Category Archives: Post Code Lottery

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”.

See the source image

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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Hywel Dda cancels operations after ‘critical pressures’

It is all so predictable. See one of NHSreality’s first post in 2012. The goose that laid the golden eggs has been killed. Without sufficient and efficient General Practice the whole hospital service is overburdened. Without sufficient staff and with too much work the system implodes.. The lack of service in West Wales emphasises the post-code rationing and the inverse care law.

BBC News 6th Jan 2020: Hywel Dda cancels operations after ‘critical pressures’

A health board has cancelled planned operations at four of its hospitals “in the interest of patient safety”.

Hywel Dda University Health Board made the decision after “an extraordinary weekend” of “critical pressures”.

On Monday, inpatient operations were cancelled at Bronglais, Glangwili, Prince Philip and Withybush hospitals in mid and west Wales.

The health board said it had contacted the patients affected and outpatient appointments continued as normal.

No decisions have been taken yet to cancel more non-emergency operations on Tuesday, it added.

Dr Philip Kloer, the health board’s medical director, said the weekend saw hospitals “at a level of escalation not seen before”.

“It is in the interest of patient safety that we have postponed planned operations today,” he added.

“I understand this may be frustrating for those who have waited for their operation and I apologise for this.”

He said the health board would redeploy staff where additional support was needed, including contacting those on leave.

“We are also working with our colleagues in the local authority and the families of those well enough to be discharged to ensure our medically well can go home or to an appropriate care setting as soon as possible,” Dr Kloer added.

In a statement, the health board said “critical pressures” had been felt across all of its hospital accident and emergency (A&E) departments, GPs and community services.

Figures published last month showed accident and emergency performance at hospitals in Wales was at a record low for the third month running and the Welsh Ambulance Service failed to meet its response time target for the first time in four years.

The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

A review of a decade… Population health matters. Education is the answer, and not just about health, but also about health systems and the choices that have to be made….

The recent John Pilger film / documentary produced by ITV “The dirty war on the NHS” was released on terrestrial TV Tuesday evening. It has been available in cinema before this, but possibly suppressed before the election. The film begins with anecdotes, and derides the privatisation. It fails to compare UK with any other system than the USA, which we in the professions all know is inferior. It fails to give comparative population numbers, and it does not mention really cheap and effective systems such as Cuba. In EU there are at least 4 other systems that have consistently scored better on survival and life expectancy, but the producer seems fixated on the USA (Is there a worse system?). He says that the politicians are equally fixated! God save us all. From the political footballs that are the 4 health services….

In the final analysis the duty of a government is to populations ahead of individuals. That’s why defence and internal security come above health in Maslow’s hierarchy of needs. That’s why immunisation programs are more important than surgery for cancer. In the UK health lottery, poorer people are missing out because the waiting lists mean richer people buy faster (private) care. There is a problem: fear. The original single health service, which devolution has replaced with 4 health services, was In Place of Fear.  A Free Health Service 1952 Chapter 5 In Place of Fear People fear cancer more than they fear infectious diseases (measles), demographic lifestyle diseases (Obesity, Diabetes) less than they fear cancer…. Education is the answer, and not just about health, but also about health systems and the rationing choices that have to be made.

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The Dirty War on the NHS showing at Queen’s Film Theatre …

Nigel Hawkes reports in the BMJ on “The 2010s: a decade of disappointment in UK healthcare”, BMJ 2019;367:l6895

Despite health system reforms, improvements in life expectancy and neonatal mortality have stalled. Nigel Hawkes reflects on the past 10 years

A decade that began with a Conservative health secretary promising to transform the NHS in England through market discipline, legally enforced, ended with an election manifesto from his party embracing the polar opposite. Competition is dead; long live cooperation.

This meant that, even before the general election votes were counted, a 30 year experiment in the English NHS was over. “Choice and competition,” a mantra pursued as energetically by the Labour governments of Tony Blair as by the Conservatives, was dead.

How the NHS is organised generally makes less difference than its planners hope, though competition and choice seemed to have some successes, including shorter waiting times. But this was before the 2008 financial crisis cast its long shadow over the succeeding decade.

Faltering progress

Since then, progress has faltered, not only in the UK but across Europe. Decades of improvement in life expectancy have plateaued, even gone into reverse.1 Neonatal health has paused in its steady improvement.2 Doctors are demoralised, GP surgeries and hospitals are under siege, and public satisfaction with the NHS, which rose sharply between 2000 and 2010, has fallen back as quickly as it rose.3 The 2010s have proved to be a decade of disappointment.

Many blame austerity. In England, health department spending rose by an average 1.5% a year over the decade, much slower than the long term average growth of 3.7% a year.4 Productivity improvements failed to fill the gap. The pips began to squeak.

