Category Archives: Post Code Lottery

When will public anger over the NHS reach a political tipping point? More NHS mental health patients treated privately…

It seems we are a long way from the tipping point whilst “most” services are up and running for the articulate and coherent. NHSreality has opined that “civil unrest” is not far below the surface, but whilst the Regional Health services can hoodwink their populations, and whilst citizens (mainly healthy) can remain in denial as their elderly and mentally infirm get a “rough deal”, and whilst the media and press, including Toynbee, fail to grasp that “overt rationing” is a pragmatic necessity, post coded and covert rationing will drive more and more into private care, and result in a two tier service. Harry may have had “counselling” but I expect it was private, unlimited, and done by a fully trained psychology counsellor. In the Health service it would be limited to six sessions, provided by a Nurse Counsellor who has done an extra short course, and terminated when the allowed sessions expired.

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Polly Toynbee in the Guardian 13th April asks: When will public anger over the NHS reach a political tipping point?

here is an ebb and flow in reporting on the NHS as Trump, Syria and Brexit dominate front pages. But the pressure-cooker state of the entire service still worsens. This morning’s latest figures are just a snapshot of deterioration – but every target is missed: for A&E, ambulance response times, for treating psychosis within a week, for cancer waiting times, blocked beds and diagnostic tests.

“Demand” is rising, the government says, as if serious illness were a choice, though the pressure comes from well-predicted, rapidly increasing numbers of old, sick people: this February’s A&E figures are, as ever, better than deepest winter January, but worse than February last year, as this crisis ratchets up.

Major A&E centres are treating 81.2% of patients within four hours, against a target of 95%, which used to be hit before 2010. The government likes to blame frivolous users of A&E, but those are easily triaged to on-site GPs. Serious delays are because of very ill people needing to be admitted with no empty beds: bed occupancy is at dangerous levels, as Chris Hopson of NHS providers warns, where doctors often have to decide “one in, one out”, discharging those who still need more care too early.

Take the temperature in virtually every part of the NHS and the wonder is how the heroically overstretched staff keep the wheels on the trolley. Take this week alone: the Royal College of Physicians says 84% of doctors have to cope with staff shortages and gaps in rotas.

GPs? Two years after a government promise of 5,000 more GPs, numbers are still falling. They dropped by 400 just in the last three months of last year: as doctors find the workload unmanageable some escape abroad, take earlier retirement or become locums. Too few new doctors want the burden of running a GP partnership, so 92 practices closed last year, tipping hundreds of thousands more patients on to already overloaded neighbouring GP lists.

Today the Royal College of Nursing, traditionally most reluctant of unions to take action, starts consulting its members on whether to hold a strike ballot. But with public sector pay frozen yet again at 1%, when inflation will shortly hit 3%, nurses are departing – as are doctors – for less stressful, better-paid work. Recruitment from the EU is plummeting, as predicted…..

…This is the dismal background to the reorganisation that the head of NHS England, Simon Stevens, is attempting, almost undercover. His state-of-play review of his five-year forward plan passed hardly noticed, announcing a first tranche of England’s 44 STPs, (sustainability and transformation plans) to reconnect local services fragmented by the Lansley 2012 act.

Most observers think it the right way to go, putting the NHS and social care under a united structure with one finance hub, ending destructive and expensive competition and tendering of services. But hardly anyone thinks this can be done with no new money: every STP calls for capital for new beds and units. Virtually all involve closures and mergers stirring a local political outcry.

Jeremy Hunt, who always presented himself as the patient’s ally, rooting out poor quality, wallowing in the Labour disaster at Mid-Staffs, has fallen uncharacteristically quiet. He has nothing much to say about patient safety in A&Es or elderly patients turned out of beds too soon. Not even deaths on trolleys in A&E corridors in Worcester roused his usual righteous ire.

Concern about the NHS has risen high in recent polling: what no one knows is when public anger will reach a political tipping point. Theresa May and Philip Hammond stay iron-clad adamant: all this is NHS shroud-waving and there will be no more money. Lack of any opposition helps, but can they really tough it out where Margaret Thatcher, John Major and Tony Blair all bent in the face of NHS crises?

Chris Smyth in the Times 18th April reports: Sick children ‘denied drugs to save money’ and Spendthrift NHS regions face big cuts. This is the reality of todays health services, and which/what quality of service depends on which. post-code you live in. You cannot plan for the deficit, because the “priorities” change from year to year.

