Category Archives: Post Code Lottery

A cash injection alone won’t cure NHS ills. Lets be clear: there is no more money, and no Brexit dividend.

David Smith in the Sunday Times opines 28th Jan 2018: A cash injection alone won’t cure NHS ills and I have been warning the Liberals that extra hypothecated or otherwise tax would solve nothing without the ideological and philosophical changes which will win the support of the professionals. All health systems are rationed: most overtly, but not the UKs 4 health services. Lets be clear: there is no more money, and no Brexit dividend.

If it is winter, there must be a National Health Service crisis — and indeed there is. There was one last year, which was described by the Red Cross as a “humanitarian crisis”, and there is one this year. There was one in 2005, halfway through the biggest increase in NHS spending in its history, and there was one in 2008, even further into that splurge.

Look hard enough and there is a crisis every year, though they vary in severity. I do not diminish the distress for people caught up in this one, but it would almost have been bad manners not to have a crisis in this, the year the NHS celebrates its 70th birthday.

The question is what to do about it. This one has provoked much debate, and two things should be clarified at the outset. The first is the idea that there will be some kind of Brexit dividend available for the NHS, as claimed by both Boris Johnson, the foreign secretary, and Liam Fox, the trade secretary.

There will not be. Any saving on Britain’s next contributions to the EU budget — and we are yet to see whether there will be any — will be swamped by other effects on the public finances. Britain will be borrowing more, not less, in future years and, as the Institute for Fiscal Studies put it a few days ago: “Brexit has reduced rather than increased the funds available for the NHS (and other public services), both in the short and long term.”

The other thing this winter crisis has done is bring forward an old chestnut: a dedicated, or hypothecated, NHS tax. There are many reasons why this is a bad idea but two will suffice.

One is that tying something as important as NHS spending to the stream of revenue for one particular tax would be hugely risky. What happens when revenue falls short? You might respond by putting up the tax but there is no guarantee that a higher tax rate means an increase in revenues.

Second, hypothecation destroys the ability of governments to spread revenues across popular public services, such as the NHS, and unpopular ones, of which there is a fairly long list. If the NHS is to be financed out of taxation, it should be out of general taxation (which includes national insurance).

The financial backdrop to this crisis is that the NHS is four-fifths of the way through the tightest decade for spending in its history. NHS spending has risen by an average of 4% a year in real terms since 1948, an increase that accelerated to 5%-6% in the 2000s. In the current decade, real increases in NHS spending are averaging 1% to 1.5% a year, alongside a rising population.

As long ago as the 1980s, it was discovered that NHS spending needed to rise by 2% a year in real terms just to keep up with higher medical inflation and technological advances. That figure may have increased. When the population is adjusted for age (an ageing population puts greater demands on the NHS), per capita spending is now essentially flat. Money is tight.

So what should be done? It would be folly to pretend that next year’s winter crisis could be averted by action taken now but, over time, we should be able to do better than an NHS that lurches from crisis to crisis.

There are five things that can be done. The health service can be helped over time by taxing more, borrowing more, rationing more, charging users more (which itself could ration use), or introducing genuine efficiency improvements.

Taxing more is always a possibility. This was the route used by Gordon Brown in the early 2000s when, much to the distress of business, employer and employee, national insurance was raised to put more money into the NHS. These days there is not much low-hanging fruit for the Tories when it comes to tax increases for either business or individuals. A Labour government would be much less constrained.

The second route is to borrow more, which was what Philip Hammond did in November. Faced with an underlying deterioration in the public finances, he chose to spend more, notably on the NHS. Will it be enough, and the last time that happens? No. There will be more borrowing in future.

What about rationing? A problem for the NHS is that the range of services, and treatments, increases in line with medical advances and demographics. Nice, the National Institute for Health and Care Excellence, has the task of issuing guidelines, including guidelines on which new treatments should be used, based on a budget impact test, but some costs of healthcare rise naturally — for example, because of the ageing population — and are not easily rationed.

Many people favour a different kind of rationing by dropping the NHS “free at the point of delivery” maxim. Prescription charges were introduced early in the NHS’s history and people have for many years expected to pay when visiting an NHS dentist. Paying for a GP appointment, as is the practice in many other countries with state healthcare systems, or charging a penalty for patients who do not show up for appointments, could be a way to go. But the politics of that is very tricky and charging for GP appointments might have the unintended consequence of directing more people to already highly pressured casualty departments.

That leaves efficiency. Three years ago, NHS England, having identified a £30bn funding gap by the early 2020s, committed to £22bn of efficiency savings in return for £8bn more in government money. It is fair to say that progress in achieving those efficiency savings has been disappointing.

As in the past, top-down pledges of this kind tend not to work. Tony Blair and Gordon Brown’s NHS spending splurge was supposed to be a return for reform and greater efficiency. We had the splurge but not the efficiency.

Far better, as the think tank Reform argues, is that ideas that reduce waste and improve efficiency develop on the ground and are spread around the NHS. Some of that happens now. Not enough of it does. An excessively bureaucratic organisation that employs at least 1.5m people across the UK is not an obvious candidate to be fast on its feet when it comes to efficiency savings. There is good practice in the NHS, however, some of which has eased the pressure on A&E departments in some parts of the country even this winter, and it needs to be spread. Otherwise, each winter crisis will stretch, unbroken, until the next.

In one bound, Britain’s job market was free. After two months in which the Office for National Statistics had reported falling employment, the latest release showed a strong bounce. Employment in the September-November period of last year was up by 102,000 compared with June-August, and by 415,000 on a year earlier. While self-employment fell, full-time employee employment rose strongly.