Austerity had an effect, certainly, but not only in the UK. Eurostat data on life expectancy, for example, do not show the UK as a conspicuous outlier,1 with an increase in life expectancy at birth (sexes combined) between 2010 and 2017 of 0.7 years, greater than in France, Germany, and Italy but less than in Spain, Switzerland, and Sweden. For life expectancy at 65, the UK fared worse than all these countries except Germany over the same period. Not a good performance, but other countries also struggled.

The decline in UK infant mortality tailed off after 2010, a trend also seen in other countries.2 In 2010 the UK had 4.3 infant deaths per 1000 live births, while France had 3.6. By 2016 the gap had narrowed: the UK down to 3.9, France up to 3.7. Similar countries saw little progress or, in some cases, declines.

The common challenge, at home and abroad, is affordability. How can any healthcare system continue to pay for care whose costs rise inexorably year by year, unaffected by the state of the rest of the economy? This question has dominated domestic politics in the US during the Obama and Trump administrations, with no sign of consensus emerging. In France, often seen as an exemplar of good medical provision, the state has recently been forced to take over €10bn in public hospital debt after months of protests and strikes by healthcare workers.

Can digital health cut costs and improve outcomes? Certainly many think so, even though experience during the 2010s was mixed. Websites and phone services such as NHS 111 (launched in 2013) have not reduced demand. Health apps appeal to the young and fit, not the old and multimorbid people who fill the wards. The same applies to “digital first” online services such as GP at Hand, 94% of whose patients are under 45. Electronic health records have made slow progress, and the promise of a paperless NHS by 2020 is already in the wastepaper basket.

Sluggish drug pipelines

The 2010s were not a great decade for new drugs, either. Pharma pipelines were sluggish, though they picked up later in the decade. About half of newly licensed drugs were biologicals, which are around 20 times as expensive as traditional drugs and account for almost all the increase in the drugs bill. A splendid exception to this gloomy picture was new treatments for hepatitis C, which NHS England, swallowing hard, finally agreed to pay for.

Credit, too, should go to Public Health England for championing electronic cigarettes, which has given tobacco cessation a boost at no cost to the public purse.56 Critics of vaping, vociferous at the start of the decade, have largely fallen silent, in the UK at least.

If somebody could come up with a similar technological fix for obesity they would be the hero of the 2020s, as exhortation has failed. The decade began with 26% of men and women classified as obese in the Health Survey for England. In 2018 (the latest data available) the figure for men remained the same, while that for women had risen to 29%.7

To end on a brighter note, sometimes things can change for reasons that aren’t immediately obvious. The teenage conception rate in England and Wales, long the cause of hand wringing, halved in the 2010s from 34.3 per 1000 women in 2010 to 17.9 in 2017.8 All credit to those who brought this about: mostly young people making sensible decisions.

Rapid Response:

Re: The 2010s: a decade of disappointment in UK healthcare

Dear Editor,

Market discipline not adequately implemented with the difficult arithmetic of personnel and costs, faltering steps are not confined to UK healthcare but easily extend to the continent. A huge influx of refugees creates changed equations of healthcare costs. Westwards, insurance has risen in costs and coverage affected. In developing countries, the percentage expenditure on health has the scope of being enhanced for better output.

In short, in the last decade, almost at a global level, disenchantment with health services has grown. Outbreaks continue to threaten and lifestyle disorders dominate. Influence of AI may take over, but at what pace may be a guess difficult to make.

Dr Murar E Yeolekar, Mumbai.

US Hospital to advise London on safety….. and what a terrible record their country has when treating populations

Meningitis B – Can Wales afford it? Government’s treat populations and not individuals.

Prudent healthcare reforms and a suggestion for GP recruitment

The numbers of GPs have increased, but the number of Full Time GPs, (Which means 9 sessions a week) has reduced because more and more are taking options to mix and match their portfolio careers.

The first letter below is correct: GPs need portfolio careers to survive themselves, and for the local service to survive. Changing the shape of the job…. In the festive season (see below ) doctors cannot be expected to behave like turkeys in their voting… Ask around and I expect you will find demoralised people who did not know who to vote for, but in a PR system would have voted Liberal.

The Times letters 18th December 2019:

Sir, Libby Purves makes some very good points about the crisis in A&E departments in many NHS hospitals (“Don’t just throw money at the NHS, be smart”, Dec 16). She suggests a return to convalescent homes or cottage hospitals, with both staffed by nursing auxiliaries and overseen by local GPs. Patients who did not require the “high tech” care provided by the acute hospital but required good nursing and general care before returning to their home or other long-term care could be transferred to one of these units. I was a GP and we had a 100-bed unit that did just this. The patients were well cared for and many were able to return home. Like many other units, however, it was closed; all we have now is a 600-bed acute hospital some miles away.

