Category Archives: Post Code Lottery

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

The breaking up of the old “National” health service into the 5/6 different health services (If we include London) is a form of self harm in many ways. The benefits of a large mutual in health, where we cannot predict our future diseases, or our own “lottery of life” ticket, were fully understood by Aneurin Bevan.

The NHS Executive (England) announced 26th October: NHS ahead of schedule for procurement savings but this is still small savings in relation to the potential. The Logistics Manager, Supply Chain reports 30th October: NHS Supply Chain delivers £250mn of savings, nearing £300mn …But the “Public Finance” site 9th November reveals the truth in its concern to compare: DoH to rank NHS hospitals in ‘procurement league tables’. You have to believe in the power of the mutual to understand the reduction in risk, as well as the potential savings. Devolving powers is all very well, and “liberal”, but if it reduces life expectancy by increasing risk, reducing choice and purchasing power, and makes a Regions (such as Wales) bust then it is not a public good.  Imagine if we were so “liberal” as to give each citizen a health budget of their own? The benefits of mutuality are lost as those lucky enough to avoid disease choose to lead hedonistic lifestyles at the expense of the unlucky. The post-code lottery is reality, but nobody knows it until they are a victim. Dead patients don’t vote.

With the inefficiencies in mind, one wonders why London has been approved as the 6th health system in the UK? The only explanation I can believe is that it muddies the water even further: it allows more comparisons, and less choice. Politicians of course, with access to London will always have access to the best! For the rest of us it will be second rate care or a private plan/ purchase option.Image result for the mutual health cartoonI wonder if the youngsters understand the principles behind a mutual organisation? It is not hard to find examples which we revere such as the John Lewis partnership. The question of “what is the John Lewis Model” was addressed in the Guardian. If you want to read and then answer questions on a “business case study” the opportunity is here.  In Insurance, such as the old NHS, the advantages are clearer still…

Oliver Wright reports in the Times 20th November 2017: No cash bailout until you make savings, Hammond tells NHS ( a reality warning before the budget ).

Health service leaders have failed to keep their promise to save billions of pounds to spend on frontline services, Philip Hammond claimed yesterday, as he ruled out a budget bailout for the NHS.

The chancellor rejected calls by Simon Stevens, the chief executive of NHS England, for a £4 billion funding boost, saying that people running public services often claimed “Armageddon” if they did not get the money they wanted from a budget.

He warned that although the government might find some money for “particular pressure points” in the NHS it would not be at the scale demanded by Mr Stevens. The chancellor is understood to be prepared to find the money to fund limited pay rises for nurses and some capital investment programmes but there will be no significant increase in total NHS revenues.

Mr Hammond’s comments came after Mr Stevens said that the government should honour the pledge of the Vote Leave campaign and hand some of the money “saved” by Brexit to the NHS…….

Drawing on analysis by the Health Foundation, King’s Fund and Nuffield Trust charities, Mr Stevens suggested that the NHS needed about £4 billion more next year to prevent patient care from deteriorating.

Mr Hammond said that the government had already agreed to provide the NHS with an extra £10 billion by 2020 — a figure requested by Mr Stevens in his five-year plan.

“That plan is not being delivered,” Mr Hammond said. “We need to get it back on track.” He added: “In the run-up to budget, people running all kinds of services come to see us and they always have very large numbers that are absolutely essential, otherwise Armageddon will arrive.

“I don’t contest for one moment that the NHS is under pressure. We have been doing some very careful work with the Department of Health, with the NHS, to look at where those pressures are, to look at the capital needs of the NHS, to look at where the particular pressure points around targets are. And we will seek to address those in a sensible and measured and balanced way.”

His remarks about the five-year plan irritated NHS England, which sent out a series of tweets shortly after Mr Hammond was interviewed on The Andrew Marr Show on BBC One, citing “evidence” that Mr Stevens’s reforms were working. The shadow health secretary, Jonathan Ashworth, described Mr Hammond as out of touch. Mr Ashworth said that an extra £6 billion was needed to avert “Armageddon”.

He told Sunday With Niall Paterson on Sky: “It’s incredibly serious and if I may say so I’ve seen Philip Hammond doing interviews today, being dismissive of the calls for more money for the NHS, saying well you know it’s not going to be Armageddon.

“This is happening now, today, in the NHS, and if he doesn’t realise that, he’s completely out of touch. We are calling on the chancellor to put aside an extra £6 billion in this budget.”