This was good news, although, as I sometimes get reminded by statisticians, the margin of error on these figures is large. So the small falls in employment of the previous two months may not have been falls at all, and the latest rise may have been exaggerated.

One oddity of the latest figures was that a good rise in employment coincided with a 0.5% fall in hours worked in the economy, despite an increase in full-time employment. That will be good for one measure of productivity, output per hour, which should show another robust rise in the fourth quarter of last year. But the other measure, output per person employed, may well go in the opposite direction.

The employment news boosted the pound to its best level against the dollar since before the EU referendum. So too did the belief that something is stirring on wages, which in turn could bring forward the next interest rate rise from the Bank of England. Friday’s slightly better and expected fourth quarter GDP figures pointed in a similar direction.

The uptick in wages in the official figures was tiny. Average earnings growth for total pay was 2.5% in the three months to November, the same as the upward-revised figure for the previous month, but lower than the 2.6% and 2.7% of a year earlier. Regular pay growth edged up from 2.3% to 2.4%.

There was a bit more excitement in the latest figures for pay settlements from XpertHR, a firm that monitors them. Early 2018 pay settlements have moved up to a median of 2.5%, it says, after being stuck at 2% last year. Indeed, this was the highest since early 2014.

There have, of course, been false dawns before. This might be another, but it could be that, at last, in what economists would see as evidence of a classic Phillips curve relationship, wages are responding to low unemployment.

Planning overall change without evidence that it will be effective, and the probability that it simply encourages duplication…

In Search of the Perfect Health System – a new book reviewed

BBC News 27th Jan: Paper headlines: NHS ‘rationing’ ops and Brexit turf wars



Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

Short termism rules, and shames the politicians who have denied that the system needs long term solutions. In our first past the post system with 5 year time horizons, we can expect no more. Proportional Representation, and a depoliticised ideology is urgently needed. Suggestions that an extra 1% tax (Liberals and Labour) don’t win the votes of the caring professions, who know the four Health Systems are not founded on an ideological or financial rock. Caring for people needs humans, not robots, and plenty of them. Anyone would think there was a conspiracy to ruin the Health Services.

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The Western Telegraph reports 19th Jan 2018: Extra funding to help NHS used for short term fixes, report finds

Additional funding aimed at helping the NHS get on a financially sustainable footing has instead been spent on coping with existing pressures, according to a report.

The National Audit Office (NAO) warned that “repeated short-term funding boosts could turn into the new normal” when funding with a long-term plan would be more effective.

Clinical commissioning groups and trusts are increasingly reliant on one-off measures to deliver savings, rather than recurrent savings that are realised each year, the report said.

The NHS was given an additional £1.8 billion Sustainability and Transformation Fund in 2016/17 ahead of the service having to survive on significantly less funding growth from 2017/18 onwards. It was also intended to give it stability to improve performance and transform services, to achieve a sustainable health system.

The report said this financial boost helped the NHS improve its financial position and overall the combined trust deficit reduced from £2,447 million in 2015/16 to £791 million in 2016/17.

But despite its overall financial position improving, the report said the NHS is struggling to manage increased activity and demand within its budget and has not met NHS access targets.

Furthermore, measures it took to rebalance its finances have restricted money available for longer-term transformation, which it said is essential for the NHS to meet demand, drive efficiencies and improve the service.

It said that, for example, the department transferred £1.2 billion of its £5.8 billion budget for capital projects to fund the day-to-day activities of NHS bodies.

On top of this funding, many trusts are receiving large levels of in-year cash injections, most of which are loans from the department, which have worsened rather than improved their financial performance. Extra cash support increased from £2.4 billion in 2015/16 to £3.1 billion in 2016/17.

It said progress has been made in setting up 44 new partnership arrangements across health and local government, which are laying the foundations for a more strategic approach to meeting the demand for health services within the resources available.

But the report added that, in reality, partnerships’ effectiveness varies and their tight financial positions make it difficult for them to shift focus from short-term day-to-day pressures to delivering transformation of services.

Amyas Morse, head of the National Audit Office, said: “The NHS has received extra funding, but this has mostly been used to cope with current pressures and has not provided the stable platform intended from which to transform services”

“Repeated short-term funding-boosts could turn into the new normal, when the public purse may be better served by a long-term funding settlement that provides a stable platform for sustained improvements.”

Chief executive of the King’s Fund, Chris Ham, said: “Across the country, there are encouraging examples of areas that are changing services so that they better meet the needs of local people. But transforming services requires investment, and the speed of progress in Greater Manchester, for example, has only been possible because of upfront investment.

“Yet, most of the Sustainability and Transformation Fund is being spent on addressing acute hospital deficits rather than being invested in new service models, which is holding back progress.”

British Medical Association council chairman, Dr Chaand Nagpaul, said: “This report provides clear evidence that investment designed to help the NHS transform and improve patient services is instead being used to firefight and meet existing pressures and deficits.

Financial sustainability of the NHS -The financial performance of NHS bodies worsened considerably in 2015-16, according to the National Audit Office.

