTEM in NZ and Sweden

A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.

A general practitioner is trying to follow the dentists into private practice. NHSreality has warned that this was likely, and that when patients demand a choice from their ambulance – (private or public A&E?) that will herald the end of Aneurin Bevan’s dream. The perverse incentives in private care need to be exposed.. but even if we get an honest debate I think rationing by price and access may be acceptable in Bournemouth, but not away from the retired rich, and the tooth fairies… It will be interesting to see if Dorset tries to stop/discipline this Dr… watch this space. If it is allowed it will spread…

Laura Bennett reported in the Sun 14th Feb 2017: WANT TO SEE A DOC? THAT’LL BE £145 – GP warns general practice ‘on brink of collapse’ as he launches private service in NHS surgery – Patients can cough up to see a doc or pay £40 for a phone chat – Dr Tim Alder ( Poole Road Medical Practice – Bournemouth ) has launched a new private service at his NHS surgery so patients can pay to skip the four-week wait for an appointment

AN NHS GP surgery has told patients they can skip waiting lists to see their doctor – if they cough up £145.

The surgery has launched a private service – operated by exactly the same NHS doctors – to run alongside its NHS services.

But patients have to fork out £40 for a 10-minute phone consultation, £80 for a 20 minute face-to-face appointment and £145 for a 40-minute consultation.

Dr Tim Alder warned general practice was on “the brink of collapse” and “heading for privatisation” as he decided to launch the controversial Dorset Private GP Service at Poole Road Medical Centre in Bournemouth, Dorset.
NHS patients at the surgery have to wait four weeks for a seven-minute appointment with one of the practice’s four doctors if they are not eligible for its same-day walk-in service.
But critics have slated the move as a “kick in the teeth” for the NHS and patients, claiming it creates a two-tier health system and goes against the principle of reducing inequalities in healthcare.

Dr Alder said increasing demand, a recruitment crisis and lack of funding as well as private provider Virgin Care taking over practices across the country meant the new service was the only way to safeguard the surgery’s future.

He said: “The Government is not trying to save general practice and now it is on the brink of collapse. But when it’s gone, they’ll realise how good we have been at blocking access to the hospitals. By then, it will be too late.
“We have to try something different now to make ourselves stronger in anticipation NHS primary care will be even worse.
“The worry is that Virgin Care, who are already buying up practices, are going to come in and would then just take us over.
“I suppose we’d rather be in charge of our own destiny.”

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

The risks of private care… overstated?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

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The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Dental care for children is still free in the UK Health Services. Despite this, many parents don’t know this and assume that because they can only get private care locally, that their children are under the same “rules of the game”. I am told that the most common operation on UK children is now dental extraction or clearance. It used to be grommets, or tonsillectomy… These are still common in the privately driven health services such as the US. But in UK medicine all children for non dental operations are seen and assessed by someone else prior to surgery. Dentistry is different. The same person assesses as operates – and this is a matter of legalised perverse incentives. Having a Dental Hygienist make the diagnoses, and the dental surgeon operate would remove this perverse incentive, probably reduce the need for surgery, and save money by rationing sensibly. The way to control the dental profession is the same as the medical profession – overcapacity.

Tonsillectomy and grommets are now part of the “proven unnecessary” operations in 90% of the cases performed when they topped the list in the UK. Good dental care prevents heart valve disease and many other problems. It is a disgrace that there is no education campaign to help parents be aware of their free dental service.

Ross Lydall in the Evening Standard 6th March 2017 reports: Parents ‘must make sure their children visit a dentist by the age of one’

Nine of the 10 boroughs with the UK’s worst rates for dental care are in the capital — with two-thirds of children aged up to 17 in Kensington and Chelsea, Hackney and Tower Hamlets not having seen a dentist last year.

Professor Nigel Hunt, dean of the Royal College of Surgeons’ faculty of dental surgery, said: “The number of children in London who did not see a dentist in 2016 is unacceptable…..

A toddler in Texas dies after unnecessary dental work. Reported in the Mail 29th March 2016.

Tonsillectomy the most common operation for kids in the USA.

THE most common operation being performed on children today is the insertion of tubes into the ears to combat the effects of middle-ear infections. 1986 New York Times

Public Health England survey: New PHE survey finds 12% of 3 year olds (In England – it will be worse in Wales) have tooth decay 30th September 2014

Who is entitled to free dental care in England? Health England

How could your teeth look after 10 years of sweetened soft drinks – The Mail

Why were doctors treated differently to dentists? Perverse…

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

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…

Dentistry now outside the Health Services for most of the nation

Five million children failed to see a dentist in past year..

