Category Archives: General Practitioners

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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Cynical de-commissioning bringing back fear.. Dying patients waiting hours for pain relief in NHS funding shortfall.

Fear of death is not as great as fear of dying. Dying without support, a comforting and competent carer, and without pain relief, is a return to the standards for the uninsured pre 1948. Aneurin Bevan was trying to replace fear when he published In Place of Fear A Free Health Service 1952 (Chapter 5 of In Place of Fear), and he conducted open debates on exactly what the purpose of his new service would be. Some of his speeches can be re-read, and some are even on film. It is cynical, and so tempting, for the de-commissioning GPs and Health Boards to ration the care of those who will never vote.

When Dennis Campbell in the Guardian 13th March 2017 reports on the King’s Fund opinion we should all worry: Dying patients waiting hours for pain relief in NHS funding shortfall – Overworked district nurses struggling to care for dying patients, with one in seven posts cut in two years, warns King’s Fund

Dying patients are waiting up to eight hours to receive pain relief because of cuts to district nursing services during the NHS’s unprecedented budget squeeze, a new report has revealed.

Severe financial pressures on the NHS are leading to longer waits for treatment and a short-sighted and growing rationing of care that is storing up problems for the future, according to a study by the King’s Fund health thinktank.

The report quotes one unnamed manager of a hospice saying: “The district nurses working at night are not able to give effective response times; you can wait up to eight hours … for patients experiencing pain and discomfort in the last two to three days of their life, it has a massive impact. It’s a frightening time for patients.”

The King’s Fund research has found that district nursing and sexual health services are among the areas of care most affected by six years of the NHS in England receiving annual budget increases of 1.2%, far less than its historic average of 3.7% rises.

It highlights how the diminishing number of district nurses are struggling to give patients prompt high-quality care because they are increasingly overworked.

The need to balance budgets and the smaller numbers of district nurses are prompting some NHS bodies to restrict their eligibility criteria for patients seeking help, refusing it for those with serious mobility problems unless they are completely housebound.

“We heard some examples of providers attempting to limit access. This was mainly through tightening referral criteria, particularly in relation to patients being ‘housebound’. Increasingly, if patients are able to visit their general practice (even if doing so is challenging), they will not be eligible to receive care from district nurses,” the report states.

The past two years have seen a loss of one in seven (14.8%) district nursing posts. “There is a significant gap between demand for district nursing and the available resources in terms of funding and staff numbers,” researchers found. Heavier workloads are contributing to 20% vacancy rates in some places.

The report also warns: “Pressures in district nursing are affecting the quality of patient care. Staff are increasingly rushed. Visits have become more task-focused, and there is less opportunity for thorough assessments. This dilution of quality may damage patient experience and outcomes.”

Many services provided by acute hospitals have been “relatively protected” despite the lack of investment in the NHS in recent years, the authors say.

However, genito-urinary medicine services have been hard hit, with cuts of up to 20% in 2014/15-2015/16 in some places in the budgets for testing for and treatment of sexually transmitted infections. “This has resulted in fewer clinics and reductions in staff in some areas, while there have also been cuts to prevention and outreach services. This could put patients and the general population at greater risk of infection,” the report adds.

The number of hip replacements has also started to fall, despite growing demand for them caused by the ageing population. Slightly fewer were carried out in 2015-16 than the year before as NHS clinical commissioning groups (CCGs) sought to save money by making surgery conditional on losing weight or giving up smoking. Waiting times for the procedure have also lengthened and more patients are waiting longer than the supposed maximum 18 weeks.

“It’s a disgrace that as a result of the Tory funding squeeze many elderly people are forced to live in prolonged agony and without independence because they are denied a hip replacement in reasonable time,” said Jonathan Ashworth, the shadow health secretary.

“Patients are unfairly suffering the consequences of a deliberately underfunded NHS at breaking point,” said Dr Mark Porter, chair of council at the British Medical Association.

The King’s Fund warns that rationing of care will become ever more common. “Although NHS funding growth began to slow in 2010/11, it appears to have taken some time for financial constraints to impact on patient care, and our data suggests that these impacts will spread and intensify,” the report adds.

The Department of Health has told CCGs not to ration care, despite the tight financial constraints it has imposed. NHS England said only: “Ultimately these are legally decisions for CCGs, but informed by best evidence and national guidance where appropriate.”