New Statesman 18th Jan 2018: Patient care is key to a thriving health system

More nurses are leaving than joining and both the Times and the Guardian report that: we are ‘Haemorrhaging nurses’: one in 10 quit NHS England each year – Data showing 33,000 nurses left in 2016-17 triggers warning of ‘dangerous and downward spiral’

Two letters in The Times 17th Jan 2018 on remedies:

Sir, Rachel Sylvester argues for funding responsibility for social care to be given to the newly named Department of Health and Social Care (Comment, Jan 15). She is right. The barrier between the budgets for health and social care is unhelpful and the Barker Commission into the future of health and care recommended a single, ring-fenced budget covering both. We also agree that we need to increase the amount we spend on health and social care. The Barker Commission made the case for spending to rise as a proportion of GDP to bring us into line with countries such as France and Germany. This increase would be significant, but is affordable if we are prepared to make hard choices. We could means-test universal benefits such as winter fuel allowances and change national insurance so that better-off older people contribute more. Polling suggests that a clear majority of people are prepared to accept tax rises to fund the NHS. A cross-party consensus is now needed to make this happen.
Chris Ham

CEO, The King’s Fund

Sir, Rachel Sylvester is right about the need to increase NHS funding. This could be done without raising any new taxes by amending the NHS charging system. At present the government pays for everyone’s treatment. In France the elderly, unemployed, poor and children receive 100 per cent free treatment. Others have a proportion of their costs — usually 70 per cent — paid by the state. If they wish they can take out private insurance for the rest. My monthly insurance cost of €100 is less than my car insurance. In effect, this is an additional health tax on those who can afford to pay without all the complications of raising and hypothecating it.

France spends a higher proportion of GDP on its health service, with the top-up coming through health insurance. A recent analysis by the Nuffield Trust, published in the BMJ, estimated that if Britain were to spend the same as France the NHS would have another £24 billion a year — substantially more than the Brexit bus’s promised £350 million a week.
Paul Barnes

L’Horte, Languedoc-Roussillon

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Yet another surgery closes. St Clements in Neyland …. How to make a population angry…

Yet another surgery closes.. NHSreality has been told of scores of surgeries closing since the last post on this subject. Neyland has two surgeries, and so one will have to do. Some closures lead to large travelling needs, great inconvenience, and sometimes expense. The idea that “access” should be free and easy is being challenged by a thinning primary care workforce – why? There are just not enough doctors, and this is only the beginning of a ten year decline. A&E departments, particularly in Wales, (Owain Clarke for BBC Wales: A&E safety risks ‘unacceptable’, first minister warned) are imploding, and as NHSreality has pointed out in the past, there may come a day when ambulances ask the patient to choose between state A&E and Private A&E departments. Do the people of Neyland, who have another practice they can attend, prefer a surgery manned by paramedics and nurses, untrained in differential diagnosis or living with uncertainty? Fortunately, Pembrokeshire is benefitting from increasing numbers of Trainee applicants for General Practice, mainly due to financial inducements, and will be relatively better off in 5 years time than other regions. In the last 6  months 50,000 patients have lost their surgery.….. over 2 years about 4 million. This becomes a sizeable, angry, voting population….

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The Western Telegraph reports 17th Jan 2018: Public meeting announced to fight plans to close St Clements Surgery in Neyland.

Neyland looks set to lose one of its two doctor’s surgeries.

Argyle Medical Group is planning to close the St Clement’s Surgery, it announced on Wednesday.

It means Neyland patients will have to pay £1.50 a time to cross the Cleddau Bridge to attend appointments in Pembroke Dock’s Argyle Street surgery.

Argyle Street itself is already under major pressure with photographs over recent months showing patients in large queues trying to get appointments.

In a statement posted on Facebook on Wednesday evening, Argyle Medical Group, said: “Argyle Medical Group has submitted an application to Hywel Dda Local Health Board to close the Branch Surgery at St. Clements Neyland.

“The reason for this application is to consolidate & maintain patient care services at a time of reduced GP numbers at the practice.

“Despite concerted attempts at GP recruitment over recent years the practice has been unsuccessful. The practice has been successful in recruiting a further Nurse & Pharmacy practitioner & is continuing to try to recruit further such practitioners.

“The practice plans to increase its capacity to deal with urgent medical problems by offering increased clinical practitioner appointments. These practitioners will be backed up by a GP to provide immediate advice as needed. It is planned this service will be provided from Argyle Surgery, Pembroke Dock alone.

“Argyle Medical Group will continue to provide the full range General Medical Services to its registered patients in Neyland & the surrounding area. In order to facilitate the enhanced same-day service at Argyle Surgery it is proposed that appointments at St. Oswalds Surgery, Pembroke will change from a same day to a pre-booked appointment system.

“The practice consider this action to be the only option to enable a safe level of clinical care to be offered to all its registered patients at a time when recruitment & retention of clinical staff is extremely challenging.”

The move has sparked anger in the town with patients blasting the decision as ‘absolutely disgraceful.’

Neyland county councillor Simon Hancock said the move cannot be allowed to happen.

He has organised a meeting for Neyland residents.

Cllr Hancock said: “A public meeting will be held at Neyland Athletic Club next Thursday 25 January at 7pm to protest against the proposed closure of St. Clement’s Surgery. It cannot be allowed to happen.

“A campaign committee will be formed. Please come along to show your support for a matter of enormous importance for every person and family registered there.”

Cllr Hancock, who is mayor of Neyland, added: “The proposed closure of the surgery is completely unacceptable and will put patients in Neyland and the surrounding villages at risk.

“A town of the size of Neyland needs good quality medical facilities and the Argylr Medical Group will be breaching their responsibilities in seeking to close their Neyland base.

“People without transport will be disadvantaged, people will have to pay travel costs and the consequences when the Cleddau Bridge is closed to all traffic are  too shocking to contemplate.

“I hope we have an excellent and representative turnout  to the public meeting to fight the proposed closure. Simply this is a battle Neyland cannot afford to lose.”

Fellow Neyland county councillor Paul Miller, said: “‘While I understand recruitment of GP’s is difficult this proposed move is a serious betrayal, by the Argyle Medical Group, of its patients in Neyland.

