Category Archives: Perverse Incentives

Ambulances use unproven scoring system to ration their service…

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My local hospital, manned by locums, is failing – and costing us millions. Now holiday pay should be added!!

The local DGH ( District General Hospital ) in my area is similar to many others around the country. Manned largely by locum doctors the emphasis in the media is always on clinical services. But the old fashioned manager who stayed locally for life, and committed to the hospital, has long gone. In fact managers move on every 2 years, leaving their changes and messes behind to be sorted out and corrected by the next generation of managers. Their short term commitment (in management) is equivalent to that of locum doctors. They never see the long term effects and perverse outcomes of their actions.. and they ever give or receive exit interviews to independent HR ( Human Resources ) staff. The net result is that Trust Boards and government have no idea of the truth. 

At a local stay in hospital I had my history taken 10 times, to paper and never to computer. None of the history takers had bothered to look at the notes and indeed seemed to ignore them. It was in 1996 that as a member of the Local Health Group ( Board predecessor ) I proposed ( and was defeated ) that Pembrokeshire GPs moved to one computer system and had this available in Care on Call and A&E. So no progress in 25 years! Notes still get lost and so much is missing that nobody seems to trust the written record held in 3″ thick cardboard folders.

Many of the doctors are locums. The cost of these is exorbitant, but they get what the “market” has to give. Poor manpower planning ( and rationing of places in med school ) has led to a 15 year shortfall and there is no solution other than recruitment of more potential doctors and nurses. The outcomes of todays policy will feed through only after 2-3 elections!! So which honest politician will take the necessary action in our First Past The Post ( FPTP ) system? To add to the expense, a new legal judgement gives locums holiday rights to add to their pension rights. I wonder if they will get sick leave as well?

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Jonathan Ames in the Times 14th September 2019 reports: Locum ruling will cost NHS millions

The NHS faces a bill for hundreds of millions of pounds after a court ruled that locum GPs were workers and eligible for holiday pay.

The judgment, which sheds new light on how the so-called gig economy extends beyond fast-food delivery riders and other low-paid jobs, could lead to self-employed locums, who earn on average about £140,000 a year, receiving back-dated holiday pay for up to six years — which could amount to tens of thousands of pounds each.

The development comes after a tribunal backed a claim by a locum GP in Gateshead that she was entitled to holiday pay despite arguments that she was self-employed. Reshma Narayan sued Community Based Care Health, a provider of locum GPs to the NHS, claiming that she should not be considered as self-employed.

She was entitled to holiday pay as a worker, she said. An employment tribunal judge agreed and an appeal hearing in London has upheld the decision this month. “This is a leading-edge ruling,” said Jane Callan, an employment law barrister at Trinity Chambers in Newcastle, who acted for Dr Narayan.

Legal experts told The Times that it was difficult to put a firm figure on the amount to which locum GPs could be entitled. However, Carolyn Brown, an employment law specialist at the business consultancy RSM, said: “This ruling could well cost the health service hundreds of millions.”

Conservative estimates suggest that the cost, excluding back payments, could be about £250 million a year. In 2017-18 the NHS spent £9 billion on 7,543 GP service providers.

Figures from the General Medical Council show that there are about 20,000 locum GPs practising in Britain. The National Association of GPs says that one in five patients attending a surgery is seen by a locum. The highest-paid locum GPs can earn £1,000 a day, but agency fees can reduce the figure by about 30 per cent. The number of locums affected by the ruling is unknown.

Lawyers say that some locums are self-employed because they offer their services to surgeries around the country. However, many work in relatively narrow geographical areas and for a consistent group of surgeries. According to employment law specialists, that group will be eligible to benefit.

“This case serves as a further reminder of the challenges of establishing self-employment in long-term integrated working relationships,” Ms Brown said. She added that the ruling “underlines how challenging each working status determination is and how each determination has to be evaluated on its own facts”.

Community Based Care Health declined to comment.

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If health and social care funding is combined, the reality of a “quicksand” foundation will be faster..

Perhaps the public need to feel and see the unreality of the situation regarding social care. With so many of the population ignoring their possible future needs, and health care being free, whilst social care is means tested, there is a perverse incentive for those making the decisions (who also hold the purse strings) to class as much as possible as “social”, and as little as possible as “medical”. The actuary is founded in reality, but even their solution only applies to 33% of us!