I met another retired GP this morning. He had been away: his wife, who is disabled, had suffered a serious injury to her face and he had taken her to the acute hospital A&E. They were there for about ten hours; the place was chaotic, being full of people suffering from minor ailments whom in the past we as GPs would have dealt with. When she was treated by the medical staff the care was first-class. We both agreed that it was time that the problem of GP out-of-hours care was sorted out; the pressure on A&E departments would then reduce.
GBR Fisher

Cononley, W Yorks

Sir, Libby Purves makes an important case for new convalescent homes but creating them will take time. A quick interim fix would be for the government to seek bids for building basic accommodation modelled on budget hotels over hospital car parks. Hotel operators and some house builders would respond quickly, a standard brief could be produced and a new permitted development right or development order could avoid planning delays.
Brian Waters

Chairman, London Planning & Development Forum

Sir, In her article Libby Purves makes many good points about the medium-term future of the NHS. A further core problem is unscheduled care. Until there is more integration between GPs and emergency departments problems are likely to continue. It is a pity that the so-called internal market of 1990 widened this chasm and that budgets within the system still drive change. The royal colleges of both the physicians and GPs advocate generalists, and some emergency departments have innovative ideas. There is, however, a need to devise a qualification for interested GPs to integrate seamlessly within emergency departments, thus allowing patients to see the most appropriate person on arrival.

Who knows, perhaps by offering a dual base this could help to solve the problem of GP recruitment.
Dr Michael Houghton, FRCGP, FRCP

Preston, Lancs

Sir, I went to my local surgery last week. The person before me was a “no show”; the nurse told me that there had been four “no shows” the day before. Last year I had knee replacement surgery. I was given an ice machine to take home after the operation. I didn’t want it and didn’t use it, preferring the flexibility of using frozen peas. I tried to return it but it was refused on the grounds of cross-contamination. I was also unable to return the crutches for the same reason. Throwing money at the NHS is not the answer to all its problems.
Ann Hadingham

Alton, Hants

Times letters: Prudent reform of the NHS and social care

Don’t throw money at the 4 health services. Put the plug in first, and then concentrate on recovery in 10-15 years time…

 

A&E is a National Accident waiting to be repeated over and over again… Northern Ireland is worse, but there are two tier waits in parts of Wales as well.

Not only is the standard variable, and post coded so that the outcome is rather random, but its getting worse. No amount of money can replace staff who are no longer available. A&E is a National Accident waiting to be repeated over and over again… This is for England. There are no comparable figures for the other dispensations where figures are far worse. Even the 4 hour waiting standard does not imply seeing a responsible diagnostician, but a triage nurse! Northern Ireland is worst of all… There are “two tier” waiting lists in Wales as well, particularly at Oswestry. Because money moves with the patient, and NI cannot pay, choice of going elsewhere is being denied…

Carol Hylton on 3rd December 2019 wrote to the BBC asking “Election 2019: What will you do about A&E provision in West Hertfordshire?”.

Nick Triggle revealed 13th December on BBC News Website: Every major A&E misses wait target for first time

Every major A&E unit in England has failed to hit its four-hour waiting time target for the first time, NHS figures show.

All 118 units fell below the 95% threshold in November as the NHS posted its worst performance since targets were introduced more than a decade ago.

Alongside the growing waits in A&E, the data showed there were record delays finding beds for the sickest patients.

The numbers on waiting lists for routine care also hit an all-time high.

NHS England medical director Prof Stephen Powis said the NHS was facing a “very tough few months”.

He said staff were “pulling out all the stops” but added that increasing demand, particularly among patients with complex illnesses, and a shortage of staff were making it difficult.

Nigel Edwards, of the Nuffield Trust think tank, said the figures were “very worrying” as the coldest months were still to come.

He said: “Returning to Downing Street, Boris Johnson has been met by an immediate reminder of the grim winter his government faces in the English NHS.”

Worst ever month for A&E

Overall just 81.4% of A&E patients were seen within four hours last month – that is the worst performance since the target was introduced in 2004.

The figures include those seen in major A&E units, as well as minor-injury units and walk-in centres….

BBC NI reports today 16th December: Stormont stalemate: Medical leaders call for end to deadlock

Tomáš Tengely-Evans reports in the Socialist WOrker today 16th December: Historic Strike in Northern Ireland NHS  as waiting lists for all surgery beat all records. Allan Preston for the Belfast Telegraph November 23rd reports on “Waiting times that would not be tolerated elsewhere : Steve Aitken, Ulster Unionist Leader.

November 20th: Northern Ireland’s healthcare system is broken

and Waiting lists ‘two-tier health system leaves poor behind’

The Belfast Telegraph Today: Block on Northern Ireland patient transfers to GB to help tackle …

and the staff are demoralised: Northern Ireland hospitals cancel operations due to staff shortage…