“I’ll be standing side by side with the people of the town in opposition to what would be a serious backward step in the provision of vital medical care.

“The Health Board must block this request and engage with us in an urgent conversation about providing a sustainable GP service for Neyland.”

Preseli Pembrokeshire MO Stephen Crabb said: “This is hugely disappointing news that St Clements Surgery feel the need to close due to a failure to recruit.

“Pembrokeshire is a fantastic place to live and work and more should have been done by the Hywel Dda University Health Board and the Welsh Government, who hold power over the NHS in Wales, to ensure that St Clements Surgery had staff in place to remain open.

“The Welsh Labour Government have known about recruitment problems in rural practices for a long time and have failed to come up with a strategy.

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

Jeremy Hunt to unveil state-backed GP indemnity deal. Bribery is an admission of perverse recruitment and education processes..

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

Patient died in care of unqualified paramedics

Its more than a thin front line, as half timers take over from deserters…

2,000 foreign GPs needed to tackle growing shortage. How about an apology to 20 years of rejected applicants to medical school?

Jan 27th 2016 – almost 2 years ago: The sick parade – of GP closures. This list heralds the end of the health service as we knew it.

Nick Bostock in GPonline 18th Jan 2018 Practice mergers or closures affect 50000 patients in 6 months.

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Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

There is no perfect healthcare system, but some are better than others in results, and others are better in sustainability. The UK thinks it’s 4 healthcare systems are good enough, but most people are stoically accepting of shared rooms, cross infections, lack of post-code equality, and long waits for access…. until they themselves are victims. Then it’s too late, and if they can afford it they go privately.

Mark Littlewood (director-general of the Institute of Economic Affairs.) opines in the Times business comment 15th Jan 2017: Winter has come and Britain needs a cure for its ailing health service

In the hit television series Game of Thrones, there is a recurring and unsettling meme. “Winter is coming,” mutter the leading characters in hushed tones. We, the viewers, are left in no doubt that the impact of this seasonal event will be dramatic indeed. Little can be done, apparently, to prepare for it, you just need to brace yourself for its icy grip and its life-threatening impact.

Those who fret about the state of the National Health Service often seem caught in this same cycle of despair. Each year, we can be certain that the weather will worsen and the temperature will drop in the Christmas and New Year period, but we can’t seem to do a great deal to equip ourselves to tackle the associated impact on people’s health.

Although some winters are worse than others, this is now an annual event. We can simply expect, every year, there to be a lack of available beds, missed targets on treatment times and the cancellation of a swathe of operations. Lives are lost and patients remain in pain and misery as a result. The only upside seems to be that the high level of human suffering is at last opening up the beginnings of a measured debate about whether there may be alternative models of healthcare provision that are preferable to the UK system. Other European countries also have winters, but they don’t appear to be accompanied by high-profile political battles about the unbearable stresses and pressures on their health services.

A rational approach to considering whether we have more to learn about healthcare from the rest of Europe than to teach it needs to have some agreed parameters. First, we need to be clear about where we stand on funding. This should, in theory, be relatively straightforward. The UK spends about 10 per cent of GDP on healthcare, both public and private, up from a more miserly 6 per cent at the start of the century. This is a little lower than some other rich EU countries but not by an order of magnitude. In the same way that you might expect a £30 bottle of wine to be of modestly higher quality than a £25 bottle, you might also expect Swiss or German healthcare to be just a little better than its British equivalent. There shouldn’t be a great deal in it, especially if the producers of the £25 bottle purport to be the envy of the entire world.

Enhanced funding might well improve results, but it cannot be the only factor in explaining wildly different health outcomes, given that the UK finds itself broadly in the middle of the pack on expenditure.

Second, we should accept that there is almost unanimous agreement about two underlying principles of healthcare provision, right across the political spectrum. High quality healthcare should be universally accessible and essentially free at the point of delivery. Of course, the NHS itself occasionally diverts from the latter rule, with modest charges for prescriptions and the like, but the key idea is that everyone needs to be able to access treatment and surgery and no one should need to pay prohibitive fees to receive it. Very likely, the staunch public support for the NHS in opinion polls is really a reflection of an underlying commitment to universality and no material charges at the point of need, rather than for the NHS branding or name. Where debate tends to veer off up a blind alley is the unspoken assumption that the UK system is unique in the world in adhering to these two vital principles. The truth is that virtually every developed country has embraced both principles with the same unbending commitment that we have in Britain.

Third, we need to agree that anyone who frames the choice over healthcare systems as essentially being a binary decision between the NHS and the American system should be excluded from the debate. It is an extraordinarily Anglocentric and narrow-minded approach to assume that no country other than the UK and the US should have their own system even considered as a viable option. I have met no one who wants to adopt the American approach to healthcare on this side of the Atlantic; it is fiendishly expensive and appallingly bad at securing access to good treatment for poorer members of society. In some areas it does produce impressive aggregated results (for example, on cancer survival rates) but given that the Americans spend an enormous 16 per cent of national income on health, it is disappointing that their results aren’t considerably better.

If we approach the debate in this way, we may well conclude that the schemes used by most countries on the Continent are preferable to the NHS model. Although systems vary, the basic idea is that each individual has an insurance package that pays out when they need treatment. Those with the means to do so would have to pay for this insurance themselves — in the same way that drivers are obliged to take out motor insurance. Those on tighter budgets would have their premium topped up, or wholly paid for, by the taxpayer. We could insist, through the law, that pre-existing conditions are not considered in the premium charged, so the system is equitable and the risks shared across society. The question as to how much we should spend on healthcare overall is an important argument, but a separate one.