NHS England declined to comment but is understood to reject suggestions that the plan it set out for NHS efficiency savings is not working.


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The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

Devolution of health to Wales was a mistake?

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

The democratic deficit. Applies to health as well as devolution, and to leaving the EU. The first honest party should get public support.

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….

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

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it


Disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

We are facing disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

Emma Forde for the BBC News 12th November 2017: ‘I’m dealing with life-threatening situations – but I’m not a clinician, I’m a mum’

Hayley Smallman’s 15-year-old daughter Holly has a series of complex, life-limiting health conditions.

Her cerebral palsy, chronic lung disease and epilepsy mean she needs 24-hour care at their home in Liverpool.

It is estimated there are 40,000 children like Holly living with life-limiting and life-threatening conditions in England alone.

Many of them need palliative care round-the-clock, which is largely provided at home by their families but with the support of community children’s nurses and community paediatricians.

‘Alone and scared’

Hayley says: “I have a community matron and a community physio. They work Monday to Friday, 9am till 5pm. They are great.”

But when it comes to out-of-hours and weekends, Hayley says she is left without any support…..

On the same day: ‘Postcode lottery’ for dying children’s care, report finds

Families of dying children lack support because of a “postcode lottery” in palliative care services, according to a report.

The Institute for Policy Research says 49,000 children have life-limiting or life-threatening conditions in the UK.

The report says Scotland is “leading the way” in ensuring the right care is available to all, but the rest of the UK must follow suit.

The government says it is committed to tackling end of life care variations.

The IPR, based at the University of Bath, blamed a “piecemeal” approach to polices around palliative care and helping the bereaved for a wide difference in services across the UK – notably for children.

According to children’s charity Together for Short Lives – which contributed to the report – seriously ill children are “being forgotten or ignored” by nearly one in ten clinical commissioning groups (CCGs) in England as important services are not being made available.

Only 73% of CCGs provide palliative children’s nursing out of hours and at weekends, meaning children have to go into hospital rather than be treated in the community, the report found…..

…James Cooper, public affairs and policy manager at the charity, said: “The way in which children’s palliative care in the UK is planned and funded represents a postcode lottery.

“The current policy and funding environment has failed to adequately acknowledge the needs of these children, their families, or those that work to support them.”

He said families of children with life-limiting conditions have to co-ordinate a “vast array of professionals and agencies” for the care their children rely on.

“While a number of positive policy initiatives are being developed by the UK’s governments and other agencies, more work is needed to make sure that they bring about more joined-up plans, assessments and services with children and families at their centre,” he added.

The IPR report praised work in Scotland where the government is investing £30m following a pledge to provide palliative care for all who need it by 2021, “regardless of age, gender, diagnosis, social group or location.”

But it criticised the rest of the UK for being “ill-prepared” for the ageing population, and left with “disjointed policies” for people of all ages.

The report’s lead author, Dr Kate Woodthorpe, said: “For too long we have been complacent about death’s social and economic consequences, and our policy responses.

Government can no longer ignore the many, many challenges outlined in this brief.”

Other issues highlighted in the report

  • Only one in six employers have policies in place for employees providing palliative care for someone with a terminal illness
  • Growing funeral poverty – 45,000 people annually seek help from the state to meet the cost
  • A lack of burial space and concerns regarding crematoria capacity
  • One of the lowest rates of organ donation in Europe, while more than one in ten people die in the UK before they get the transplant they need
  • Nearly two-thirds of the UK population do not have a will

The report said the example of the devolution of powers and resources to Scotland offered a framework to tailor services to local populations and allow best practices to be shared.

“National and regional devolution is showing early indications that innovation and modernisation is possible, and Scotland is arguably leading the way with ambitious targets and re-organisation of key policy areas,” added Dr Woodthorpe.

“It is up to the rest of the country as to whether they wait to see how well Scotland fairs, or whether they use this as an opportunity to review, consolidate and improve how they support dying, death and bereavement.”

Scotland’s Health Secretary Shona Robison, said it was “extremely heartening” to be recognised by the report, adding: “It is a tribute to the compassion, commitment and dedication of those working across our health and social care services.

“To achieve our aim it is essential we create the right conditions nationally to support local communities in their planning and delivery of those services and support – to help ensure that the unique characteristics of each individual and family are met.”