No wonder the people “ignore their future costs” when they have been told they can have (in health) Everything for everyone for ever. 

I have had several families as patients who have deliberately given away property in plenty of time to avoid the state getting their hands on their cash, and to ensure it all passes on to the next generation. Since inheritance tax is a double tax I am in favour of abolishing it, but that does not mean lucky people who live into their late 90s should avoid payments. The system needs to be altered, and to face reality.

Despite the warnings, especially from “Community Care” the politicians will not grasp the nettle. Homes are going to close. There are many areas of the country where the privately funded are so few that there is only one payment schedule. In richer areas the wealthy often subsidise the state funded clients….. its one of the questions needing asking when being admitted to a home and in my view, in the interests of openness, needs to be publicised on their internal notices, literature and website.

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

Nick Triggle for BBC News 26th June reports: Care cuts inevitable in ‘fragile and failing’ system

The Actuary 25th June 2019 (They really do know) reports: Social care reforms proposed for third of UK population – Around a third of the UK population could benefit from targeted government incentives that boost saving for social care, the Pension Policy Institute (PPI) has proposed.

The Mirror reports that the social care time bomb is set to explode as millions ignore future costs entirely. 

Luke Haynes in “Community Care” opines 26th |June 2019: Worsening social care funding position wreaking increased human cost, warn directors – Numbers affected by home care provider closures double as fragile care market and NHS cost shifts exacerbate financial woes for councils

Update 26th June 2019: Next PM should lift constraints on public spending to fund social care like the NHS – report finds

( A report equally in the clouds of unreality. If we cannot afford the one for free, we cannot afford both! ) The BMJ opinion from Anita Charlesworth is well intentioned but unrealistic.

Dominic Brady in Public Finance reports: “Social Care heads are unsure that they can provide minimum finance…”

Anita Charlesworth in the BMJ opines: We need a social care system that is as much a source of national pride as the NHS

The care of autistic children is a disgrace. Covert systems lead to perverse outcomes..

The Times analysis of the situation is summed up well by Oliver Wright but he fails to appreciate that if we need to ration health care covertly, there are fewer votes to be lost in dereliction of duty to those who cannot represent themselves.  Treatment of the mentally ill is a toxic mix of political and NHS failure

n the aftermath of the Winterbourne View care home scandal Jeremy Hunt pledged to make improving the care of vulnerable patients a central mission of his time as health secretary.

But despite speeches, policy documents, steering groups and delivery groups two reports next week will lay bare the continued failure of the system to protect those least able to help themselves. One of those reports was commissioned by Mr Hunt’s successor and Tory leadership rival, Matt Hancock. He won’t be thanking him for it.

Part of the problem is political. For example, despite introducing minimum standards for how adults on mental health wards should be treated in 2014, no such standards exist for children. For that, responsibility rests with ministers.

They are also responsible for a system that provides no incentives to minimise the use of expensive in-patient mental health beds. Those beds are paid for by the NHS whereas community care is paid for by stretched local authorities.

The NHS itself should not be absolved of blame. One former Conservative health minister said they had been shocked by just how unresponsive NHS leaders were to reform. It is certainly true that the NHS has jealously guarded its freedom to set spending priorities.

Finally, despite being the authors of one of the reports the Care Quality Commission, which inspects mental health units, bears some responsibility. That it took a minister, under pressure from the media, to uncover the continued failure of these units is shocking.



Oliver Wright and Greg Hurst report in the Times 18th May 2019: Autistic children are routinely restrained and drugged in care

Autistic children as young ten are being detained and subjected to chemical and physical restraint hundreds of times a month, two reports will say next week.

Ministers are braced for fresh revelations about the inappropriate treatment of children with learning disabilities more than six years after Jeremy Hunt, when health secretary, pledged to end the “normalisation of cruelty” in parts of the care system.

One report from the children’s commissioner reveals that in a single month last year 75 children were restrained 820 times, an average of 11 per child.