 

 

 

 

 

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

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You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

The “burning deck”…. A great opportunity for no-fault compensation. Paying for Grandpa – how to pay for it all

The Mirror and all the other newspapers, BBC and all TV/Radio reported this week the words of our Hospital Inspector (England): NHS ‘on a burning platform’ with patients at risk warns England’s top hospital inspector – Professor Sir Mike Richards warned thanks to rising demand and “economic pressures” safety remains a “real concern“. Damien Gayle in the Guardian reports: NHS ‘standing on burning platform’ of outdated acute care model – Campaigners say inspectors’ report highlights impact of cuts to urgent and emergency services with demand putting patients at risk

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Following the NHS comparison report 2015 – (The Economist Intelligence Unit) in 2015

and on Jan 13 2017: England’s National Health Service: No more money for the NHS

The Economist (apologies for reproducing the whole article) prints: Paying-for-grandpa (How to pay for it all in the on line edition ) which compares the virtues of three options, more money, new models of care (Sustainability Transformation Plans), and a German style social insurance scheme. The latter is the only real option, and the author advocates either hypothecated taxation from wages, or a tax on hereditary wealth. The problems are partly around self employed (and there are many more of them than there were), who will largely avoid the former, and the really wealthy who will evade the latter.

A hybrid might be possible, but unless and until we deal with a tax on real wealth (not waiting until death), like the French, we will not have a system which feels equitable to the majority. The problem with taxing wealth is that any announcement will mean it leaves and goes overseas.. So it needs a world solution to wealth tax, and that is a long way off.

NHSreality firmly believes there should be a national debate, but it looks as if this may be omitted, and an announcement will be made. One wonders if it will be honest enough to address rationing overtly.

But in the post truth world appearances matter more than debate about ideology. The Telegraph (Laura Donelly) reports 28th Feb 2017: Every hospital ordered to change its logo by NHS “identity managers” in move which prompts ridicule.

The issue of Medical Negligence claims arose this week, and with the intention of a quick fix and raising £250m the government announced a change to the discount rate ( Ogden actuarial tables) at which compensation is calculated – to a negative or minus 0.75%. (The Scotsman –Car insurance costs set to soar after ‘crazy’ compensation rule change) (The Guardian –NHS faces £1bn annual bill after ‘reckless’ change to injury payouts) They quickly seemed to change their minds when the longer implications on personal injuries to victims of the health services were factored in over time.  (Insurance CEOs to meet UK finance minister over discount rate cut – trade body)

The fact that younger drivers would be uninsurable and perversely tempted to drive without insurance added to their change of heart.. But No Fault Compensation would be so much better. When a doctor makes a mistake at present he is thinking of his insurance, the time taken in the complaint process, and his mental health. He should be thinking of the patient and their family, and apologising as soon as possible. This is a great opportunity to re-visit no-fault compensation, at the same time as we change the whole basis of health funding.

March 3rd edition of Economist: (How to pay for it all on the on line edition )

Rob Merrick in The Independent 28th Feb 2017 reports: GPs urgently examine 173 cases of patients who may have been harmed after massive NHS data loss – But Health Secretary Jeremy Hunt denies Labour claims of a ‘cover-up’ and insists no evidence has yet been found of patients being put at risk

Adam Brimelow reported in 2013 for BBC News reports: NHS spends £700 on negligence cover for every birth – one wonders what the figure is now some 4 years later? NHS negligence claims bill tops £1bn (BBC 17th Jan 2015). It is possibly £2 bn!

In the National Interest we need to establish financial control…

The rising costs of failure: Worst hospitals cost NHS £300m

Former Natural History Museum boss wins £500,000 payout after ambulance was 17 minutes late

Patient complaints hit a ‘wall of silence’ from NHS – No fault compensation would help change the culture…

BBC – 10 charts that show what’s gone wrong with social care –

Nick Triggle for the BBC 2nd March: NHS standing on burning platform, inspectors warn

Hypothecated Taxation for the UK Health Services – India Keable-Elliott (report)

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No party is offering a credible alternative….. the future of the 4 UK Health Services may lie in social media

Richard Vize in The Guardian 25th Feb 2017 offers: “The NHS is struggling. Labour must offer a credible health policy” , but as we know from NHSreality’s 4 years, none of the political parties is prepared to talk and answer questions honestly. There are occasional managed releases of “good news”, ( Portsmouth News 19th Feb 2017: Cancer charity welcomes NHS pledge on stem cell treatment ) whenever possible, but these are mere distractions. Management at the top recognises this, and hence is demoralised and allows errors such as letter, note, and data loss. It appears this was manual records, and IT systems could be much safer, as long as such were not managed and designed internally..Breach of security in national diagnostic indexes may follow…  No politician or party is offering a credible alternative to the current rules of the game: Everything for everyone for ever…..Therefore the future of the 4 UK Health Services may lie in the pressure built up by social media.