The Department of Health said it had made a commitment to address variations within end of life care, including investing £11 million from NHS England into funding for the Children’s Hospice Grant.

A spokeswoman said: “We want all children and their families to receive high quality, compassionate and tailored care at the end of their life, regardless of where they live. That’s why we have committed to improving care in all settings.”

Update 12th November – And I forgot to mention child and adolescent mental health. A letter from an exasperated mother in the Sunday Times reads:

Psychiatry crisis takes toll on young anorexics

The woeful provision for young people with eating disorders led to my daughter being transferred in March to Edinburgh — even though we live in Hampshire (“Crisis in child psychiatry as vacancies soar”, News, last week).

It is totally unsustainable and she cannot build a life outside while she receives care. In early summer she was ready to move on but beds and/or funding were not available, so she has relapsed and lost hope.

This happens to patients time and again; hence the cyclical nature of anorexia. As a mother, I feel I am fighting on all fronts every day to get the right treatment for my daughter — with her condition and her daily or future care — while also dealing with grief and sadness for all that has been lost for our daughter and family, and the fears over what lies ahead for her.

There is a desperate need for more inpatient beds and a variety of treatment settings community, acute or inpatient and step-down) in which there is a greater range of therapy options to enable all the complexities of the illness to be addressed. One size does not fit all.

Incentives to train more psychiatrists, mental health nurses and support workers, plus a specialist eating disorders pathway for therapists, are essential.
Jemma Perkins, Andover

Private health care variations in price, access and quality… as the safety net fails

Anna Hodgekiss dramatizes for the Mail with the headline: Scandal of private health sharks overcharging their patients by up to £12,000 but it is evident that, as the safety net fails more frequently, that those who have the means will use them to get better treatment. Speed (avoiding waiting lists) and choice (consultant not junior) and fewer complications (less infections in private hospitals) mean we are morphing to a two tier system. Differences in outcomes between those with means and those without could well lead to civil unrest. Exactly what Aneurin wanted to avoid. Bringing back fear?

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Patients who pay for private surgery are falling victim to massive price variations of up to £12,000 for the same procedure.

A report by medical industry experts shows that depending on the provider and location, the quoted price of a total hip replacement ranges from £8,945 to £14,880, while a commonly performed varicose vein procedure can cost anything from £1,995 to £4,340.

However, a Mail on Sunday investigation has found that patients are often being charged several times this amount, with one woman quoted £15,000 for a vein operation.

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A Mail on Sunday investigation has found dramatic differences in the costs of private health treatment with a £1,500 difference in the bill for a simple back operation

There can even be a near £1,500 difference in the cost of simple back pain injections, and the bill for cataract surgery can almost double from one place to another.

The figures relate to the amounts that self-pay patients – rather than those having procedures covered by private insurance – are having to fork out for treatment

An increasing number of desperate Britons are being forced to self-pay as NHS rationing cuts deeper and waiting lists grow ever longer. More than four million people are currently waiting for NHS surgery – the highest figure since 2007 – according to NHS England.

And in October it was revealed that patients in Northern Ireland are waiting up to three years for an initial consultation about having surgery, following a GP referral.

The report, published by Private Healthcare UK, predicts that the self-pay market will surge over the next five years.

The Mail on Sunday also reported last month that record numbers of Britons are shelling out up to £15,000 for vital operations after being told they must wait for months by NHS hospitals.

In total, patients are forking out £623 million a year for self-pay treatment. They are cashing in ISAs or pensions, taking out loans and even ‘maxing out’ credit cards to fund treatment they should have had sooner on the NHS.

Experts are urging private patients to shop around after the report – which gathers data that providers are now obliged to publish – found alarming differences in prices. For example, the bill for an injection of local anaesthetic and steroids for back pain ranges from £950 to £2,370, while a knee replacement can cost anything from £8,750 to £15,410. Meanwhile, the quoted guide price of cataract surgery for one eye varies across the UK from £1,850 to £3,350.

The report highlights that the cheapest providers are specialist centres – day surgery centres for procedures such as steroid injections, veins and optical surgery – as opposed to private hospitals offering a range of services.

Some providers, including Spire and Nuffield Health, have prices that vary so much that they are often listed as both the cheapest and most expensive option, depending on the location of their centre.

For example, the highest bill for cataract surgery is found at Nuffield’s hospital in Exeter, where the procedure costs £3,350 for one eye. Yet the cheapest provider in the South East is the company’s Chichester hospital, where the same operation costs £2,090.

