Category Archives: Post Code Lottery

What nonsense from Mr Drakeford…. Politician afraid to acknowledge the poor manpower planning, and his responsibility to the whole population..

Politicians should make the decisions about populations and their health. Doctors, apart from public health specialists, should “put their patient at the centre of their concern”. So when the BBC publishes 3rd Feb 2020: Royal Glamorgan: First minister criticises politicians on A&E plans they are never questioning Mark Drakeford’s comment:

“It is for doctors, not politicians, to decide the future of the Royal Glamorgan Hospital’s A&E department, Labour First Minister Mark Drakeford has said”.

This downgrading and closing of hospitals is driven by staff shortages. Its the same in Haverfordwest, Blackpool, Scarborough and all the peripheral and deprived areas without a teaching hospital and tertiary care. Mr Drakeford has relatively little power over the short term supply of doctors, but he could initiate the virtual medical school, and allow far more people to train. And that gives a long term solution. Meanwhile its going to get worse.. and worse.

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

A reversal of raioning for SE Londoners needing IVF

Jamie Bennett-Ness reports 24th Jan 2020 for Newsshopper: Discriminatory ban on single women in SE London getting NHS-funded IVF is reversed

NHS bodies in south east London have announced they are reversing a policy which denied single women from receiving funded-IVF treatment because of the burden created by single parents.

The policy, which saw single women denied funded IVF servies because of the “burden on society” caused by single-parent families, was branded “discriminatory and cruel” by one Labour MP.

NHS South East London, which includes the NHS commissioning groups for Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark, pledged to carry out a review of their IVF policy following criticism……

 

If it applies in England that the “poorest get the worst health care”, it does in all 4 health services.

There are perverse outcomes of the austerity years, but more as a result of the rationing of places in medical school over decades. Add to this the removal of nursing grants and subsidies, and less than ideal recruitment for all the para-medical specialities. The short term horizon of politicians has led to a situation where the miners of Tredegar once again get a worse service than the bankers of London. I wonder if any of our politicians have read it? We have to reconfigure the 4 health services.

Spin doctors? Richard Smith isn’t buying it. “The NHS doesn’t need more money, it needs a radical rethink”. 2020

Aneurin Bevan: In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear 1948

Dennis Campbell in the Guardian 23rd Jan 2020: England’s poorest ” get worse NHS care ” than wealthiest citizens

England’s poorest people get worse NHS care – Nuffield Trust
New QualityWatch analysis shows that people living in the most deprived areas of England experience worse NHS care. Read this scrolling story to find out how inequalities have changed over 10 years, and read this briefing for the low-down behind the numbers. The story was exclusively covered by the Guardian.

 

2016:What am I afraid of? More and more… Bringing back fear..

2017: Bringing back fear, and suffering. A return to 19th century inequalities.. How quickly politicians destroyed what was the best safety net in the world?

Cynical de-commissioning bringing back fear.. Dying patients waiting hours for pain relief in NHS funding shortfall.

2018: Bringing back fear – in the media led society. Lets charge for screening tests and spend the money elsewhere.

2016: What is the true story behind NICE stopping “A&E safe staffing guidance” levels? Money and fear of civil unrest…

The thin edge of the wedge. Is private A&E going to thrive and become the shape of the future? Aneurin Bevan, what would you do?

 

 

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

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

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

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

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

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

Foundation professor of oncology, University of London

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

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

Retired GP, Martock, Somerset

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

Rye, E Sussex

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

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

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

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

United Kingdom August 27 2019

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

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

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

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Update 29th Jan Times letters 2020:

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

Retired NHS consultant
Haverfordwest, Pembrokeshire

 

The reaality of cultural dissonance.. A GP Trainee recalls her hospital experience of discipline..

A letter in the Times from Dr Katie Musgrave 20th January informs readers of the reality of being a junior doctor in todays overmanaged health services. Read it at the end of this post.

The Bury St Edmonds terrorising of staff, threatening them with fingerprinting, and generally demoralising them further, is indicative of the whole of the 4 health services. 

The idea that managers can treat doctors as staff on a factory production line has led to this situation. Changing a culture is very difficult... especially for a state monopoly which most people still love the idea of… especially when the trust are all bust. No single person I have asked seems to realise that with the Brexit devaluation of the pound all costs have risen by 18%…

Add to this the overhead inherent in Wales (As opposed to Scotland and N Ireland) because of the Welsh Government..

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Bury St Edmunds Hospital in the dock. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn,

Missed appointments dont cost except in a factory model of General Practice. 20,000 missed appointments is actually welcome to most GPs. Now if there was a disincentive to make a claim….

Kent NHS ‘to send surgery patients to France’ – setting a precedent? Can the fragmented UK health services recover without some form of zero-budgeting and revolutionary reconfiguration based on overt rationing?”

NHS WHISTLEBLOWERS
Sir, Your report on West Suffolk Hospital (“Anger over ‘witch hunt’ in hospital”, Jan 17) will be shocking to many but did not surprise me. My husband (a GP) and I have just exchanged memories of times when, as junior doctors, we were both brought before committees accused of minor misdemeanours. He had logged into a results system online and forgotten to log out. Someone had subsequently used his account to look at a consultant’s personal medical results. He was made to “confess” and sign a document admitting his negligent behaviour. I was once accused of dropping a blood bottle into a regular bin rather than a clinical bin. The bottle had been traced to me and a committee put together to sanction me for this crime. At another hospital I was called to answer for having examined a child in the wrong clinical room. Apparently I had been anonymously reported. Such bullying tactics are widespread in the NHS and do indeed keep doctors from raising genuine concerns about patient safety. If, from your early years of training, you have been consistently threatened and undermined, it can be very difficult to maintain the resilience to speak up. We need independent advocates for NHS whistleblowers.
Dr Katie Musgrave, GP trainee
Loddiswell, Devon

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A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades

We need investment in buildings, plant and people. The crisis is here and now. A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades.