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Mayday Mayday – for the Health Services: Hospital faces charges over Caesarean tragedy. Dead patients don’t vote.

Patients suffer in GP funding lottery. Ager and civil unrest to follow?

Child cancer results improving. In a “cradle to grave” Health Service we are not doing badly at cradles.. but we are doing badly as patients approach their grave.

Dead people don’t vote… End-of-life care ‘deeply concerning’

The NHS and reckless election promises. How about posthumous voting?

 

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

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You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

Speaking up – Whistleblowing in the NHS – file on four. The profession needs a scapegoat – Mr Hunt.

Nothing has substantially changed since the Francis report – indeed the leadership of politicians was not referred to in the debate, making out that the lack of a proper lead in cultural change was needed from Management, when actually it is needed from Politicians. The only way to find out if Jamie Grierson is correct is to do exit interviews on all staff (like those in file on four), and have these done by an independent Human Recourses body. SOSR means “some other serious reason” and all whistle-blowers need to consider whether this might be attached to their file after spilling the beans. The admirable ideology of whistle-blowers contrasts strongly with the ideology of HR departments described in File on Four today. If 66% of doctors are under “serious stress” then the profession, and the public, need a scapegoat….. Mr Hunt will do as a sub for all the successive ministers of health. Civil unrest is likely without honesty. The current winter “murmurings” of starlings will become a riot of protest and discontent. One of the major reasons for a state to exist ;”keeping it’s citizens safe”, is failing…

Speaking up – Whistleblowing in th NHS – file on four and part of the report is from BBC Liverpool (Staffing ‘inadequate’ at Chester baby death hospital)

Dave Simonds 12/02/2017

This is reinforced by Jamie Grierson in the Guardian: NHS hasn’t improved enough since Mid Staffs, says inquiry lawyer

Robert Francis, whose report uncovered poor care in hospital trust, says pressures on health service generally are ‘pretty bad’

Current conditions in the NHS ”sound familiar” to those that existed during the Mid Staffordshire scandal, according to the lawyer who chaired the inquiry into the hospital trust.

Sir Robert Francis QC said the health service was being hit by a combination of financial pressures and high demand.

The barrister whose 2013 report uncovered poor care in Mid Staffordshire said the pressures the health service was under were “pretty bad”.

His remarks came after a week of scrutiny of the NHS, with performance figures showing a raft of missed targets and record waiting times, leading health secretary Jeremy Hunt to say conditions were “completely unacceptable”.

Francis told the BBC’s The Andrew Marr Show on Sunday: “I think they are pretty bad. We’ve got a virtual storm of financial pressures, increased demand, difficulties finding staffing, and pressure on the service to continue delivering. And some of that sounds quite familiar, as it was those were the conditions pertaining at the time of Mid Staffordshire.

“Things have changed since then, so the very fact that we’re talking about this today the way that we are, the very fact that the secretary of state says things are unacceptable, shows that there’s a greater level of transparency.

“So people are talking about the problems in a way that they weren’t before. But the system is running extremely hot at the moment and it’s only working at all because of the almost superhuman efforts of the staff of the NHS, and it can’t carry on like that indefinitely without something badly going, or risking going badly wrong.”….

NHS Surgeons kicking their heels as thousands of operations delayed.

Michele Hanson opines: We are a rich country that can afford to pay for proper care – so why don’t we?  and Why are GPs having to beg for appointments to get their patients treated in hospitals?

Matthew Weaver reports: A&E in England had worst delays ever in January, leak suggests – Provisional data shows an unprecedented number of patients spending longer than four hours waiting to be seen

Dennis Cambell reports: Two-thirds of young hospital doctors (Anaesthetists) under serious stress, survey reveals -Trainee anaesthetists complain of fatigue, disillusionment, ‘burnout’ and fears for patients’ safety as pressure mounts on NHS

Undercapacity leads to undersupply. When skills are valuable and in short supply they demand high payment, especially if working “overtime”. Which party believes in market forces? All parties have failed to control the supply in a market it commands completely?

