Category Archives: Professionals

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.

Image result for nhs fear cartoon

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


The costs of hospital failures extend to morale in all areas of the 4 health services.

All hospitals are now failing. Just because we hear about some (Like Bury St Edmunds) does not mean the rest are clean. The endemic failure to provide sufficient people is compounded by insufficient new builds, old plant needing replacement and inadequate imaging facilities, and of course the professional radiologists to read these images. Wales has avoided PFI but all its buildings and equipment, with a few exceptions, is stone age. Its people will be asked to travel further than ever to get help, and choice is absent. The complaints alone are epidemic, and the costs set aside for future litigation are enormous. The costs of hospital failures extend to morale in all areas of the 4 health services.

Alistair Osborne opines 17th Jan 2020 in the Times: Beware real cost of hospital failure

evolutionary zeal is not a trait typically associated with the Conservative Party. But at least Boris Johnson is promising an “infrastructure revolution”. What it entails is anyone’s guess, apart from spending £100 billion over five years. So, it’s lucky that the National Audit Office has popped up with a handy guide — on how not to do it.

It’s had a poke around the Midland Metropolitan and Royal Liverpool University hospital projects: a duo as sick as you might expect given they were being built by the now bust Carillion under the similarly kaput private finance initiative. Naturally, the patients are still waiting to see either hospital.

The 646-bed Liverpool scheme, due to open in 2017, is now running at least five years late, costing £1.06 billion to build and run: not the budgeted £746 million. Meantime, the 669-bed Midland Met, due to start operations in October 2018, will cost at least £988 million, up from the initial £686 million. It opens in July 2022.

Not the finest advert, then, for injecting private capital and expertise into the delivery of public projects. Except for one thing: the NAO reckons the taxpayer is barely out of pocket — because “the private sector has borne most of the cost increase”. It’s lost £603 million, shared between investors in the PFI companies, Carillion and insurers. Indeed the NAO believes that the taxpayer will be 3 per cent worse off with Midland Met and 1 per cent better off with Liverpool. And that includes the 30-year running costs.

It seems barely credible, given what’s gone on. After Carillion keeled over in January 2018, the health trusts and government wrongly assumed that “the PFI companies would complete the hospitals, as contractually required, by replacing Carillion”. Instead they had to terminate the PFI schemes and “use public finance to complete the hospitals with new contractors”. Consulting engineer Arup then found that the Liverpool work was so shoddy that the new contractor “had to strip out three floors of the building” to reinforce its structure.

So, how come the taxpayer’s no worse off? Simple, really. Because the government held the PFI investors to their contract — not paying for hospitals they’d failed to deliver. It then inherited two half-built hospitals that taxpayer funds are finishing off. True, the health department coughed up £42 million to avoid a “lengthy contractual termination process” in Liverpool: a sum it could have dodged given its rocketing costs. But that’s hindsight.

Does it all prove, then, that PFI works? Well, not really. The real cost is that both hospitals are years late. And there’s still a risk that the final price will exceed NAO estimates. Moreover, the affair says much about the government’s addiction to picking the lowest cost contractor. As the NAO notes over Liverpool: Carillion’s pricing may have been “too low to meet the required specification”.

Still, at least there’s a lesson here for BoJo: infrastructure revolutions are harder than they look.

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. 

Image result for dementia drugs cartoon

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.”

Image result for dementia drugs cartoon

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

Image result for dementia drugs cartoon



NHS 111 is a disgrace… How to get rid of it?

I have personal experience of the inefficiency and risks attached to incorrect advice from NHS 111. One of my relatives was ill after a delivery, with fever and I wanted to ring 999. I was stopped by the relative who demanded I ring NHS111. The advice for a post partum sepsis was to ring her GP, and was not to attend hospital. There are too few full time GPs to run a proper out of hours service…. There are so many part timers that any form of continuity of care, particularly when we are terminally ill, has virtually disappeared. Experimental technology is being used in reality. There is a real need to bring experienced diagnosticians closer to the initial presentation, whether it is by phone, in GP or in A&E (or whatever it is named). How do we get rid of NHS 111?

