Category Archives: Professionals

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

 

Nurses consider whether to strike over low pay – if all nurses joined an agency on striking what could happen?

It takes a lot to make the nurses even think of striking. However there is a solution: they ALL join the agencies!  NHSreality believes that if this happened reality would come home to the politicians and the UK citizens. Nurses are underpaid…

James Gallagher for BBC news reports 14th April 2017: Nurses consider whether to strike over low pay

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NHS managers still growing as GP posts fall

The Observer reports 15th April 2017: Number of NHS managers still growing as GP posts fall again – Doctors say ministers’ ‘bureaucracy busting’ shakeup has failed to switch resources and manpower to the front line

The number of NHS managers has grown by almost 18% in the four years since the government introduced a “bureaucracy-busting” shakeup of the health service, according to the latest official data.

The rise of about 4,650 in total management posts since April 2013, when the controversial Health and Social Care Act came into force, contrasts with an alarming fall in the number of GPs over recent months at a time of unprecedented demand for health care. The figures have drawn criticism from the British Medical Association (BMA), who say ministers are failing in their central objective of shifting more resources and manpower from back-office posts to the front line….

Managers are at odds over rationing, and management recognises the case, but the “rules” don’t allow them to speak out.

 

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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Older GPs wish to remain self employed – but do the new ones? If you run down the system, committment is less.

Do we want a committed GP workforce? If so we need to treat GPs and their practices as if they were businesses that the state values. Older GPs wish to remain self employed – but do the new ones? If you run down the system, committment is less. The hearts and minds of most junior doctors are no longer with the Health Services and they see themselves as a scarce commodity, overworked and stressed whatever they do, so they might as well get paid well, and maximise their lifestyle choices. This is why there are so many part time GPs. The same will happen in Hospitals. It seems ironic that whilst the governement tries to get as many people as possible off it’s payroll elsewhere, that peers recommend going the other way.  Do they think it’s worked with Nurses? (Nurses gear up for action over pay cap) How many patients will a salaried doctor have to see in a day? At present he/she deals with them all….  This “problem” is a result of undercapacity rationing, and will only be solved by overcapacity panning – in over 10 years..

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Chris Smyth on April 5th reports in the Times: It’s time GPs went on the staff, say peers

GPs must be employed directly by the NHS as their “small business” model is holding back patient care, a House of Lords committee says.

Patients also need to take responsibility for eating and exercising properly rather than just demanding the NHS patch them up when they fall ill.

Condemning a government “culture of short-termism”, the Lords select committee on the long-term sustainability of the NHS recommends a decade of funding increases for health and social care in line with economic growth. The NHS must also stop relying on foreign doctors and nurses, the committee report says.

Hospitals will have to change “radically”, including closures and centralisations of specialist care.

Simon Stevens, head of NHS England, wants more patients treated in GP surgeries with tests, specialist consultations and mental health therapy available. The report published today says achieving this will require an end to the 1948 model where family doctors own and run individual surgeries.

Initial correspondence in the Times is sympathetic with the peers. I expect later correspondence will be more balanced.

Nick Bostock for GPonline reports 28th March 2017: ‘Unclear’ how GP services can be maintained in face of workforce crisis, warns DDRB and on 29th March Full-time GP workforce dropped by 445 in three months to December 2016

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NHS confusing public by using ‘gobbledygook’

In keeping with the BMA in Wales, Nick Triggle reports that “NHS confusing public by using ‘gobbledygook'” in the Times 28th March 2017.

The BMA Wales response to the Welsh Government was that we wanted “a clearer and more honest language” to be used in health. Needless to say this has not happened, and indeed NHSreality does not blame the Welsh politicians. The recommendation for “honest language”, along with “Exit Interviews” was buried deep within the BMA response ( Our health, our health service BMA response) to that part of the Green Paper , and did not appear in any bullet point summary. The rules of the game, for Commissioners (de-commissioners) will ensure that the language barrier remains. Therefore we need to change the rules. Both language and outcomes are going to get worse.. until we agree there has to be a cost.

Imagine the scene. Up and down the country, local NHS leaders are crowded into meeting rooms discussing information transfers and ambulatory care, when someone jumps up and shouts “I’ve had enough of sticky toffee puddings”.

Confused? You’re not the only one. The language being used by the health service is simply gobbledygook, says the Plain English Campaign (PEC).

Steve Jenner, the campaign’s spokesman, said the health service was riddled with “jargon” when it comes to explaining anything from the closure of hospital services to major incidents.d he even believes the NHS may be doing this on purpose.

“If you use impenetrable language it means the public has no clue what is going on. I can’t help thinking that suits the NHS sometimes,” he said.

“What this jargon is describing is very important. It should be articulated very clearly.

“We expect doctors to clearly explain themselves. It should be the same for the NHS management,” he added.

Sticky toffee puddings or important NHS plans?

STPs – dubbed sticky toffee puddings by some in the health service – are among one of the most important developments in the health service in recent years.

But you would never guess from the official name – sustainability and transformation plans.

However, the jargon goes further than that, according to the PEC. Look through most plans – there are 44 of them – and you will find some strange phrases.

Cambridgeshire and Peterborough’s documents, for example, talk about investing in “system-wide quality improvements” and developing a “shared understanding of all the interrelated issues”, while being able to learn “what it means to us as individuals and as organisations”.

Meanwhile, documents from North Central London shared the experience of one patient’s care that went wrong.

It says due to “hand-offs, inefficiencies and suboptimal advice and information transfers” the “patient’s pathway” went on for too long.

Another popular “pathway” is the ambulatory patient pathway. What does that mean? The patient can go home after being seen in hospital.

Is the NHS involved in a medieval battle?

Vanguards are a term used to describe the formation of a medieval army. But the NHS has also – ahem – deployed the term.

There are 50 vanguards that have been set up to test new ways of running services. They were created in 2015 and include schemes to get hospital doctors working in community clinics and to provide advice via video link-ups as well as the creation of super hubs in the community bringing together GPs, district nurses and council care teams.

You should not be surprised to hear evidence of what works best in the vanguard programmes will then be fed into the STP process.

But it’s not just in England where jargon can be found. Northern Ireland’s 10-year health strategy, published last autumn, promised to shift the focus from “treatment of periods of acute illness and reactive crisis approaches, towards a model underpinned by a more holistic approach to health and social care”.

Or, more simply, try to get people to live more healthily and give them better support to stop them needing hospital care.

Running hot or just busy?

Taps run hot, but so too, it seems, does the NHS. Commentators and health service managers have been using the phrase to describe just how busy hospitals and, in particular, A&Es were this winter.

It may be a bit of an odd phrase, but it is at least easier to understand than Operational Pressures Escalation Level Four.

That is the new name for a black alert – when hospitals get so busy they have to cancel non-emergency operations, divert ambulances and call in extra staff.

And guess what red alerts – the level down from black – were renamed? Yes, that’s right, Operational Pressures Escalation Level Three.

Guidance issued by NHS England last year ordered hospitals to use the new terminology when communicating with the public and media.

Not everyone obeyed. Newspaper coverage this winter was littered with reports of black and red alerts.

And what did NHS England make of this? They were unable to provide the BBC with a response.

The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

In Search of the Perfect Health System ( a new book reviewed )

The BMA response ( Our health, our health service BMA response) to that part of the Green Paper

 

 

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….