In another report the Care Quality Commission is expected to reveal children and adults being subjected to long periods of prolonged seclusion and segregation in secure and rehabilitation mental health wards.

The CQC report was commissioned by Mr Hunt’s successor, Matt Hancock, after revelations of abuse in mental health institutions seven years after the Winterbourne View care home scandal in Gloucestershire which resulted in six workers jailed for abuse and neglect.….


Despite “run through” blackmail, a large majority of doctors are opting out and taking a career break.

Despite “run through” training blackmail, a large majority of doctors are opting out and taking a career break. The Foundation Programme was first proposed by England’s Chief Medical Officer, Professor Sir Liam Donaldson in 2002…. Some countries, (India) use financial measures to entice their doctors to work for the state for their first 5 years. Doctors can be posted to unpopular outlying areas, so they try to avoid this, and even borrow to pay their way out. The “Perverse outcomes” of the foundation programme could only have been avoided by overcapacity of doctors and it has been through many administrations that places have been rationed.

Since “run through” training (GMC)  was advanced, and the penalties for “uncoupled training” were made clear at the start of the “Foundation Programme”, the profession have felt bullied, and coerced into a narrow based training, rather than the broad based training of yesteryear.

Knock on effects mean that opening up an abdomen often needs several specialities present. The convention of Human Rights states that a person may elect to take his skills to anywhere that wants and allows him, and in Europe this is part of the free movement of people in the European Convention of Human Rights. SO blackmailing doctors to stay in the UK, for fear that they will not get posts on their return, has backfired. The profession as a whole has voted with it’s feet. There is a world market in doctors, and medics reserve the right to take their trade where they wish. A perverse outcome from the wrong incentive at the wrong time…

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The BMJ Editorial by Jennifer Cleland, John Simpson, and Peter Johnston “Doctors opt out of training after foundation years,” (BMJ 2019;365:l1509 )

The UK’s inflexible training system looks increasingly unsustainable

There has been an explicit assumption in the UK that doctors will seamlessly progress upwards through the postgraduate training pathway. This was perhaps the case in the early years of the UK’s foundation programme (the first two years of generic training following medical school)—in 2010, 83% of foundation year 2 (FY2) doctors progressed directly from foundation to specialty training, including primary care. By 2018, however, that figure had fallen to 38%.1 Nearly two thirds of UK medical graduates now opt out of the training pathway at the first natural opportunity.

Most doctors who opt out return to specialty training within three years.2 This suggests that the break from formal training is the postgraduate equivalent of gap year—a time to recuperate from intense educational experiences, resolve uncertainties about the next steps in life, and make a curriculum vitae more competitive.345 Qualitative research suggests these are common reasons for not entering specialty training after FY2.5

Taking dedicated time to plan a career that may last more than 40 years is sensible. That doing so does not align with our current training system suggests a need for change. This is already happening. Doctors are opting to work overseas for a year or two, or take a “service job” (a post which is not linked to a formal training programme) to gain experience. Academic or clinical fellowship posts are also proliferating.2 These posts are designed to support medical education and other areas of activity, such as quality improvement, usually combined with some clinical service—often supporting rota gaps. These posts work for individuals, and also work for the NHS by keeping early career doctors in the UK.

But they are an isolated solution that could cause ripple effects throughout a complex training system.6 Fellowship posts, for example, are largely funded with money saved from unfilled specialty training posts. The two options compete for funding and are at the mercy of shifting trends. Fellowships will be a sustainable option only if they attract independent funding as, in the current system, an increase in the uptake of specialty posts would decrease the funding available for fellowships.

More fundamental changes to postgraduate training should consider the following: the interactions between individuals and the system at different points in the pathway; how different elements of medical education and training relate to each other and to the wider social and political landscape; and how systemic changes may benefit training and, ultimately, healthcare. Research shows, for example, strong connections between admission decisions by medical schools and the choices made by FY2 doctors about both specialty and place of work.78

The relation between medical school admissions policies and medical workforce planning is not simple or linear.9 Shifting the focus of admissions, however, from a stifling emphasis on high academic achievement10 to a model better aligned with social accountability would be a good first step towards a better match between the two. Such a model would select a mix of students with the personal attributes and motivation to train and work in the NHS, across the full range of localities and specialties. To facilitate this change, selection policies should consider the views of a broader cross section of stakeholders, including representatives from community and hospital medicine, employers, patients and the public, and government.11

Similarly, medical education and training in the UK involves many separate systems, including medical schools, the Foundation Programme, postgraduate training providers such as Health Education England and NHS Education for Scotland, and the royal colleges. All must work together across boundaries to ensure a smooth transition between foundation and specialty training. Consider, for example, the potential value of aligning medical school admissions (such as dropping the high academic requirements) with increases in intake (through government reform) and royal colleges rethinking how training programmes are constructed, assessed, and regulated.