Keith Pollard, chief executive of Private Healthcare UK, said the figures emphasised the need for stringent research before committing to any hospital or clinic. ‘There has always been a wide variation in pricing,’ he explained. ‘But companies are now being ordered by the Government to publish their prices on their websites.’

When asked about the huge disparity in pricing, Nuffield Health said: ‘Our prices vary according to surgeon and anaesthetist fees and local market conditions.’ Spire Healthcare refused to comment.

Mr Ian Eardley, vice-president of the Royal College of Surgeons, said many desperate patients who did not fit the criteria for NHS treatment were now opting to go private if they could afford it. ‘There are some elective procedures, such as hip and knee replacements, where patients are being denied access due to local NHS policy. They may be told to go away and lose some weight before they are eligible,’ he said.

‘With procedures such as varicose veins, cosmetic appearance is no longer enough to get surgery. You must be at risk of developing other symptoms, such as painful ulcers, in order to be considered eligible on the NHS.’

Six things every self-payer needs to know

1 Mr Ian Eardley, vice-president of the Royal College of Surgeons, says: ‘Ask a potential surgeon how frequently they operate and what their results are.’ Details of how many procedures a surgeon has done and what their results are can be found on the NHS Choices website.

2 ‘If you are offered a new procedure, approach it with caution,’ urges Mr Eardley. ‘Don’t be afraid to get a second opinion or ask to speak to other patients who have had it.’

3 If you are going to be in hospital for a few days, stay in one with low infection rates. ‘Every hospital will have been assessed by the Care Quality Commission and you can read the report on the CQC website,’ says Mr Eardley.

Lower prices don’t always mean lower quality: clinics that specialise in a limited number of procedures can offer savings.

Check the Private Healthcare Information Network (, which compiles information such as hospital performance, patient satisfaction and CQC rating.

Ask about hidden extras. What happens if something goes wrong? Is follow-up care covered? Make sure you and the surgeon are on the same page in terms of what you consider a successful outcome. For example, improvement in variables such as pain, movement and quality of life.

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It’s about to blow up. There is no Mr Fawkes to arrest, blame and punish (hang draw and quarter) for the coming NHS failures

If you are planning a holiday rather than saving that heard earned cash, you might want to consider the true cost of health care, what will not be available to you in your particular Post Code, and what you could afford to buy straight, or insure for. Being off work for long periods, especially for mental health problems is soul destroying, and reduces standards of living. Houses have to be re-possessed, and re-employment is difficult. Only the large state employers seem to ignore the mental health record. Small organisations are unlikely to keep those who keep needing time off unpredictably. If you do go on holiday, especially to Greece, take cash! The bomb under the health service is about to go up, and there is no Mr Fawkes to arrest, blame and punish (hang draw and quarter) for it’s failures. If, like most people you cannot contemplate a life without mutual health cover, find out what your premium would be and take it off your income… scary. “The sums involved are colossal” – see below, and tinkering with fraud and overseas patients are distractions.

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Tony Stubbington reports in The Sunday Times 6th November : NHS cash crisis reveals the fractures in our finances. The chancellor has little room to prop up the health service in his budget

At Birmingham Children’s Hospital, staff who go the extra mile get the chance to be named “Star of the Month”. Looking through the recent nominations for the award, Sarah-Jane Marsh noticed a worrying trend. The number of people who were nominated for working through weekends or holidays without extra pay was “unbelievable”, said the chief executive of Birmingham Women’s and Children’s NHS Foundation Trust.

“We are running on goodwill,” she said. “People don’t take breaks. They work through annual leave. Over the past two years we’ve been cut to the bone.”

The trust’s funding has not kept pace with steadily rising patient numbers and the soaring cost of ever-more sophisticated treatments, according to Marsh. Staff have stretched themselves, but the cracks are starting to show. In the three months to September, the trust missed its target for A&E waiting times for the first time since 2003, she said.

Her complaints cut to the heart of the dilemma facing Philip Hammond as he prepares for an extremely politically charged budget on November 22. Most government departments claim they are at breaking point and have started leaking stories about the strains on policing, social care, prisons and creaking infrastructure.

Yet there is simply not enough money to throw more than a bit of cash at some minor problems and hope for the best. The chancellor already faces a productivity slowdown expected to blow a hole in plans to balance the budget by the middle of the next decade. A cash injection for the NHS could sink these plans.


