Category Archives: Guest

Thank god the Welsh were wise enough to avoid PFI

The collapse of Carillion was foreseen. In May 2013 there was a campaign not to use PFI in Liverpool. The BMJ summarises the history of a tempting short-termism idea, which has made some parts of the country even less well served. It has led to great wealth for the directors and officers of PFI companies as well.

Richard Smith in an editorial in the BMJ opines (BMJ 2018;360:k311 ):  Failure of the private finance initiative

Was predictable and predicted

In 1999 TheBMJ called the private finance initiative (PFI) “perfidious financial idiocy,”1 and in 2017 the Office for Budget Responsibility described it as a “fiscal illusion.”2 Now a data driven report from the National Audit Office shows that PFIs have been more expensive than the use of public financing for the building of hospitals, schools, and other public buildings and has mostly not realised the benefits hoped for.3 Published in the same week as the collapse of Carillion, a large company fulfilling PFI contracts, the report has helped propel private financing and provision of public services high on the political agenda.

The difference between conventional public procurement of new buildings and PFIs lies in the financing. In both cases private contractors do the work, but with PFIs the money comes from the private sector. The public sector then pays back the private sector over some 25-30 years from when the building is delivered. The UK has over 700 PFI projects with a capital value of around £60bn (€68bn; $83bn). Annual charges were £10.3bn in 2016-17, and even without any new projects charges will continue into the 2040s and cost £199bn. It’s important to note, however, that over the past 20 years the contribution of PFI, at around £3bn a year, is relatively small compared with public capital investment of around £50bn a year.3

The main attraction of PFI to the government is that privately raised capital does not add to national debt. Nevertheless, it is paid for from the public purse in the form of annual charges, and the Treasury knew when it launched PFI in 1989 that it would be more expensive because privately raised capital is more expensive than publicly raised capital and carries other costs (insurance and management costs). It hoped, however, that it would achieve value for money through efficiencies and better outcomes. The National Audit Office report dashes those hopes.

Even the National Audit Office does not have access to all the government’s PFI contracts, but its study of a group of schools found that PFI costs are about 40% higher than funding with public money. A study in 2011 by the House of Commons Treasury Committee found that a PFI hospital cost 70% more than a publicly financed one.4 The Treasury disputes these findings.

Save now, pay later

PFI is also attractive to government ministers because there are savings in the early years: the costs come later. The National Audit Office’s study of the schools showed that despite the overall costs being higher, costs were lower for the first 15 years. The Department of Health had greater flexibility in its budget between 1997 and 2009 because the capital investment was greater than the charges, but by 2015 charges were almost £2bn greater than capital investment. This lack of flexibility is much more severe in some NHS trusts, with one trust paying 20% of its turnover in PFI charges.3

The National Audit Office analysed the hoped for benefits to see if they outweighed the extra costs. It found that PFI projects are more often delivered on time and within budget than non-PFI projects but did not find any savings in construction costs. Similarly, it found no evidence of operational efficiencies, and there were higher maintenance costs in PFI hospitals but also higher standards.

Lack of flexibility may prove to be one of the biggest problems with PFI projects lasting 25-30 years. The report describes how Liverpool City Council is paying £4m a year for a school that is empty; overall it will pay £47m for a school that cost £24m to build. Most observers of the NHS recognise the need to shift services from hospitals to the community.5 Inflexible, long term PFIs preserve the domination of hospitals at the expense of community services.

Health authorities and local authorities have, however, now recognised the idiocy and seen through the illusion: between 2002 and 2007 there were an average of 55 PFI deals a year, whereas there was only one in 2016-17. Nevertheless, the public sector will be paying average charges of £7.7bn over the next 25 years, and the National Audit Office concludes that it is difficult to reduce the costs.

Despite the criticism of PFI since its inception, the overall performance of PFI has never been quantified. In the face of higher financing costs and continuing criticism, the Treasury relaunched PFI as PF2 in 2012, but the National Audit Office concludes that it’s not much different—hence the low uptake. Yet the poor state of the nation’s finances means that there may have to be some continuing use of PF2.

The combination of the National Audit Office report and the collapse of Carillion has led to calls to end all use of the private sector for providing public services, but this would probably be a mistake. The Financial Times points out that if there is a market in the service, performance can be easily measured, and the service isn’t integral to the purpose and reputation of government, then outsourcing to the private sector can work.6 Catering meets all three criteria, whereas probation services meet none of them.