NHS ‘pays £7.5m a year for 20 most expensive agency doctors’ – Watchdog says health service could save £300m a year if locums charged within set price cap, after data found some are paid £375,000 a year

Jeremy Hunt: NHS problems completely unacceptable – Health secretary says there is no excuse for some of health service’s shortcomings after figures show record delays for patients

One in six A&E departments at risk of closure or downgrade- As many as 33 casualty departments across the UK could be lost by 2021 in an attempt to save £22bn from the NHS’s budget

Alexandra Topping reports: Woman, 89, trapped in hospital for six months despite being fit to leave – University Hospitals Bristol NHS trust launches inquiry after lack of social care led to stay that cost health service £80,000

BBC News: 2000 NHS doctors call on prime minister to increase spending

Robert Pigott for BBC news reports: NHS Health Check: ‘Most staff have been attacked’, doctor says

Nick Triggle reports for BBC News: 10 charts that show why the NHS is in trouble

An “existential crisis”? – as civil unrest gets closer… 

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The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

A Times leading article alludes (correctly) that undergraduates are less value to the state than graduates who enter medical school. But Zawad Iqbal in “Doctors’ training needs streamlining before it’s too late” does highlight the problem of declining standards, and lowest common denominator medicine. The problem with the new GMC suggestion is that too low a standard may be deemed acceptable in order for us to have enough doctors in the short term. The fact that NHSreality would never have chosen to start from here is omitted. Long term rationing of medical school places, as well as too many undergraduates and too few graduates is to blame. A ten year program of capacity management may be undermined if we admit too many overseas doctors suddenly.. On the other hand, if the bar is set high enough… OK, I forget, nurses can do the job of a GP can’t they? NHSreality feels it is already too late, and it’s going to get worse… (Katie Gibbons reports from Kent: NHS operations postponed to save cash). Decommissioning is going to get worse still.

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In a letter to The Times 3rd Feb 2017 Prof Derrick Wilmot of Sheffield writes: on DOCTORS’ TRAINING..

Sir, A medical licensing assessment for doctors is long overdue (“Doctors face tough new test on basic skills”, Feb 1). There is a similar situation for dentists. A third of the dentists entered each year on the General Dental Council’s register qualified at an overseas university. UK graduates are not tested by a common examination but by the individual university dental schools, which do try, mostly with success, to maintain sufficient quality and commonality. Many of the overseas new dentists entering the UK come from EU countries and cannot be tested. Brexit is the ideal opportunity to introduce a new robust common assessment for all doctors and dentists registering in the UK.

Recent years have seen a frightening increase in medical and dental litigation. Evidence for an association is weak but if a basic clinical education is lacking problems surely lie ahead both for the practitioner and, more worryingly, for the patient.

Emeritus Professor Derrick Willmot of Sheffield University, and past dean, Faculty of Dental Surgery, Royal College of Surgeons: Doctors’ training needs streamlining before it’s too late

The news that thousands of newly qualified doctors aren’t confident enough to perform basic tasks such as taking blood is a real canary in the coal mine moment — a warning sign that the way we teach doctors urgently needs to change.

Part of the problem is that the basic structure of medical training hasn’t changed in more than a hundred years. The General Medical Council sets the standards for undergraduate medical education and supervises the training and education of students. But the content and length of a medical degree varies widely, depending on which institution you attend, and the different medical schools are allowed to set their own criteria for licensing doctors.

There is no common standard to practise in the UK. Doctors from the European Union can work here if they’ve passed relevant exams in their own country. Doctors from other parts of the world are given a separate test, resulting in a confusing system with no overall benchmark.

So it’s a relief that medical regulators now want to introduce a standard test. But that’s still some years away and frankly it’s not enough. We should seize the opportunity to conduct a bigger and more wholesale review of how we train our doctors and whether these decades-old methods are up to scratch.

What doctors needed to know ten years ago is often a world away from what they need to know today. Basic science and clinical science remain the core modules on medical courses but healthcare delivery is becoming ever more important. As well as introducing a common approach to basics such as taking blood samples and performing lumbar punctures, areas such as data analysis, IT skills and interpersonal ability must play a bigger role in medical training.

One of the biggest opportunities being missed is in postgraduate medical education. This is because postgraduate training falls under the NHS rather than a university or medical school. Our doctors need to keep learning new skills if they’re going to give their increasingly well-informed patients the best treatments. The doctor of the future will not necessarily carry a stethoscope around his or her neck but will more likely be one of a specialist team working alongside health technicians, pharmacists and nurses.

Rather than introduce a new standard test for doctors after they have qualified, they and their patients would be better served if medical schools standardised the courses they begin at 18.