Image result for cash crisis cartoonThe Sunday Times 5th November reports on child and adolescent mental health with:

Parents beg universities for help after rash of suicides.

Crisis in child psychiatry as vacancies soar.

Coroner attacks failures of care for anorexic teacher.

But these are the thin edge of a very large wedge. No commissioning group fails to accept that child psychiatry is core health service provision, but in a cradle to grave and un-rationed NHS, why is dementia excluded? Why is palliative and terminal care funded by charities? Why is psychiatry (40% of GP work, and rising) not part of the training for all GPs? We know it is unpopular, but it becomes much less o once doctors are exposed to it as a speciality. I wonder how many of our UK psychiatrists trained in a UK medical school? This is a speciality that needs good communication and cultural awareness…. Even in Germany they have trouble with “fakes” which makes me wonder about quality control…

Shortage Occupation List – Royal College of Psychiatrists

1,000 more psychiatrists needed to tackle ‘unacceptable failings’ in care

Shrinking: The Recruitment Crisis in Psychiatry | The Psychiatry SHO*

Why Don’t Medical Students Choose Psychiatry? | The Strangest Loop

Psychiatric nursing: an unpopular choice. – NCBI

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Legal threat to NHS for using cheap drug Avastin

Sometimes rationing can be a rational process, and the use of Avastin is such a case. My mother has it in Norwich, and so, provided it is equivalent to the other products, everyone should have it. In New Zealand the rule is that you have the cheapest product on the state, and if you choose anything different you pay for it. Commissioners need protection from this risk, and the law needs changing.

Chris Smyth reports in the Times 1st September 2017: Legal threat to NHS for using cheap drug Avastin

Pharmaceutical companies have threatened legal action against the NHS for offering patients a cheaper eye drug that could save the health service hundreds of millions of pounds.

Ministers have hit back, demanding that competition regulators investigate whether collusion between the companies is blocking doctors from prescribing the cheaper medicine, a practice the companies have previously denied.

The row centres on Avastin, a cancer drug that has proved just as effective as Lucentis and Eylea, two branded drugs, in treating wet age-related macular degeneration, a condition that affects 600,000 people in Britain.

Avastin costs a tenth of the other two drugs but, unlike them, is not licensed as an eye treatment, making doctors reluctant to prescribe it because it would put them at risk of disciplinary action.

The National Institute for Health and Care Excellence has judged that Avastin is just as safe and effective as the other drugs but said it cannot recommend an unlicensed treatment.

However, 12 health groups in the northeast have decided to offer it to patients, explaining that it would save money and avoid the need to ration other treatments, such as IVF.

“Every patient who chooses the cheaper alternative drug will help the NHS to fund important medical treatment in other areas,” David Hambleton, chief executive of South Tyneside clinical commissioning group, writes in The BMJ. “Drug companies should not dictate which treatments are available.”

However, the bodies have been threatened with a judicial review by Novartis and Bayer, which sell the licensed drugs, claiming that using unlicensed ones is against British and EU law and “runs the risk of setting a precedent that undermines the regulatory framework and NHS constitution”.

Nationwide, half a million injections of the eye drugs are given each year and according to one estimate, if all doctors switched to Avastin, the NHS would save £450 million a year. However, officials say this does not include discounts, with true savings about £100 million.

Julie Wood, the chief executive of NHS Clinical Commissioners, which represents local funding groups, said: “We cannot afford to ignore the savings of at least £100 million per annum.”

Roche, which makes Avastin, has not applied to license it for eye treatment. The Department of Health has asked the Competition and Markets Authority to look into why this is, citing financial links between Roche and Novartis, which makes Lucentis.

Novartis said in a statement that the northeast policy was misleading doctors. “Unlicensed medicines have not undergone the same regulatory scrutiny as licensed medicines,” it insisted.

Roche said it could not comment while the legal case was continuing.


Unfairness in infertility is symptomatic of a far more important unfairness – in survival and life expectancy.