The public sector should be smart rather than ideological and avoid the illusion of a “free lunch,” as The BMJ said in 1999.1

Footnotes

  • Competing interest. RS wrote the 1999 editorial on PFI, when he was editor of The BMJ. He worked for UnitedHealth Group, a private company supplying services to the NHS from 2004 to 2015 and still has shares in the company. He is also the chair of Patients Know Best, a private company selling into the NHS. This position is unpaid but RS owns share options (about 1% equity) in the company. He is also a paid consultant for an artificial intelligence company Medial EarlySign, which hopes to sell into the NHS.

 

 

 

English Health Service to reject more PFI – but not the hedge funds!

NHS ‘leaking millions’ in PFI contracts. No PFIs in Wales…. unless GP premises count.

Ending the Blair/Brown short term mania for PFI Hospital Builds

Campaigners urge bosses not to use PFI to build new Royal Liverpool Hospital

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The “State of health and care in England” – is declining and worryingly underfunded…

In The BMJ Chris Ham of the Kings Fund reports on the “State of health and care in England.

(BMJ 2017;359:j4799 This is worrying and there is inadequate funding, but the word omitted by Mr Ham is “rationing” – of course. 

Services are at full stretch and struggling to maintain standards

The annual assessment of health and social care by the Care Quality Commission (CQC) provides a veritable treasure trove of information about the state of services in England.1 Based on inspections of 21 256 adult social care services, 152 NHS acute trusts, 197 independent acute hospitals, 18 NHS community health trusts, 54 NHS mental health trusts, 226 independent mental health locations, 10 NHS ambulance trusts, and 7028 primary care services over three years, the assessment offers grounds for concern and reassurance in equal measure.

The CQC’s headline finding is that most services are good and many providers have improved the quality and safety of care since inspections. Behind this headline lies a much more nuanced assessment, with variations between and within services and evidence of growing pressures on staff and deterioration of quality in some services. Adult social care is identified as a particular concern, with a reduction in nursing home beds, providers of domiciliary care handing back contracts to dozens of local authorities, and an estimated 48% increase in the number of older people not receiving the help they need since 2010.

The CQC argues that health and care services are working at full stretch and that staff resilience is not inexhaustible. It is hard to escape the conclusion that standards in many services are likely to fall in future as a result of continuing financial pressures. Support for this view can be found in evidence by Simon Stevens, chief executive of NHS England, to the House of Commons Health Committee on the day the report was published. Stevens warned that low levels of funding growth for the NHS in the next two years would result in deteriorations in care, a reminder if one were needed of the dangers that lie ahead.2

Challenges for NHS, government, and CQC

The challenge for the NHS arising from CQC’s assessment is to learn lessons from the experience of NHS trusts that are performing well even in the face of financial and operational pressures. According to the CQC, the characteristics of acute hospital trusts that have improved care include strong leadership, engaged staff, cultures that empower staff to improve care, a shared vision, and an outward looking approach. There is more work to do to embed these characteristics in all NHS providers to ensure that patients receive the best possible care.

The challenge for the government is to find a sustainable solution for the future funding of adult social care, described by the CQC as “one of the greatest unresolved public policy issues of our time.” The promised green paper on adult social care provides an opportunity to tackle this problem if the will exists within the government to examine all the options and to move beyond the sticking plaster solutions like the Better Care Fund that have so far failed to deliver.3 A good starting point is the report of the Barker Commission, which laid out the hard choices on tax and spending that need to be confronted in securing sustainable funding for the future.4

The challenge for CQC is to use the intelligence and understanding it has acquired to support improvements in care and not just to hold up a mirror to how services perform now. It also has more work to do to assess the performance of local systems of care as well as the organisations providing care. Its observation that high quality care is delivered when services are joined up around the needs of people reinforces the importance of work to integrate care through implementing the NHS five year forward and sustainability and transformation plans.5

Continuing to give priority to the development of these new care models will not be easy when so much management and clinical time is focused on reducing financial deficits and meeting waiting time targets. The CQC’s warnings about the perilous state of some services could have the unintended effect of strengthening the focus on these operational matters at the expense of work to transform care. Securing the future of health and social care depends on doing things differently, not doing more of the same a bit better, and leaders at all levels have a responsibility to make sure this happens. This must include providing additional funding to sustain services while options for the longer term are explored in work on the green paper.