George Greenwood for BBC 18th April: More NHS mental health patients treated privately

 

Doctors warn NHS is rationing best drugs to cut costs

Far better to have fairness in rationing so that all of us know what is excluded, wherever we live. Devolution and GP Commissioning have ensured inequality, and covert rationing of fearful conditions. Remember, drugs do not improve the health of populations… This is an issue for public health consultants, but are there any left?

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Jon Ungoed-Thomas in the Sunday Times 16th April reports: Doctors warn NHS is rationing best drugs to cut costs

Hospital doctors have revealed how some of the best available medicines are being rationed by the NHS in a cost-cutting drive.

Doctors including gastroenterologists, rheumatologists and dermatologists say they are being prevented from prescribing the most appropriate drugs by their local clinical commissioning groups (CCGs).

CCGs are already reducing the number of hip and knee operations by using pain thresholds to ration procedures.

Now a survey of 200 clinicians, commissioned by the drugs company UCB and conducted by ComRes, has found that seven out of 10 clinicians claim NHS funding pressures have restricted their ability to prescribe approved medications.

The Breast Cancer Now charity revealed last year that some women were missing out on a potentially life-saving drug that costs 43p a day. Bisphosphonates cut the risk of cancer spreading to the bone, but many CCGs have blocked their use.

Dr Thomas Sheeran, a consultant rheumatologist at the Royal Wolverhampton NHS Trust, said bureaucratic hurdles and financial restrictions were hampering clinicians. “It’s frustrating that the people we have to try to persuade are accountants and the CCGs,” he said.

In one case last year he said a woman at risk of going blind was turned down by her local CCG for £2,000 of drugs to save her sight. The woman was admitted as an emergency patient so the trust could pay for treatment.

The drug in question, infliximab, is approved for use by the National Institute for Health and Care Excellence (Nice) for some conditions, but the treatment for this patient was considered experimental.

Sheeran said another drug used to treat arthritis and approved by Nice, abatacept, was not being permitted by Wolverhampton CCG for some patients.

He said there were concerns that patients who were not given the most suitable drug were more likely to be readmitted to hospital, so the drive to cut the drugs budget was in fact not cost effective.

Patients are entitled to drugs approved by Nice for specific conditions, but there is often no national guidance and CCGs make their own funding decisions.

A spokesman for NHS England said: “As the NHS goes into the most financially challenging few years in its history, it is right that we strive to ensure maximum value for patients from every penny available, but ultimately these are legally decisions for clinical commissioning groups, informed by best evidence and national guidance where appropriate.”

A spokesman for Wolverhampton CCG said that although it could not comment on individual cases, “a number of individual funding requests have been approved for the prescribing of abatacept”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NHSreality has long supported No Fault compensation.

Harmonising Compensation in NZ

NO-FAULT MEDICAL LIABILITY COMPENSATION SYSTEM in NZ and Sweden

We all pay the same tax…. but “Scotland gets cancer drug that is too expensive for England”. The Times advocates rationing ..

Whilst it will not mean a disaster in differential outcomes for the population, this post-code differential highlights the anomalies of our 4 regional health services. It reinforces the WHO opinion that there is no longer an NHS. It brings back fear when we should be reducing it, and it makes it clear that rationing overtly is the pragmatic answer. I too would exclude Kadcyla for terminal patients. The main beneficiaries of the Scottish decision are Roche shareholders.. The Times leader advocates rationing, but not necessarily “overtly”.

 Chris Smyth reports 12th April 2017 in the Times: Scotland gets cancer drug that is too expensive for England

A life-extending breast cancer drug rejected as too expensive for England and Wales is to be made available to Scottish patients.

Scotland has also become the first part of the United Kingdom to offer a pill that cuts the risk of HIV infection by 90 per cent after NHS England fought a court battle to avoid paying for it. Campaigners warned that English taxpayers would not put up with subsidising treatments in Scotland that they could not get themselves.

Scottish public spending is £10,500 a head against £8,800 in England, with the NHS getting £2,100 and £1,900 per person respectively. English and Welsh taxpayers contribute more to Scottish health spending through the Barnett formula.

The drug Kadcyla can offer an extra nine months of life to patients…

We should all care about the UKs unequal health services. “Who Cares: the play that puts the NHS under the knife”

All the Health Services are sinking – who will be bold enough to re-design their replacements, before its too late to take to the lifeboats?