£68m out of £122bn is significant when all other demands are considered. Ask the commissioners. Why should fertility be treated differently to stent insertions or stroke or cancer treatments? At least these are life saving. Every health system rations care. The debate should be about whether this rationing should be overt or covert, and whether different for different post codes/regions. Rationing by insurance differentials as in many EU countries is giving better overall outcomes and is less unfair than what we face now. Nobody knows in advance what will be rationed for them. Their future health demand results from the lottery of life, but the unfairness results from the lottery of where we live, and the dishonesty inherent in a lack of national debate. . The WHO will not in future report on an NHS: rather on 4 systems of covert rationing. A pragmatic and honest debate is needed on what the health services are for, and whether the founding principles outlined by Aneurin Bevan (in place of fear, chapter 5) need to be reassessed and rewritten. Meanwhile our denial is bringing back fear, especially to those without the means to make a private choice.( Politicians often go privately….) 

 The hearts and minds of the coalface workers are disengaged from the politics because of this denial. They are also concerned that the media may be colluding in the denial, so that things get worse. 

 Three MPs write a letter to the Times revealing their state of denial and poor understanding of the rationing decisions commissioners are having to take to keep within budget.. The Times then follows up with a leader which is equally banal. “Unfairness in Infertility”. There will be fewer staff now that we are leaving Europe, and Katie Gibbons reports 30th October that “Staffing crisis will put NHS care at risk, says charity”. The Kings fund report is more circumspect but they really agree. Rationing by not having enough people with sufficient skills is a disgrace, and reflects more on our politician and political system than anything. Unfairness in infertility is symptomatic of a far more important unfairness – in survival and life expectancy. Of course genetic selection IVF should be a choice for those with inherited diseases, but in other cases we need to question priorities. (See Letter from Richard Childs in the Times 2nd November 201& – posted at the end, followed by another letter on cost and perverse incentives from Prof Nargund)


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NHSreality ‘ response to the Times is:

“£68m out of £122bn is significant when all other demands are considered. Ask the commissioners. Why should fertility be treated differently to stent insertions or stroke or cancer treatments? At least these are life saving.

Every health system rations care. The debate should be about whether this  rationing should be overt or covert, and whether different for different post codes/regions. Rationing by insurance differentials as in many EU countries is giving better overall outcomes and is less unfair than what we face now.

Nobody knows in advance what will be rationed for them. Their future health demand results from the lottery of life, but the unfairness results from the lottery of where we live, and the dishonesty inherent in a lack of national debate. .

The WHO will not in future report on an NHS: rather on 4 systems of covert rationing.

A pragmatic and honest debate is needed on what the health services are for, and whether the founding principles outlined by Aneurin Bevan (in place of fear, chapter 5) need to be reassessed and rewritten.

Meanwhile our denial is bringing back fear, especially to those without the means to make a private choice.( Politicians often go privately….)

The hearts and minds of the coalface workers are disengaged from the politics because of this denial. They are also concerned that the media may be colluding in the denial, so that things get worse.

CUTS TO IVF CYCLES – The Times letters 31st October 2017
Sir, This month marks the 40th anniversary of the creation of the embryo that went on to become Louise Brown, the world’s first IVF baby. This medical breakthrough has brought joy to countless people.

In England, the provision of IVF treatment on the NHS is now reaching crisis point, with clinical commissioning groups (CCGs) decommissioning services, and several areas in the southeast offering no service at all. Research carried out by Fertility Fairness shows that the number of CCGs offering the Nice-recommended three IVF cycles to eligible women under 40 has halved in the past five years so that only 12 per cent now follow national clinical guidance. CCGs need to be held accountable for these cuts but neither the government nor NHS England seem to have the powers or the appetite to do this. Even when CCGs consult their local population, and the latter support retaining fertility services, the CCGs cut them anyway. Surely the time has come to consider commissioning this service centrally in England, as they do in the devolved nations, so that the provision of fertility treatment is equitable.
Steve McCabe, MP (Lab); Tom Brake, MP (Lib Dem); Ed Vaizey, MP (Con)

Unfairness in FertilityAfter 40 years, IVF treatment on the NHS is unacceptably patchy

Whether couples have children should not depend on where they live. Forty years into the age of in-vitro fertilisation, those who could benefit should have access to it on a roughly equitable basis. Unfortunately, they do not. Huge variations in the availability of IVF on the National Health Service have emerged since local doctors’ groups were given new control over how NHS money was spent in the Lansley reforms five years ago. This is an injustice that the government has helped to create and that the government can help to end. It should do so without delay.

National guidelines on how many cycles of IVF should be available on the NHS are being ignored at the local level, and especially in the southeast. As of this year, couples having trouble conceiving in Cambridgeshire and Croydon have no chance of IVF except by paying for it themselves, while those in most of Greater Manchester are still assured of three cycles on the NHS as long as the would-be mother is under 40.