 

Hearing loss and dementia: more research is needed. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us …

More research is needed into the relationship between hearing loss and dementia. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us … The rationing of hearing aids is patently perverse, and the outcome could be more long term dementia care demand on the state. And of course the politicians making the decisions today will not be those addressing the future problem.

Image result for hearing loss and dementia cartoon

A letter from Dr Ted Leverton in the JRCGP October 2017 reads: 

Iliffe and Manthorpe’s editorial in the August issue1 is apposite in view of the publication in July of the Lancet Commissions’ report Dementia prevention, intervention, and care, which expands on several of the themes raised.2 In particular, the editorial’s focus on the role of general practice in prevention and research is to be welcomed. However they do not mention hearing loss, to which the Lancet report devotes considerable space and ascribes a significant potential preventive role. Hearing loss is independently associated with developing dementia in about one-third of cases.

Recent research has suggested that use of hearing aids may reduce or prevent the increased prevalence of dementia seen in adults with hearing loss.3,4 This needs confirmation, as current evidence is weak due to the large number of confounding factors. General practice is ideally suited to carry out this research thanks to our large-scale and long-duration databases. In the meanwhile, GPs are likely to see increasing numbers of patients asking for referral for hearing aids, as some in the commercial sector are stating this benefit of hearing aids as fact. Such referral should be expedited; GPs are sometimes accused of minimising hearing loss and delaying referral, but early users of hearing aids are more likely to use aids successfully over a longer timescale as they can be difficult to use. Hearing loss is associated with depression and social isolation;5 denial of the disability is common, as is irritability and interference with relationships. By the age of 70 years, 70% of GP patients have hearing loss. If in doubt, or if the patient is reluctant, a simple validated screening test is available over the phone or online.6

REFERENCES

  1. (2013) Hearing loss and cognitive decline in older adults. JAMA Intern Med 173(4):293299. Lin FR, Yaffe K, Xia J,et al.
  2. (2015) Hearing loss and cognition: the role of hearing aids, social isolation and depression. PLoS One 10(3):e0119616, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356542/ (accessed 5 Sep 2017). Dawes P, Emsley R, Cruickshanks KJ, et al.
  3. Action on Hearing Loss. Check your hearing. https://www.actiononhearingloss.org.uk/your-hearing/look-after-your-hearing/check-your-hearing/take-the-check.aspx (accessed 5 Sep 2017).

Whistleblowing and gagging update

If Scotland accept the proposals there will be another area of Post Code differential. Peter Gregson in Scotland posts as a guest, and NHSreality hopes that other Regional Health Services will follow (but it will take more than this to change the culture):

cropped-gagging-bdqw3y0cqaewblo.jpg

I wanted to let you know that the Scottish Parliamentary Petitions Committee will be discussing petition PE1605 this Thursday the 9th February at 9.15am. It will  take evidence from:

·         Laura Callender, Governance and Compliance Manager and Kirsty-Louise Campbell, Head of Strategy (interim), City of Edinburgh Council;

·         Cathy James, Chief Executive and Andrew Pepper-Parsons, Head of Policy, Public Concern at Work;

·         Tam Hiddleston, Secretary, Scottish Healthcare Branch, UNISON Scotland

 The agenda can be downloaded at http://www.parliament.scot/S5_PublicPetitionsCommittee/Meeting%20Papers/Public_Briefing_Pack_09.02.17.pdf

I’ll be there, but I won’t get to speak. If you want to attend, book your ticket at https://www.parliament.scot/visitandlearn/28754.aspx

You will also be able to watch it live on Parliament TV here

I’ll circulate the official report and link to the video in about 10 days’ time. (NHSreality will give a link in an update to this page)

 Here’s hoping for a revealing discussion. I think the Petition will be continued after Thursday – the clerk tells me that the Chief Exec of NHS Scotland is due to attend to discuss this but was not free on Thursday – he thinks Paul Gray will likely attend on the 2nd March.

cropped-doctor_gagged1.jpg

File on 4: Speaking Up – Whistleblowing in the NHS (BBC iPlayer 7th Feb 2017)

…Two years ago the first independent report into the treatment of whistle…

…Two years ago the first independent report into the treatment of whistle-blowers in the NHS was published. The Freedom to Speak Up report was commissioned by…