Change may be unpalatable, but the alternative is to continue with the current state of affairs—an inflexible training pipeline that fails to supply enough doctors to meet growing demand and fails to meet the needs of doctors in training. Acknowledging that systemic and structural problems exist is the first step towards developing effective, system-wide solutions.

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Overseas staff are desperately needed. Why can’t we provide them ourselves? The populism and emergence of “fascist” tendencies will make things worse..

Lets start with the answer to the question first. There is rationing of training places in all specialities, in nursing and in paramedical training. We need to aim at providing an overcapacity, especially now that the work-life-years of the average health service staff is declining. All 4 health services are dependent on overseas staff… The same pressures from “populism” are on governments worldwide. We know about the USA and Mexico, which needs the Mexicans badly. In Australia the Human Resources Directorate reports that “Labour plans to tighten skilled worker visa laws”.

The post code lottery of our devolved administrations makes shortages worse in deprived areas. This encourages more populism and fascist tendencies ….

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The fascist tendencies in populism worldwide are worrying. This talk from Israeli Yuval Noah Hurari explains how to understand what is happening...

David Oliver in the BMJ 2nd Jan 2019 opines: Falling immigration could destroy the NHS  BMJ 2019;364:k5308

Workforce gaps currently pose a major threat to the viability of our health services, as noted in a joint 2018 report by the King’s Fund, Nuffield Trust, and Health Foundation.1

One in 11 NHS clinical posts is currently unfilled, rising to one in eight nursing posts.2 The report estimates that, without concerted action, the current shortage of NHS staff employed by trusts in England—already around 100 000—will grow to an estimated 250 000 by 2030.

Some of the proposed solutions have been put forward before, by organisations including NHS Providers3 and the Royal College of Physicians.4 These centre on training more staff at home and doing more to look after staff so that more of them stay in the workforce. But this will take years, so let’s get real……

Chris Smyth in the Times 24nd April opines: New migration plan puts hospital services at risk

NHS chiefs have warned the government that “destructive” post-Brexit immigrant plans could force some hospitals to close a quarter of services, leaked minutes suggest.

Health bosses have told senior civil servants that a strategy involving a £30,000 salary threshold for any workers moving to Britain would be “the most destructive policy for NHS recruitment” because of the service’s reliance on overseas staff.

The proposals are under attack from NHS and social care services, which are short of 100,000 staff. In a white paper published last year, ministers proposed that when freedom of movement ends, all workers wanting to take up jobs must earn more than £30,000.

According to minutes of a meeting in January seen by The Daily Telegraph, one NHS director told officials that the “£30,000 limit is the most destructive policy proposal for NHS recruitment I’ve heard of”, to which another person present added “and the entire UK”. The minutes also say that the policy will be particularly “awful for social care”.

The health service relies on overseas staff, with one in ten doctors and one in 15 nurses coming from other EU countries, and there are concerns that tighter immigration controls could worsen staff shortages.

A nurse’s starting salary is £23,000 and social care workers earn even less. Health think tanks have urged the sector to be exempt from post-Brexit salary controls as 90 per cent of staff earn less than the £30,000 threshold.

Caroline Nokes, the immigration minister, has acknowledged the problem, telling MPs last month that there is a “lot of concern” about social care in particular. She promised further discussion with unions and other bodies.

• Heather Blake, a director at Prostate Cancer UK, has warned that the charity estimates “thousands of men will miss out on the support they need because there are not enough clinical nurse specialists to support them”.

Doubling NHS surcharge “punishes” international doctors for working …

The BMJ9 Jan 2019