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

The Times leader encourages rationing – a policy denied by all politicians. “Drug Frontier” – It is wrong that a cancer drug is available in Scotland and not in England or Wales – 11th April 2017:

adcyla is an advanced breast cancer drug that prolongs the life of patients for an average of nine months and in some cases for much longer. It is also, at £60,000 to £90,000 a patient, one of the most expensive cancer treatments ever brought to market. Despite this the drug is readily available to women in 18 European countries, including Germany, Austria, France and Scotland. But it is not available in England or Wales.

An important cause of this disparity is health spending per head that is significantly higher in Scotland than in England, thanks largely to the generosity of the Barnett formula by which block grants from Westminster to Holyrood for public service subsidies are calculated. For the 1,200 women in England and Wales who could benefit from Kadcyla, and who help to fund both their own and Scotland’s health services through their taxes, this is not merely back luck. It is an unconscionable injustice.

These women and their families may ask what can be done to fix such blatant unfairness. Experience suggests an answer, but not a satisfactory one. Recent pricing battles between pharmaceutical companies and the National Institute for Health and Care Excellence (Nice) involving other cancer drugs have shown that when Nice and the NHS bring to bear the full force of their leverage as one of the world’s biggest drugs buyers even the biggest companies can be persuaded to lower their prices.

“The system is working,” Sir Andrew Dillon, Nice’s chief executive, claimed last month. If so, it is working in a way that leaves patients in limbo and desperately anxious while the regulator and the drugmakers bargain with each other. In the case of Kadcyla, it has so far not worked at all. Roche Pharmaceuticals, the drug’s Swiss manufacturer, has been under pressure to lower its cost for three years and has not budged. There is still hope, since the company may decide that discounted sales to such a big customer are better than none, but as the two sides haggle, patients die.

The gap in per-capita health spending between England and Scotland is narrowing but still conspicuous. It roughly halved from £213 a person a year in 2010-11 to £103 a person four years later. The difference is not funded by any underlying strength of the Scottish economy, which has contracted as world oil prices have fallen by more than half in the past six years. It is funded chiefly by Westminster, as shown by the overall gap in per-capita public spending between the two countries. Even as Scotland’s national income has fallen with its oil revenues, its total spending per head has remained at least 18 per cent higher than in England.

The two countries’ health services are independent of each other and can set their own priorities. Simon Stevens, chief executive of NHS England, has admitted that certain costly cancer drugs once available either as a matter of course or through the Cancer Drugs Fund will no longer be because he has prioritised GP surgeries and mental health. The fund is in any case overspent and being wound up. The list of drugs not available on the health service will lengthen.

This newspaper accepts that as people live longer and treatments get costlier the NHS must ration its services or find more sources of funds. The case for a new funding model is only strengthened by the fact that a world-class treatment is available in Scotland but not in England. The case for Roche to cut its prices is even stronger.

 

Creeping closer and closer to overt rationing – but without the debate needed.

It’s not really the blood sugar which need monitoring, except in an emergency when most patients will know if they are at risk of high or low (more dangerous) sugar levels. The real testing that is helpful is the Hba1c levels, and these Glycated Haemoglobin levels are not available to patients as yet. Hba1c averages out the sugar levels over months. Rationing strips is rational.. but it should be universally and equally applied to all citizens. We have known about this since 2013 – it is not new news.If it becomes overt, and recognised by politicians then that IS news. We are creeping closer and closer to overt rationing, but without the debate needed to win hearts and minds. Nearing Easter and egg time Diabetics may need more monitoring…

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The Belfast telegraph on April 6th reports: NHS rationing ‘restricts access to diabetes testing strips’

People with diabetes are being refused blood glucose testing strips due to NHS rationing, according to a new report.

The Diabetes UK study found that people with the condition – who need to test their blood glucose levels several times a day – are having restrictions placed on how many strips they can have, sometimes by GP receptionists.

Many Clinical Commissioning Groups (CCGs), which have come under fire for rationing other NHS services, have guidance on how often people should test their blood glucose and how many boxes of strips should be issued per month.

They have also urged GPs to switch patients to cheaper blood glucose meters and cheaper strips (less than £10 for 50) – sometimes against the patient’s will.

Diabetes UK said the rationing was a “false economy” because the cost of dealing with complications caused by poorly-managed diabetes, including stroke, heart disease, amputations and blindness, is far higher.

A Diabetes UK survey of more than 6,000 people found 25% had not been prescribed enough test strips for their needs.