Image result for nhs111 cartoon

So it is no surprise to read about the problems reported by Jon Ungoed-Thomas and Jack Taylor in the Sunday Times 5th Jan 2020: Toddlers died after NHS 111 helpline said they were not in danger – The urgent medical care service faces calls for an independent investigation after a number of child fatalities

The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.

Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.

Professor Carrie MacEwen, chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”

Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.

The latest coroner’s report issued to prevent further deaths was published in November. It concerned Myla Deviren, 2, from Peterborough, who died from an intestinal blockage in August 2015….

,,,Researchers examined 2,191 patient safety incidents involving children receiving NHS care between January 1, 2005 and December 1, 2013. The majority of the 659 incidents involving diagnosis, assessment and referrals — including 10 child deaths — occurred during calls to NHS 111.

The report stated: “The safety of software used to triage children over the telephone is unclear, particularly its sensitivity to detect signs of serious illness in children.”

The NHS Pathways triage system, used by NHS 111 and in about half of ambulance services, is one focus of the inquest into the death of Shante Turay-Thomas, 18, from north London, who suffered a suspected allergic reaction.

Leigh Day, the legal firm representing Shante’s family, said she was assigned an ambulance with a response time of two hours (category 3), but a 999 call to the London ambulance service with suspected anaphylaxis would trigger an ambulance with a target response time of seven minutes (category 1).

NHS 111 is operated by various providers, and NHS Digital supports the NHS Pathways triaging software. The 24-hour service is free to use.

Professor Jonathan Benger, acting interim chief medical officer at NHS Digital, said: “NHS Pathways supports the remote assessment of more than 17m calls each year and is a safe and robust system.”

NHS Digital said that since 2016 there had been changes to improve identification of patients at risk of critical illness; where a clinical safety issue is raised, an assessment is made within 24 hours.

NHS England said serious safety incidents involving NHS 111 were “thankfully rare” and more than half of callers received advice from qualified clinicians.

Professor Martin Marshall, chairman of the Royal College of General Practitioners, said: “Patients need to be reassured that valuable lessons have been learnt if we are to maintain public trust and confidence in NHS triage systems.”

Dr Chaand Nagpaul, chairman of the British Medical Association (BMA) council, said: “There is clearly much more to do be done to ensure there is adequate assessment, expertise and support on hand for those who contact the service.”

Image result for nhs111 cartoon

So why did Mr Stevens get an honour? He failed…

In the New Year’s Honour’s list: HSJ reports that “NHS England chief executive Simon Stevens has been knighted in the 2020 new year’s honours list.”

Why did he get an honour when he has FAILED to deliver an honest debate that he asked for in 2014. Health service provision is like death. We wont face it honestly. Rather similar to the environment..

2019: Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

 2018: Public must pay for better NHS, says Stevens to spineless politicians at King’s Fund

2014: A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)



March 2019: Melting down….We are all getting what we deserve. Without honesty to ration overtly the system will only get worse.

An unhappy new year looms for the 4 UK Health Dispensations. A worsening disaster…. Hold onto your life..

Nobody discusses reality in health any more. So just a few thoughts for an “unhappy” new year for the 4 UK Health Dispensations. A worsening disaster…. Hold onto your life..

Hugh Pym reports 20th December for BBC news: Political heat eases but NHS chill sets in

Nick Triggle reports for the BBC 29th December 2019: Why 2020 will be a crucial year for the NHS

So 2020 looks set to be a crucial year as ministers seek to meet the challenges facing the health service in England head-on.

But what are the most pressing issues for the Westminster Parliament to address in the year ahead?

Reducing waiting times

Health is devolved, meaning the Department of Health and Social Care does not control health policy in the rest of the UK, although Scotland, Wales and Northern Ireland will be watching closely to see what it does.