Image result for dishonest politics cartoon…and the perverse incentives may make patients lie as well. The post-truth medical world is really here in the UK today.

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….The manner of Labour’s defeat in Copeland is instructive. It took the most emotionally charged line possible, on an issue of great local sensitivity, on its signature issue of the National Health Service, and lost to the government.

Yet the defeat came as evidence mounts that all three of the drivers of current NHS policy – quality and efficiency improvements under the Five Year Forward View, reconfiguration of local health systems under the Sustainability and Transformation Plan (STP) process, and devolution, are in difficulty.

NHS accused of covering up huge data loss that put thousands at risk – Exclusive: More than 500,000 pieces of patient data between GPs and hospitals went undelivered between 2011 and 2016

Pithed politicians collude in unsafe care, ministers told

NHS data-sharing project scrapped – another opportunity missed..

Health service ‘at risk of sudden collapse’ – and the honest debate has yet to occur

Happy 2017: …politicians’ ‘persistent, blinkered denial’ – Say no to a post-truth health service

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Edit babies’ genes to wipe out inherited disease, say scientists

If the politicians are going to fund this then most doctors will be pleased, and eat their hats! This is expensive in the initial commitment, but would save millions decades later.. …. not the sort of investment politicians like, as it wont win votes at the next election. Religious objections should be over-ridden. This is a pragmatic decision. No perverse incentives should ration the option out, and certainly not on a post code basis.

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Oliver Moody reports 15th Feb 2017: Edit babies’ genes to wipe out inherited disease, say scientists

The genetic engineering of babies is the only way to stop some cases of inherited conditions such as cystic fibrosis and Huntington’s disease spreading down the generations, according to a landmark report that raises the prospect of the first human trials of the technology.

Gene editing, in which mutations are cut out of DNA with “molecular scissors”, has been used for two decades as a temporary tool to help patients’ bodies to rid themselves of diseases such as cancer, but not to make lasting changes that parents can pass on to their children.

The genetic surgery, known as germline modification, could give some couples their only hope of having healthy children, but it is fiercely opposed by many critics on the ground that it could alter the course of human evolution or be abused in attempts to create “designer babies”.

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In 2015 a research summit called for an international moratorium on this kind of research. Some scientists pushed for an outright ban on gene-editing human embryos that could never grow into children.

Yesterday, however, the US National Academies of Sciences, Engineering and Medicine concluded that clinical trials could begin once “technical challenges are overcome” and if the benefits of the therapy justified its risks. They said that researchers had to win the support of the general public, that the technique would be appropriate for only a small minority of patients and that trying to improve babies with the technology was a step too far.

The report, which has been endorsed by the Royal Society and the Wellcome Trust in Britain, marks a significant shift in scientific opinion, from distrust to cautious optimism. Sir Venki Ramakrishnan, the society’s president, said: “The hope is that we can develop safe and publicly acceptable ways to not only treat more disease but also offer parents the option of not passing on the risk of inherited diseases to their children and future generations. Our ability to do this is by no means guaranteed but today’s report will hopefully send a strong signal to scientists to continue advancing our knowledge.”

The Church of England has left open the possibility of backing the treatments but the Rev Brendan McCarthy, its national adviser on medical ethics, told The Times it would be “precipitate” to begin trials in the near future. “We do not believe sufficient debate has taken place or sufficient evidence been gathered to begin human trials,” he said.

The Roman Catholic church is implacably opposed. David Albert Jones, a spokesman for the Catholic Bishops’ Conference of England and Wales, said: “It is naive to believe that its use could be restricted to only a few serious conditions. Experience shows that once a bright line has been crossed, technology extends to more and more uses further and further from the original proposal.”

Analysis
Do we dare to change the letters in our own book of life? Until a few years ago this question would have been wild speculation (Oliver Moody writes).

Now, thanks to a series of scientific advances — most notably the discovery of a DNA-cutting enzyme known as CRISPR/Cas9 — it has a tang of urgency.

The US national academies’ report on making changes to the gene pool is 261 pages long and very careful. It maps out a thicket of ethical and practical problems, yet this is the first time human germline editing has been described by a weighty scientific organisation as a plausible and desirable prospect. Mostly, though, the report is significant precisely because of the number of caveats it contains: this is the sound of scientists gearing up for the debate of their lives.

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