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Inside Health changed from 7th to 14th Feb – listen to questions and answers in a public debate

Inside Health is broadcast on the BBC 8th Feb:

Join us in the BBC Radio Theatre in London on 8th February 2017!

BBC Radio 4’s Inside Health is hosting a special debate on the current state of the NHS. Dr Mark Porter and guests discuss what needs to give.

The last few months have seen the service creaking under unprecedented demand, and there is likely to be worse to come.  Something needs to give. Is it simply a matter of more resources, or do we also need to change our expectations of what the NHS provides? Is rationalisation and rationing the way forward?

Mark is to discuss the issues with a panel including regular contributor Margaret McCartney GP, Claire Marx, president of the Royal College of Surgeons, and Chris Hopson, chief executive of NHS Providers.

Tickets will be available from the BBC website soon

email Questions to:  insidehealth@bbc.co.uk

NHSreality questions:

Would the panel like to pre-determine their interpretation of the current ideology and philosophy of their NHS, and whether it coincides with Aneurin Bevan’s original article?  

In view of this ideology (if they all agree) is it sustainable, given that technology and demographics are advancing faster than our ability to pay, for best and universal health care? 

The WHO does not intend to report on the NHS but rather on 4 different systems when it next reports and compares outcomes. In what ways are the Regional Health services, from a patient’s perspective, (in  a patient centred NHS) (England, Ireland, Scotland and Wales) still “National”? 

Large companies conduct exit interviews on their staff who leave or retire, or get promoted. Is the panel aware that there are very few (if any) Exit Interviews conducted in the Health Trusts (which are much larger organizations)? It is BMA policy (In Wales) to ask for these – would the panel support this? How would you give feedback from these interviews so that it made a difference? 

What does the panel think of the language of health? Trusts describe prioritization, restriction and limiting, but not rationing. Is this language honest in a “patient centered” health service? 

Do the panel members feel that covert rationing is preferable / more ethical to overt rationing or vice versa?  Would it be fairer if patients knew what services they were not entitled to? 

The Medical profession believes that the language of health care should be more honest with regard to rationing: do you agree? 

If rationing were to be allowed to be debated, where would the panel begin the debate? 

How would the panel set about changing the culture of fear in the Health Services of the UK? 

Does the panel think that it is right to reject 9:11 applicants to medical school, and then recruit the shortfall from overseas, and countries that can least afford to lose doctors? 

Does the panel believe we as taxpayers would get better value from graduate medical students as opposed to undergraduates (as in many other countries)? 

In view of the litigation bills: Does the panel believe a “no fault compensation” system would give a payback over time (longer than one term of office)? 

How would the panel de-politicize health so that it was not a political football? 

Does the panel feel hypothecated taxation, allied to rationing could be a way forward? 

What are the arguments against providing patients with the true cost of every good or service they receive, even if there is no charge? 

How would the panel design a system that encouraged patient autonomy rather than a paternalistic state?

In a “free” health service (cradle to grave) why is neonatal and maternal health fully funded and yet palliative and terminal care depends on charities?

Are there any goods and services which are so cheap that everyone, whatever their means, should pay for them?

How would the panel address the disengaged, cynical and angry professionals in the medical professions? Given that these real people are in the majority, and they will not be the ones sending questions in to you, and will not be listening to your answers how will you get your new and inspirational message across to them?

Do you think all ministers and health board members should let their citizens know annually whether or not they have Private Medical Insurance?

Would the panel members know of any other country whose funding is open ended? What is their opinion of the New Zealand system which used to be similar to ours? Is there any other country whose system they would hold up as equivalent or better than our own?

How would the panel like to change the dental contract so that, once there are enough Dentists, they will be tempted to have Health Service patients?

Does the panel agree with the 1982 report by Prof Robert Duthrie (1925-2005) of Oxford University: to reduce complications, lower waiting lists and raise standards we need a national network of cold orthopaedic centres. This would reduce infections and complications.

Does the panel think that cold orthopaedic centres should be an option/choice for everyone in the UK Health Services? 

Does the panel feel that, with increasing bacterial resistance and cross infections, associated with over occupancy of hospital beds, that patients are more or less likely to choose the private option if they can afford it? What effect does this have on equality?

If you had the power to act, what would the panel members first actions be; in the short term, and then in the long term, to address staff shortages?

Are there some goods and services which are so cheap that everyone, whatever their means should pay for? Eg: 10 paracetamol. Paracetamol liquid. Suppositories for piles.