This is unfair. It is especially galling for couples trying unsuccessfully to have children for want of enough IVF treatments, who through their taxes are subsidising effective treatments for others for no better reason than their postcode.

Such a lottery is avoidable. Since April this year, commissioning of IVF in Scotland has been centralised so that all couples who could benefit are guaranteed three cycles. Commissioning has also been centralised in Wales and Northern Ireland, although the provision there is less generous. MPs are demanding a similar centralisation of IVF provision in England.

Four decades ago, Patrick Steptoe and Robert Edwards pioneered the laboratory fertilisation of a human embryo and its successful re- implantation into the womb of the egg’s donor, Lesley Brown. Later knighted, Sir Robert was also awarded a Nobel prize for his work in reproductive medicine. Mrs Brown’s daughter, Louise, the world’s first IVF baby, is this week attending a fertility conference in Texas at which she has said the heartache of couples denied access to the treatment that gave her life can be devastating.

More and more people hoping to conceive in this way are being affected. National guidelines recommend up to three IVF cycles for women under 40, but these are not binding. Replies to Freedom of Information requests sent to clinical commissioning groups (CCGs) by a fertility pressure group reveal that the number following the guidelines has halved in the past five years to one in eight. Thirteen CCGs have stopped offering IVF in the past year. Nationally, one in 30 offers none at all.
For a given locality, the arguments against generous provision can seem compelling. IVF is not strictly a health treatment. Its effectiveness falls steeply as women approach 40. It is expensive, and resources are finite. At the national level, however, these arguments carry less weight. The NHS funds IVF for roughly 20,000 couples a year at a cost of about £68 million — a small fraction of the service’s overall budget of £122 billion. Guaranteeing three IVF cycles for all women who might benefit from it would carry an extra cost, but so would withholding the treatment. This cost might be measured in sadness and loneliness in later life, but would be no less real for that.
The lottery of fertility is harsh enough. There is no reason for government to make it harsher still.

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Letter from Richard Childs in The Times:

Sir, Susan Seenan, of Fertility Fairness, suggests that IVF is a “medical need”. Cancer treatment and tumour surgery are medical needs, IVF is not. It is a personal or social “want” — a very different thing. Financially the NHS is only able to provide funding for genuine medical needs. I do agree with her, though, that whether someone receives treatment of any sort should not be dependent on a postcode. A fair solution for IVF is, therefore, that irrespective of postcode no one should receive it on the NHS. Ever more scarce resources could then be diverted to addressing real medical needs.
Richard Childs

Collingham, Notts

Letter from Prof Nargund:

Sir, Your report “First test tube baby Louise Brown warns over ‘devastating’ impact of IVF cuts”, Oct 31) covers increasingly familiar and depressing ground. However, the continued reporting of IVF funding cuts misses the crux of the issue. The scale of the NHS budget is not the problem; the existing budget could easily fund the required IVF treatments in accordance with National Institute for Health and Care Excellence guidelines. The real problem is twofold: first, there is a fundamental deficit of IVF pricing knowledge within the NHS and among NHS commissioners. Simply put, a lack of awareness as to the various methods of IVF delivery, treatment and drug doses is resulting in a flawed (and highly expensive) procurement process.

Second, and more worryingly, the problem is compounded by the vested interests of the drug companies and IVF providers, where both enjoy a lack of transparency on IVF costs and profit at the expense of NHS patients.

If these challenges were to be sufficiently addressed we could halt the NHS rationing of treatment and help those denied treatment by virtue of their postcode.
Praful Nargun
CEO, ABC IVF, Harley Street


Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

The WHO will be reporting on the gross overall outcome comparators of different health systems and the next time they do, it will not be on the British “National Health System” but on the 4 Principalities in charge of their own health budgets. The long term rationing of medical school places, and the generalised under-capacity, mean that post code rationing is reality for a common and serious illness. More will follow. It’s going to get worse because none of the profession would have started from here. The BMA has been asking for more medical school places for years…. and only now are applications rising – we have to wait 10 years or more for most of the new entrants to be useful.

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Dennis Campbell in the Guardian reports 1st October 2017: Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

Stroke patients in Wales are being denied a life-saving pioneering treatment after the surgical team providing it had to be mothballed because of an acute NHS shortage of the specialist doctors who undertake the procedure.