Undoubtedly the most high-profile problem – and the one used by critics to beat the Tories – has been the deterioration in waiting times.

It is now more than three years since any of the three key targets covering A&E, hospital operations and cancer have been met.

Both A&E and routine operations are at their worst levels since the respective targets have been introduced.

A&E figures

The first tranche of the extra funding the NHS is receiving – 3.4% above-inflation rises until 2023 – kicked in at the start of April 2019.

But that still has not been enough to reverse the deterioration. Many predict it will take years before the NHS gets back to where it was a decade ago, when it was regularly meeting waiting time targets….

…In fact, Boris Johnson promised to “fix the social care crisis once and for all” in his first speech on the steps of Downing Street when he took office in the summer.

The election manifesto provided no detail on how the Conservatives would do this, beyond promising that people would not have to sell their own homes to pay for care – only the poorest get help from the state.


Ministers want to set up a cross-party commission, but with both Labour and Liberal Democrats plunged into leadership races after the election, there will be huge pressure on the government to start coming up with plans.

After all, a working group of experts has already spent 18 months drawing up options for the government to consider.

It was set up after the 2017 election – exactly 20 years after Tony Blair came to power promising reform.

After more than two decades of talking, surely the time has come for action.

Filling the gaps

Another thorny issue is the workforce challenge. One in 12 posts in the NHS is unfilled.

The government is already increasing the number of doctors and nurses in training, but it will be many years before the full impact of that is felt.

NHS vacancies by staff group – see graphic on BBC link

Instead, immediate attention is turning to retaining more nurses – every year more than 30,000 leave the NHS – and international recruitment.

The number of staff coming from the EU has fallen since the referendum.


Rationing over Christmas. Just part of the routine now… in a toxic culture of denial.

Over Christmas we hate to hear about the hard truths of peoples lives. Dying alone is not something I look forward to, and I suspect I will not know the medical person who comes to see me in the last days. Continuity of care has disappeared, and in its place is part time working of both nurses and doctors. These professionals have not necessarily been trained to deal with the variety of conditions which the ageing community and General Practice demands of them, Many miss out on Paediatrics or Gynaecology or Dermatology as well. Most miss out on orthopaedics… The “hard truths” which Mr Stevens wishes to discuss (since 2014!), facing politicians and their electorate about health, are present all the year round. And its too toxic a subject for all politicians..

Image result for toxic culture health cartoon

So it is no surprise that diagnoses are late, especially for conditions with rather unspecific symptoms such as early leukaemia ( Susan Oneill in the Times 27th December: A quarter of cancer patients go to GP three times before a diagnosis ). Doctors are taught to use time as a diagnostic tool, and if all patients had all possible tests on presentation the service would surely implode. Sepsis on the other hand is severe and should be recognised by every doctor.. It is still “causing more deaths than expected” in Wigan.

Dennis Campbell reports 10th December in the Guardian: Thousands die waiting for Hospital Beds – study.

Shaun Lantern in the Independent 27th December reports that the nursing profession don’t think Boris Johnson’s NHS plan is deliverable.

Laura Donnelly in the Telegraph: Hip Rationing

The Daily Mail reports that the Scots are to get three rounds of IVF compared to the one offered by most English Trusts.

Andrew Proctor for the Dermatologists reports on the rationing of emollients (which are almost all very cheap)

It features National Eczema Society’s Chief Executive Andrew Proctor discussing the important issue of emollient rationing for people with eczema.

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The politics of health.. The Lemmings of the left leave a vacuum where Mr Stevens’ debate will not happen… Are we all lemmings as far as our health system is concerned?

The Election Horror Show, and denial… The political spin doctors are leading us into a health-less “black hole”. The Health services are too toxic for honesty…

NHS Rationing & Finances | A King’s Fund Report‎ March 2017. Understand the NHS financial pressures. How are they affecting patient care?

toxic work environment cartoon