When winter comes in Germany, the Netherlands, Switzerland or Belgium, it is not typically accompanied by their health systems plunging into crisis. They appear to be able to deal with a change in the seasons effortlessly and without spending a great deal more money than we do in Britain.

This year marks the 70th anniversary of the National Health Service, which seems a good time to ask ourselves whether we have a monopoly on wisdom in how to provide healthcare. If we wrongly conclude that we do, we should brace ourselves for many more winters like this one.

Mark Littlewood is director-general of the Institute of Economic Affairs.

Compared with 11 other countries UK ranked first – for it’s system and not for it’s outcomes

As the 4 state systems fail, more taxpayers go private. A two tier approach to rationing by default rather than by design means no fairness for anyone.

The Commonwealth Fund compares health systems. Unreality of MPs. ..

Mark Britnell “In search of the perfect health system”, (published by Macmillan Education and Palgrave ISBN 978-1-137-49661-4)  2015 – Reviewed on NHSreality


We must avoid the mistake of a hypothecated health tax – unless the tax takes income and capital into account.

Mistakes are all part of medicine. We make small mistakes all the time, and the pressures of work are part of this lack of perfection. Medical students have always helped out on teaching hospital wards, and it is fake news to suggest this is new. What is new is if their work is unsupervised, and if patients have no choice to opt out. There are some people who will take 17 stabs at a vein, and some patients will have PTSD as a result… Choice is part of Liberal philosophy, as is a progressive tax system whereby inequalities are reduced, and the tax system enhances choices. Hypothecated taxation could well be regressive rather than progressive, it could increase post-code rationing, and unless it is applied allied with an identity card, and fees are related to wealth as well as income, it may come to be regarded as grossly “unfair”. The German two tier insurance system would be better, as it is only a small percentage of high earners who get the extras, and these are not related to medical outcomes: rather to choice, comfort and convenience.. Pithed Politicians have an invidious choice: they have to choose what is less divisive, less regressive, and less unequal. Whatever they choose will be “unfair” to some, but they need to avoid the mistake of introducing a new system and of it being unsupervised. Even Iran has studied this more openly than the UK. 

In a deserts based system where co-payments are related to means, infrequent attenders who kept healthy and looked after their own needs would pay more, but less frequently.. Impoverished frequent attenders would pay less, but more often. There could be a rewards system for reducing attendance, and there could be increasing fees for multiple attendees/families. There could be tax exempt savings (Health ISAs) to encourage thrift, with tax relief on health related savings accounts.

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How to give the NHS extra billions it needs –

The PM and health secretary should be bold and support the emerging political appetite for a levy to fund social care

Another winter, another NHS crisis. With operations cancelled and ambulances queueing outside hospitals, the prime minister has already been forced to apologise to patients. Last week 68 consultants in charge of accident and emergency departments warned that people were dying “prematurely” in corridors because beds are full. Medical students are being asked to fill the staffing gaps. This is not just “shroud-waving” by health professionals or scaremongering by opposition MPs, but the result of a genuine demographic change.

The NHS crisis is really a social care crisis, created by an ageing population and exacerbated by government cuts. Although health service budgets have been ring-fenced since 2010, there has been a £6 billion reduction in spending on social care and an entirely related 50 per cent rise in the numbers of elderly people stuck in hospital because there is nowhere for them to go in the community.

Over the past decade, 929 care homes have closed and more than 30,000 places have been lost because providers can no longer afford to operate on the money they receive from the state. On average, local authorities pay £486 per week for residential care, while the typical private user is charged £700. At least one council pays a shocking £2.31 an hour to providers. Care blackspots have developed in poor areas where there are not enough wealthier “self-funders” to cross-subsidise the places paid for by the government. This is a market that is being broken by its state users at a time when the Conservative Party is calling for a more responsible capitalism.

Jeremy Hunt, the health secretary, has persuaded the prime minister to add “social care” to his job title, but the money to pay for this essential service remains at the Ministry for Housing, Communities and Local Government, which is absurd. If the rebranding is to be more than a change to the headed paper, then the budget must also be transferred to Mr Hunt. The NHS, rather than councils, should then be put in charge of commissioning social care. In Greater Manchester, where this has already happened, the service has improved dramatically while money has been saved. Delayed discharges have almost halved and A&E visits are stable, with GPs visiting care homes to reduce the number of ambulances called. The partnership has approved a pay rise for care workers to avert a recruitment crisis, but is still running a surplus.

It costs about £250 a day for someone to be on a hospital ward and £100 for a domiciliary care package, so there is a motive for the NHS to help elderly people to go home. If local authorities are funding social care, they have a perverse incentive to transfer the cost to hospitals.

Whatever happens, the Treasury will have to find more money. Care homes should be paid the true cost of the service they provide, rather than having to rely on private self-funders to top up the public sector contribution through what is in effect a stealth tax on those who are unlucky enough to need expensive residential care.

Most importantly, the government needs to address the complete unpredictability of the cost for families. Although half of us will end up spending less than £20,000 on our care, one in ten will have care costs of more than £100,000. The Tories like to say that they support those who “work hard and do the right thing” but old age is quite literally a condition lottery in which those with cancer have their treatment funded by the NHS while those with Alzheimer’s have to pay for the cost of their care.

In her first conference speech as prime minister, Theresa May argued: “The state exists to provide what individual people, communities and markets cannot.” It’s hard to think of a more perfect example than social care. The only fair solution is to pool the risk between as great a number of people as possible so that everybody loses something but nobody loses everything.