A separate poll of over 1,000 people found 27% of patients had either experienced restrictions or been refused test strips, compared to one in five four years ago.

More than half (52%) of these had Type 1 diabetes, which is controlled by insulin.

The National Institute for Health and Care Excellence (Nice) recommends that all Type 1 patients self-monitor blood glucose levels, testing at least four times a day.

People who are frequent drivers, take regular exercise or who are at high risk of suffering low blood sugar may need to test up to 10 times a day. Illness such as flu can also cause erratic blood sugar levels and more testing.

The charity said it was also concerned that people with Type 2 have been told they do not need to test their blood sugar, despite those on insulin and some medications needing to.

The report said: ” Budget constraints or ‘excessive testing’ were often the reasons given to people to explain why the restriction was occurring. People with diabetes found these restrictions stressful and had to make difficult decisions about when to test or not.”

One patient said: ” I was told they were expensive and we should test less. Only need to test four times a day. We use an (insulin) pump so need to test every two hours.”

Another said: “They said I had my allowance for the month. There is a blanket limit on the number of test strips available to diabetics across the CCG.”

Another patient said: ” Doctor’s receptionist told us we test too often “, while another said: ” I had to get my diabetes specialist nurse to ring my GP receptionist who was the one who questioned my use of strips on several occasions.”

One said: “I feel annoyed that every week or so I need to keep ordering and that I need to justify myself to a surgery person that knows nothing about what we go through. ‘

The report said people were being forced into testing less, or were trying to buy strips online or via eBay, despite concerns about quality.

It also said some patients may not meet requirements set down by the Driver and Vehicle Licensing Agency (DVLA), which says some patients must test every two hours.

In the survey, 66% of people were also given no choice of blood glucose meter and had been switched to a different, cheaper meter, without any discussion with them.

Of these, 25% were not happy with the meter provided, including that it was was too large to carry around or did not upload the data to a computer.

Some patients were forced on to cheaper meters when their test strip prescription ran out, leaving them no choice but to accept a different meter.

Diabetes UK policy manager Nikki Joule said: “These short-sighted cost savings cause people real anguish and potential financial distress.

“It also means people are struggling to manage their diabetes, which can lead to serious consequences for their health, so we urge people to challenge restrictions and refusals.

“Local policies should allow sufficient choice and flexibility for individual circumstances to be taken into account when prescribing test strips and meters for people with Type 1 or Type 2 diabetes.”

Professor Jonathan Valabhji, NHS England’s national clinical director for diabetes and obesity, said: “Ultimately these are decisions for CCGs, but should be informed by best evidence and national guidance where appropriate.

“We need to ensure adequate provision and that clinicians take into account widely recognised Nice guidelines, which are clear about the need for test strips to support people in particular with Type 1 diabetes.”

Rationing in the NHS – Analysis From Nuffield Trust – nuffieldtrust.org.uk‎

Rationing ‘already widespread in the NHS for a … – Belfast Telegraph September 2016

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Invidious options: to have to choose between fears is not necessary.

In Place of Fear (A Free Health Service 1952 Chapter 5 In Place of Fear), citizens are asked to choose between two fears: cancer or emergencies. Which is the greatest will be different for different individuals… As a 66 year old man my chances are greatest for Ischemic Heart Disease, but I have also had two cancers so I am at more risk of another than the average individual. As I get older I am at risk of a fracture, particularly fractured neck of femur, which in my case will be complex as I have had two hip replacements. There are strong arguments for individuals such as myself, living in a region (Wales) without choice, for moving near to a tertiary centre of excellence (teaching hospital). Does cancer care mean treatment as well as palliative and terminal care? The last two are mostly funded by charities… in the richer areas of the country. The life-years saved by A&E may be greater, but A&E deals with lower social classes who don’t vote… If the decision is left to patients we may not get the utilitarian result we need.. Hobson’s choice will of course be decided by administrators, as pithed politicians will sit on the fence. Given a choice, they must fund A&E properly (before cancers), but A&E is not where doctors compete to work… Such an invidious decision does not have to be made if we ration health care overtly. This is not as simple as the choices for an individual..

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Chris Smyth reports 30th March 2017: Patients must choose between A&E and cancer care, warns health chief

Patients must be told they cannot have routine operations quickly if they also want short waits for A&E, cancer care and other treatments, an NHS leader has said.