Internal NHS emails obtained by the Guardian reveal that health service bosses in Wales are pleading with hospitals in England to perform mechanical thrombectomy on their patients to save them from disability and death.

And they show one senior doctor warning Welsh NHS officials that they have “not got a grip on the situation” and deserved to be “the laughing stock of the international neurovascular community”.

Doctors who specialise in stroke care are warning that the inability of the NHS in south Wales to offer patients what they say is a “game-changing” operation illustrates a chronic UK-wide lack of consultant interventional neuroradiologists (INRs).

They perform both thrombectomy and a similar emergency procedure, called endovascular coiling, on patients deemed at imminent risk of suffering a stroke.

However, there are just 70 consultant neuroradiologists working in the NHS across the four home countries – barely half the number the Royal College of Radiologists says is needed to cope with the rising demand for mechanical thrombectomy in particular.

That shortage means a number of hospitals are unable to provide the operation themselves and must send patients elsewhere.

University Hospitals Coventry and Warwickshire NHS Trust, which is struggling to fill several vacancies for INRs, has been sending stroke patients who need coiling 50 miles north to Royal Stoke University Hospital since January and sends mechanical thrombectomy cases 20 miles away to the Queen Elizabeth hospital in Birmingham.

The Stoke hospital, which in 2009 became the first in the NHS to offer mechanical thrombectomy on a 24/7 basis, has also been treating patients from six hospitals in the east and west Midlands, and north Wales, since 2010.

Patients from Middlesbrough who need emergency stroke treatment travel the 47 miles to Newcastle to have it rather than the town’s James Cook hospital, which cannot recruit enough INRs to offer its own local population that service.

Glasgow has also had recent problems offering mechanical thrombectomy to its citizens, some of whom have instead gone the 50 miles to Edinburgh for treatment.

The problems underline the NHS’s deepening staffing crisis, which hospital bosses claim is now a bigger issue day to day than lack of money. They also threaten NHS England’s ambitious plans to hugely increase the number of patients who undergo thrombectomy as part of its plan to reduce avoidable mortality.

During a thrombectomy doctors remove a blood clot from someone’s brain using a stent. That gives patients a much better chance of walking out of hospital unaided and disability-free rather than ending up with significant paralysis, or dying. Evidence suggests it is more effective for some stroke patients with a blood clot than solely undergoing thrombolysis – receiving clot-busting drugs – which is the traditional treatment.

Cardiff and Vale University Health Board launched Wales’s first clot-retrieval service, covering the bulk of the country’s 3 million population, last August. However, it had to stop functioning in May this year when one of the three doctors providing it retired, another got a new job and the third went on sick leave, and no replacements could be found.

Stroke specialists warn that patients from south Wales could die because they can no longer have a thrombectomy. Efforts by senior NHS officials in Wales to persuade hospitals in England to perform the procedure on patients from south Wales have so far failed to lead to any formal cross-border care agreements.

The NHS in Wales estimates that 500 people a year from the country would benefit from undergoing thrombectomy. Yet hospitals in England have made clear that they already have too many cases of their own, and too few beds and staff, to help on more than an occasional ad hoc basis.

In a testy email to Welsh NHS officials last month about the disappearance of the Cardiff service, Crispin Wigfield, the North Bristol NHS Trust’s stroke lead, told them: “At the risk of being blunt most frontline clinicians think that you have not got a grip on the situation and if it wasn’t so serious Wales would be the laughing stock of the international neurovascular community.”
His hospital at the time had no spare intensive care beds to be able to accommodate stroke sufferers from Wales, he told them.
In another email Dr David Rosser, the medical director of the Birmingham trust, told Welsh NHS officials that “we are, sadly, unable to support this [request for a cross-border thrombectomy] service as we do not have the capacity [to take extra patients].” He declined Welsh colleagues’ offer to pay for the opening of extra beds, explaining that his hospital was already “opening every bed we can get staff for”.
Doctors in south Wales can only seek help from a few English hospitals because doctors have ideally between four and six hours in which to perform a thrombectomy or the chances of a patient receiving real benefit fall significantly.
Twenty stroke patients from Wales have undergone coiling since May in hospitals in Birmingham, Bristol, Oxford, Plymouth and Southampton. The Cardiff service has recruited one new INR, but does not expect to resume offering thrombectomy for some time.

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

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