The prime minister is nervous of championing reform after her disastrous manifesto pledge, dubbed the “dementia tax”. But the problem with the policy drawn up by Nick Timothy was that it raised the prospect of higher charges while failing to pool the risk. That was why Mr Hunt emailed No 10 as soon as he saw the plan (the day before the manifesto launch) to warn it was a “disaster”. With the health secretary now in charge of the green paper, due out this summer, the government will surely return to the idea of a cap on care costs, with anything above the agreed level funded by the state. Indeed, Sir Andrew Dilnot, whose commission first proposed such a scheme in 2011, has been appointed to an expert panel advising on the future of social care.

It will then be a political decision how to pay for the change. One option is to take the money out of people’s estates after they die, but this looks dangerously like the Labour plan condemned by Tories as a “death tax”. The government could raise some of the cash by means-testing pensioner benefits such as the winter fuel allowance and ending the pension triple lock but this has been ruled out by the power-sharing agreement with the DUP.

Mr Hunt is among a growing number of Tories attracted to the idea of a hypothecated health and social care levy as a way of making tax rises more palatable to the public. Last week Nick Boles, the former planning minister, proposed turning national insurance into a ring-fenced health tax. Oliver Letwin is a fan of the plan and Lord Macpherson of Earl’s Court, the former permanent secretary to the Treasury, which traditionally opposes hypothecation, has been won round to the idea.

Sarah Wollaston, the Conservative chairwoman of the health select committee, believes national insurance should also be extended to those beyond retirement age, who are presently exempt, in order to increase the money raised for health and social care. There could be a higher rate for older workers, as in Japan, which has an additional levy paid by those over 40.

Although sources say Mr Hunt is not “wedded” to the idea, he is “open to all the options”, including a dedicated tax, because he knows more money needs to be found. There would be widespread support for it on the Labour and Liberal Democrat benches.

With the number of people over 85 set to double by 2039, social care is now a much more pressing spending priority than reducing university tuition fees. There is no time for another royal commission, nor is there any need for one. A political consensus is emerging about what has to be done. It just needs courage and leadership to see it through. With nothing to lose after his reshuffle showdown, Mr Hunt is willing to be brave. The only question is whether the prime minister has the authority to back him up.

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Medical students are asked to help out in crisis-hit hospitals

Medical students have been asked to help out in overstretched hospital wards to deal with the winter backlog. The request came as leaders of Britain’s 220,000 doctors warned of a crisis in the NHS, which they said would get…

The NHS is already in crisis – Brexit could finish it off – New Statesman

Hypothecated taxation and the NHS – CentreForum (2014)

Hypothecated taxation is not the answer, and Brexit may “finish off” the UK Health services.

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

LibDems suggest hypothecated taxation – without examining the ideology

Hypothecated taxation? A separate NHS tax would rein in spending

The NHS can no longer provide everything to everyone, and we should “Look abroad for serious solutions to the NHS crisis”.

Inequity in Health Care Financing in Iran: Progressive or Regressive Mechanism?

The Inefficient English Health Service is compared with the German one. Hypothecated Taxation with choice of provider?

Laura Kuensberg comments for the BBC News 11th Jan 2018: Time for an answer on the NHS?

Pithed Politicians?

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Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

Brexiy buyers remorse may be increasing, as the message in health is clear. There is going to be less rather than more. The Guardian on 13th October published “Labour flags up Brexit poll suggesting public regrets decision”, and no wonder when rather than saving £350m we are losing more than twice than much, annually in the devaluation of the £ and the cost of imports.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts.. As the health services collapse, mainly due to lack of long term planning, and a political and media collusion of denial, some of the predictions in NHSreality are becoming true. The only thing that is National is the opportunity to buy better, faster private care…. We need more youngsters to man our service industry country, and if we don’t stay in the EU we may need to take the example of a town in Japan. (The Economist Jan 9th: A small town in Japan doubles its fertility rate).

The first part of the safety net is the GPs, and the second is the Hospitals and all their staff. 80% of health contacts are seen by GPs, but lives are saved mainly in the second net.. Rationing needs to happen at all levels and the letter from Dr Burt (below) should be read with care. NHSreality has asked for GPs to work alongside Oncologists and this alone would save millions.

Subsidising parenthood appears to work wonders

An unofficial two tier National system. (Where moneyed people go privately)

Covert and post code rationing.

A disengaged medical workforce.

A management wriggling on the inability hook: to make the books balance.

An English language which obfuscates the truth.

A collusion of denial between politicians and the media.

A system where even those fearful conditions, such as cancer, are not properly and fairly covered by the state safety net.  (Bring back fear instead of “In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear“)

Carolyn Wickware in Pulse reports 30th October 2017: GP leaders prepare for explosive vote on practices leaving the NHS

Sarah Marsh in the Guardian 11th Jan 2018: NHS winter crisis: hospital ‘felt like something out of a war zone’ – Husband of a patient and locum doctor share moving experiences of severe pressures on national health service

Kat Lay has reported on Cancer services, especially in Oxford, in the Times recently. Jan 11th: Hospice loses beds in NHS staff crisis and in the letters 12th Jan:

Cuts to cancer care owing to staff shortages

Sir, For the past three years we have been urging the government to tackle cancer workforce shortages in the NHS. It is totally unacceptable that these shortages could now lead to delays in patients getting treatment. This latest episode at the Churchill Hospital in Oxford (report, Jan 10), where chemotherapy may be delayed owing to a lack of specialist nursing staff, adds to a growing list, which includes cases where lung cancers were left undiagnosed because of a lack of radiologists. Immediate action needs to be taken by the government to deal with this, otherwise problems like the one at Oxford will become more widespread and more severe.