Simon Stevens, head of NHS England, is being urged to relax targets for waiting times as he prepares to lay out his reforms to the service today.

Niall Dickson, chief executive of the NHS Confederation, which represents all health service organisations, said that it was unrealistic to pretend that patients could have everything they had come to expect when money was so tight. “It’s not reasonable to say that all the current targets have to be met,” Mr Dickson told The Times.

“[Bosses] are on the one hand saying that mental health has to be a priority, elective care’s a priority, A&E’s a priority, cancer’s a priority and so on. Well, there’s got to be acknowledgement that some other things are not a priority.”

Mr Stevens is due to approve a structural upheaval of the NHS. It aims to better join up services around patients and to prevent illness. He has also signalled that he will spell out the financial pressures, threatening to resume a row with Theresa May over NHS funding.

Simon Stevens, head of NHS England, is being urged to relax targets for waiting times as he prepares to lay out his reforms to the service today.

Niall Dickson, chief executive of the NHS Confederation, which represents all health service organisations, said that it was unrealistic to pretend that patients could have everything they had come to expect when money was so tight. “It’s not reasonable to say that all the current targets have to be met,” Mr Dickson told The Times.

“[Bosses] are on the one hand saying that mental health has to be a priority, elective care’s a priority, A&E’s a priority, cancer’s a priority and so on. Well, there’s got to be acknowledgement that some other things are not a priority.”

Mr Stevens is due to approve a structural upheaval of the NHS. It aims to better join up services around patients and to prevent illness. He has also signalled that he will spell out the financial pressures, threatening to resume a row with Theresa May over NHS funding.

“If the money isn’t there you have to acknowledge that. It’s better to acknowledge that than to set up the system to fail,” Mr Dickson said. “It’s just unrealistic to expect the NHS to do everything and it’s unfair on patients and staff to pretend it can . . . It is disheartening, in any business, when a target is set that [staff] cannot deliver.”

The NHS is missing most of its main targets, including for A&E, routine operations, ambulance responses and cancer care. Jeremy Hunt, the health secretary, insisted this month that the target for 95 per cent of A&E patients to be seen within four hours must be met next year, despite January’s figure of 85.1 per cent being the worst on record.

Mr Dickson said: “If the government is absolutely set on, for example, A&E times and mental health, and I can see why they want to do that, then they should perhaps acknowledge that there are other areas where they could relax the targets a bit, which would allow the system to focus on those priority areas.”

Ministers have promised an extra £8 billion for the NHS by 2020 but Mr Dickson said that the “small amounts of additional money” fell well behind long-term average increases and left staff struggling to cope with rising demand from an ageing population.

He said that it was “absolutely right” to demand more savings but added: “We don’t think it’s reasonable to demand big financial savings on the one side, and on the other side expect no diminution of quality when demand is rising, without an admission that the NHS will have to prioritise some activities over others.”

Local health groups have been criticised for rationing services such as fertility treatments or barring the obese and smokers from surgery. Mr Dickson said that NHS England should back these decisions with “an honest admission that the service can’t do anything and that it’s reasonable to make decisions on the basis of priorities”.

•Only a quarter of people are satisfied with social care services, half as many as are satisfied with A&E, the least popular part of the NHS (Kat Lay writes). An annual report from the King’s Fund found that 63 per cent of people were satisfied with the NHS overall last year. Only 26 per cent were satisfied with local authority social care services, compared with 54 per cent who were happy with A&E

Pithed politicians collude in unsafe care, ministers told

Rationing in the NHS – The Nuffield Trust

Health professionals call for NHS Wales ‘vision’ by prospective parties. If you don’t have a choice in Wales, you can buy or game that choice….

HSJ implies Managers and Directors are now at odds with Politicians over rationing..

t seems that systematic rationing might become acceptable to managers (who run the HSJ). The Health Service Journal headline 10th March: “Exclusive: NHS England warns CCGs over ‘arbitrary rationing’” implies that whilst it is random rationing is not acceptable. What about systematic rationing? Are NHS England open to overt rationing yet? More importantly, are our politicians willing to say what will not be covered systematically (Nationally), and what would be acceptable locality rationing. This article is of interest to us all, but is only available if you subscribe… It implies that Managers and Directors are now at odds with Politicians over rationing..

NHS England has issued a warning to commissioning groups accusing some of “rationing” surgery using “arbitrary cut offs”, amid growing concern about the issue, HSJ can reveal.