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Nick Triggle for BBC news 13th December reports: Every major A&E misses wait target for first time

and BBC produced a report on the “Accident and Emergency crisis”.

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The search for waiting time failures in A&E reveals an epidemic of failures.

New builds, particularly under the PFI initiative have been catastrophes of long term mis-management and perverse incentives leading to perverse outcomes. These are exposed by Louise Clarence-Smith in the Times 17th Jan 2020: Soaring costs and delays expose lack of scrutiny at Carillion hospitals and “Beware the real costs of Hospital Failures”

one of which is demand for Private Treatment centres….

In The Guardian opines that A&E wait times matter. But the key issue facing the NHS is investment

 

Sensible rationing of dementia drugs – a lead from France

The first country in Europe to act on concerns over limited effectiveness In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state.

What a sensible approach. Without the expensive drugs we can have more carers. Trust Boards and Commissioners take note. The trouble is that these drugs are effective in some people, but the utilitarian approach taken by France is correct. 

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France removes state funding for dementia drugs | The BMJ 30th December 2019 and 18th January 2020 BMJ 2019;367:l6930

The first country in Europe to act on concerns over limited effectiveness

In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state. The decision followed a long campaign by the French therapeutics journal Prescrire, which subsequently declared, “The days are over when support for patients and their struggling caregivers was based on drugs raising false hopes.”

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The following month, the National Institute for Health and Care Excellence (NICE) published updated dementia guidance.2 This recommended combination therapy for the first time, advised not stopping drugs simply because the condition progressed, and relaxed regulations on primary care prescribing. In short, drugs for dementia would no longer be supported in France but would be further promoted in England and Wales. France is the only European country to take this step,3 although authorities in Belgium are considering following suit.4

Acetylcholinesterase inhibitors inhibit the breakdown of acetylcholine, a key neurotransmitter involved in memory, attention, and sleep that is often depleted in adults with dementia.5 Memantine works on a different and less well understood target thought to be involved with cognitive decline, blocking N-methyl-D-aspartate receptors to prevent toxic overstimulation and subsequent neuronal damage.6

Alzheimer’s dementia is the only licensed indication for these drugs, but NICE recommends off licence use for adults with dementia with Lewy bodies.2 No other drugs are available for any of the common dementia subtypes, and disease modifying agents remain elusive.7 These drugs are therefore the only available pharmacological treatments for dementia.

The French health authorities cite several reasons for their decision, including concerns about the clinical meaningfulness of their effects on cognition, no proved benefit for behavioural symptoms, quality of life, or time to institutionalisation, and real world indications of a rare but increased risk of bradycardia requiring hospital admission.8

Little benefit

Broad consensus exists that drug treatments for dementia produce statistically significant improvements in cognition for at least six months, but these improvements are small. A 2018 Cochrane review of donepezil trials9 reported a mean difference between treated and control groups of just 2.7 points on the cognitive section of the Alzheimer’s disease assessment scale (ADAS-Cog, scored out of 70), and 1.1 points on the mini-mental state examination (maximum score 30) at six months, favouring treatment. Cochrane reviews of the other drugs have reported cognitive benefits of similar magnitudes.101112

Whether these changes are meaningful for patients remains unclear. Researchers have attempted to quantify a threshold for a clinically important difference by triangulating changes in cognition scores with changes in clinician assessment and functional outcomes.13 But this assumes that any improvements in clinician assessment or functional outcomes equate to meaningful benefit for patients and their families, which remains debatable. Nevertheless, the authors concluded that a benefit of ≥3 on ADAS-Cog was clinically important. This uncertain finding on cognition is consistent with Cochrane reviews reporting similarly small, albeit statistically significant, changes to functional outcomes and clinician assessment.

Frustratingly, there are few qualitative or quantitative studies reporting quality of life (for patient or carer) or patient reported outcomes. Uncontrolled observational studies have suggested that drug treatment can delay nursing home admission by at least several months, although these study populations are likely to be skewed by indication bias.14

Change of emphasis

To justify depriving patients of the only available drugs when they are well tolerated and known to produce benefits (albeit of uncertain clinical relevance), there must be a clear idea of what is to be gained. The French health authorities argue that these drugs divert the attention of clinicians, researchers, and policy makers away from non-pharmacological approaches to dementia care. They expect that the decision will shift priorities from a drive to ever earlier diagnosis and treatment, to a more person centred approach, more research on non-pharmacological management options, and increased scrutiny of policy makers and commissioners to ensure adequate support for patients and their caregivers.15

They believe these changes will lead to overall benefits, although the potential merits remain hypothetical. What should the UK do now? Following France’s lead would require careful consideration of the best way to manage wholesale deprescribing, alongside a systematic evaluation of the effects. A more pragmatic approach is to “watch and wait” to see whether the hoped for benefits are realised in France.

Medworm: Re: France removes state funding for dementia drugs

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