An additional 150,000 people are expected to have cancer diagnosed annually by 2035. We need more staff, with the right training and support, in the NHS to deal with the increasing number of cancer patients who need to be diagnosed and treated. We estimate that the projected 2022 consultant oncology workforce could be roughly half the size that it may need to be to deliver the best care, with a shortage of between 1,281 and 2,067 staff. Health Education England recently published its first-ever plan to deal with the staff shortages in cancer care, but this relies heavily on stretched local areas taking action and making difficult spending decisions, and will not change the situation overnight.

We have a national ambition to achieve world-class cancer outcomes for all patients. We will not get close to achieving this — and to offering patients the best chance of long-term survival — without tackling crippling workforce shortages.
Sir Harpal Kumar

CEO, Cancer Research UK

Sir, Oncologists need to take a long hard look at what they are trying to achieve. Response rates in second and third-line chemotherapy are very poor and inevitably interfere with quality of life. There is an obsession with including patients in clinical trials, which are costly and are often used for career progression rather than cancer progression. The hardest thing for an oncologist to learn is not how to treat patients but when to treat them. Many need to learn that no treatment is often the best treatment. It takes guts to tell a cancer patient that no further active anti-cancer treatment is now right for them. The best oncologists do that.

Oncology can surely not moan about staff shortages when literally dozens of consultants and senior nurses sit down for hours on end to discuss routine cancer cases, the management usually being obvious. Multidisciplinary team-working (or medicine by committee) is the biggest waste of NHS resources bar none.
Dr Paul Burt

Retired clinical oncologist, Stockport

Sir, Cancer care at the Churchill Hospital is likely to be compromised as a result of the shortage of trained oncology nurses. The reasons are multifactorial; one that is quoted by the management of the hospital is the high cost of housing in Oxford. Training more specialist nurses takes five years, whereas the introduction of an Oxford weighting to nurses’ salaries on a par with the existing London weighting could be introduced immediately. London is not the only city with housing costs well above the national average. No doubt new money would have to be found to do this but it would go some way to help nurse recruitment in high-cost areas.
Griffith Fellows

Retired urologist, Churchill Hospital, Oxford

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

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





Its more than a thin front line, as half timers take over from deserters…

With apologies to the Economist, NHSreality feels this article is an honest summary of the situation and state of General Practice today. Where possible I have linked to previous postings in support. But even if the manpower planning had been better, and if politicians had avoided the repetitive short termism, we still  need a joined up system, and the unified electronic record is where we should start. Cash is not enough — the NHS must be forced to unify: the only cure is a properly joined-up health service (Camilla Cavendish in the Sunday Times 7th Jan 2018) Its more than a thin front line, as half timers take over from deserters… To add fuel to the fire, GP premises development has not been facilitated, even though moving care out of hospitals is policy.

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The Economist: A thinning front line The NHS’s latest problem: a shortage of GPs – As hospitals struggle with a winter crisis, a longer-term problem is brewing in primary care

IN PLOIESTI, just north of Bucharest, Daniela Margaritescu had a grand house, a big car and her own surgery. But when she set eyes on the Beechfield Medical Centre in Spalding, Lincolnshire, it was “love at first sight”. The 46-year-old Romanian was hired last year as part of a pilot scheme to recruit more foreign doctors to fill chronic vacancies in primary care. For Dr Margaritescu it is a “perfect” deal. She learns new skills, her three children attend good schools and her pay has roughly doubled. For their part, the people of Lincolnshire—who voted heavily to leave the European Union in the referendum of 2016—are happy to have new doctors at last.

As people return spluttering from their Christmas holidays, the National Health Service is entering its busiest time of the year. On January 3rd Jeremy Hunt, the health secretary, apologised to patients after non-essential operations were suspended until the end of the month to ease the pressure on hospitals. Senior doctors took to Twitter to lament the “third-world” conditions on wards. But although the scenes in hospitals, where patients have been left waiting on trolleys in corridors for hours, are dramatic, a less-noticed crisis is under way on the front lines of the NHS. General practitioners (GPs), patients’ first port of call and the gatekeepers of most health services, are a dwindling army.

Take Lincolnshire. Before the arrival of Dr Margaritescu and 24 other doctors from eastern Europe, 104 of the county’s 434 potential spots for GPs were vacant. The Beechfield practice ran three recruitment rounds without finding a suitable candidate. “People drive past [Lincolnshire] on the way to Scotland, and then again on the way back to London,” says Kieran Sharrock, medical director of the local body that represents GPs. There is no medical school in the county, depriving it of a pipeline of talent. Doctors balk at joining remote practices with lots of old patients; in some Lincolnshire surgeries, half the patients have at least four chronic diseases.

Lincolnshire’s woes are particularly severe, but across the board the NHS is struggling to hire and retain GPs. It recently changed how it counts them, so deciphering trends is tricky, but the number of GPs has probably been falling since at least 2009, during which time the number of hospital consultants has risen by a third. In 2016 Simon Stevens, the chief executive of NHS England, pledged to recruit 5,000 more GPs over the next five years. But the count has fallen further, reaching the equivalent of 33,302 full-time GPs in September, 1,290 fewer than two years earlier. The number of surgeries has dropped to 7,674, from 8,451 a decade ago. Some towns face losing most of theirs; last year seven of the eight practices in Folkestone, on the south coast, said they intended to close.

Even before the creation of the NHS in 1948, family doctors played an outsized role in providing health care in England. Their pivotal position was described in the novels of Anthony Trollope and George Eliot. Today Mr Stevens calls the GP arguably the most important job in Britain. They decide when to refer patients for hospital care, and provide a wider range of services than their peers in many countries (Polish doctors in Lincolnshire note that back home they rarely saw children or dealt with gynaecological cases). And their role is set to become even more important: the government wants more patients with chronic conditions to be cared for outside hospital, which will require GPs to co-ordinate treatment.

What seems to be the problem?

The shortage of GPs partly reflects a change in the workforce. In 2006, 43% of GPs were women; a decade later the share was 55%. It is set to rise further, since male GPs are closer to retirement age, on average. Because only one-fifth of female GPs work full-time, compared with half of male GPs, more of them are needed. A recent analysis by Imperial College London suggests that an additional 12,000 GPs will be required by 2020—more than twice the NHS’s target.

Another reason is that the job has become less attractive. GPs complain of having to do more work for less pay—and they have a point. The English population has grown by 4.3m in the past decade, and patients are seeking help more often than they used to. The number of consultations per patient increased by about 10% between 2007 and 2014, according to a study in the Lancet, a medical journal. A survey of GPs in 11 countries by the Commonwealth Fund, a think-tank, found that 92% of British GPs reported typically spending less than 15 minutes with a patient, compared with 27% of GPs in other countries. British GPs were also the most likely to say they were stressed.

One London-based GP describes a “light day”: 25-30 scheduled appointments; five to ten emergency ones; one or two home visits; 30-50 replies to be written to hospital doctors, plus a similar pile of pathology reports to read; and 10-20 repeat prescriptions to process. Some feel like secretaries, writing referrals for ungrateful patients. It is a lonely job, without the camaraderie of a hospital ward.

Over the past decade GPs’ pay has fallen. In 2004 the Labour government agreed on a contract that raised the average pay of a partner in an English surgery to £136,665 ($185,000) in today’s prices. Since then partners’ pay has slipped to £104,900, as successive governments have made the contract less generous. Salaried GPs earn an average of £63,000, less than hospital doctors with similar experience. And, unlike those clinicians, GPs pay thousands of pounds a year in indemnity insurance.

In an ordinary labour market, employers could raise pay to fill vacancies. But the NHS, the world’s fifth-largest employer (behind the American and Chinese armed forces, Walmart and McDonald’s) does not operate in an ordinary labour market. In effect, pay is set at a national level. The number of doctors to be trained in each specialism is determined centrally years in advance. Since it typically takes ten years to train a GP, failures of planning mean shortages that take a decade or more to fix.

The government has said it will increase the number of places at medical schools by 25% from September. (Unlike other degrees, there is a cap on places to study medicine, because the course is heavily subsidised.) But that will take time to translate into more GPs. It will also require universities to improve the reputation of general practice; for a certain type of thrusting medical student, only dentists are viewed with more disdain than would-be GPs.

With no end to the staffing problem in sight, some surgeries are adapting. They are employing more paramedics, nurses and pharmacists to see patients. Several surgeries are becoming mega-practices, spreading the GPs they have across many sites. Others will increasingly rely on doctors from overseas. Britain already employs a higher share of foreign doctors (27%) than the average across the 28 members of the OECD club (17%). Of the 12,771 doctors who registered in Britain in 2016, 44% had qualified overseas.

According to research by Aneez Esmail of the University of Manchester, and colleagues, foreign-trained GPs are more likely than British ones to work in poor areas, earn less money and work longer shifts. But doctors trained abroad also score lower on postgraduate medical exams, and are more often subject to complaints. In Lincolnshire the doctors recognise they have a lot to learn. Accordingly, for their first two years they get twice as much time to spend with patients as other GPs do.

Those running the pilot believe that it will continue after Britain leaves the EU, given the need for GPs. The NHS has said it wants the programme to be scaled up to attract 2,000 foreign GPs. Tomasz Grela, a genial new Polish doctor in Spalding, is not too worried about Brexit. “The medical system needs us,” he says. And although he readily concedes that he needs to get up to speed with the British system, he is showing signs of acclimatisation. Asked what frustrates him most about the NHS, he gives the same response as most British doctors: “Bureaucracy.”

This article appeared in the Britain section of the print edition under the headline “A thinning front line”

Call Dr Stalin: the NHS must be forced to unify – Cash is not enough — the only cure is a properly joined-up health service

General Practice is “Closing Down” … Presentation for a unified IT system rejected 1996 / 2001

Facing an understaffing crisis….. Those rejected during the last 30 years should be asking why?

Gender bias. The one sex change on the NHS that nobody has been talking about

A retired GP says retiring “.. was like leaving an abusive relationship”

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

An exodus because of poor planning and the shape of the job. Deprofessionalisation….

Who wants to be a GP? Rebuiling Trust is not just needed for juniors… The NHS: How bad will it get?

Here is an idea to fix the NHS: let’s get rid of GPs. Lets see how Scotland’s GPs vote…Dementia is going to overwhelm all our services, including our GPs unless we address reality…

Despite “adequate or average” funding, our waiting lists are much higher than average. Even communication is failing at a basic level…

Public must pay for better NHS, says Stevens to spineless politicians at King’s Fund

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

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

Mr Hunt needs 40,000 GPs in the next 10 years. 1,500 extra per annum with a 10 year lead in will make no difference.

Severe shortage of GPs is reaching crisis-point in Derbyshire – only 37% of GP training places filled – due political rationing of Medical School places 10 years ago, and the shape of the job

Exhausted GPs shun out-of-hours work. The long term result of rationing medical school places, of declining skill standards, and governments showing they “couldn’t care less” for years.

would the British public be happy to swap a shorter GP consultation time for a longer one that involved payment of it and additional services?

GP premises development frozen, GPs forced to publish pay from 2015: What about comparing overhead?

Child health care: adequate training for all UK GPs is long overdue

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

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