…Two years ago the first independent report into the treatment of whistle-blowers in the NHS was published. The Freedom to Speak Up report was commissioned by the government amid concerns not enough progress had been made to create a more…

Whistleblower Bullying hotline – proposed by petition for Scotland – could be rolled out across the UK

Peter Gregson, who works for the Scottish Health Service (NHS Scotland) has proposed that the Scottish Parliament cover the costs of a Whistleblower Bullying hotline in his i-petition. If accepted then this should be rolled out across the UK. But barriers to acceptance include the trade unions. Peter was asked to leave a meeting in which he was handing out leaflets (see below) recently. ( Peter Gregsons press release. )

whistleblower cartoon

So if we do stay together this could be one area where we improve the culture together. The current system of relying on line managers to back you up, is not good enough.

Whistleblower HotlineHealth workers in Scotland are being blocked from debating whether to support a Parliamentary Petition calling for a whistleblower hotline. It would allow NHS staff to report mismanagement, bullying, perceived negligence, malpractice or ill treatment of a patient by a member of staff.

The Petition PE1605 is shortly to go before MSPs and union support is crucial to seeing it implemented. But all four big health sector unions either won’t support (or won’t allow their members to discuss) the Petition, which calls upon the Scottish Government to establish an independent national whistleblower hotline for NHS staff to replace the current helpline. It would differ in that it would investigate reports about mismanagement and malpractice, often without recourse to NHS managers.

The reason why the unions oppose the measure is because they say they are tied into partnership arrangements with NHS Boards and will do nothing that might undermine that. But it is clear that they have not even discussed the scheme with NHS Management; they have rather instinctively chosen to side with what they think managers will say.

It is unreasonable of them to assume that NHS bosses will oppose a hotline. When a similar approach was made by the same petitioner to Edinburgh Council in 2013 the Corporate Management Team initially opposed it, but now pay tribute to its success. The hotline has been in place since May 2014 and was recently lauded by the Council in its Whistleblowing Annual Report : “Many of the recommendations that have resulted from investigations have led to amendments to policy, improvements to procedures and processes, the development and sharing of best practice and improved service delivery.”

 

Whistleblower reports are taken by the Council’s Governance Risk And Best Value (GRBV) Committee and have led to numerous improvements at the Council.

The Petition to the Scottish Parliament has been signed by politicians from right across the spectrum. Supporters include MSPs Kezia Dugdale (Scottish Labour Leader); Jeremy Balfour (Conservative Shadow Minister for Childcare & Early Years- who also helms Edinburgh’s GRBV Committee) and Green MSPs Alison Johnstone and Andy Wightman.

It is supported by The UK Patients Association, by Action for a Safe and Accountable People’s NHS (ASAPNHS), the Scotland Patients Association, the NHS Lothian Branch of Unite and Accountability Scotland.

The only agencies refusing to support the scheme are the unions and staff associations…..

Whistleblowing cartoons, Whistleblowing cartoon, funny, Whistleblowing picture, Whistleblowing pictures, Whistleblowing image, Whistleblowing images, Whistleblowing illustration, Whistleblowing illustrations

'And this is Mr Proctor, he manages the hospitals whistleblowing support team.'..

 

1 in 20 Welsh voters wants to abolish Welsh Assembly Government – and the “One party state”

Wales is funded and founded differently to Scotland. The monies available for Health and Education in particular are less, and this is because of the structure. The Nuffield Trust commented earlier this year. In effect more money would be available for Health and Education under the former regime with a Welsh office. If 1 in 20 want abolition without publicity and media coverage, how many more will vote next time? Turnout was just over 50%.. When will the dying “one party state” of Wales change?

How will abolishing the welsh Assembly benefit the people of Wales ? If readers consider that £350 m is equivalent to one fully staffed new hospital per annum. From waiting times, mortality and morbidity, life expectancy and general standards overall it looks to the professions as if Devolution of Health in Wales was a mistake. How much worse must it get before the voters realise this?

tumblr_mqonr5CU981qhiaqno1_500

James Cole writes in Walesonline Letters Tuesday 10th May 2016: ‘Abolish’ Party is proving worthy

Thank you one and all who voted for the Abolish the Assembly Party.More than 44,286 votes! Abolish is now the largest party in Wales (in terms of votes) that doesn’t have a seat in the Senedd.

Making a huge gain first time out was clearly beyond reality. However, we got 44,286 votes despite the fact that perhaps most voters were either still unaware of our existence or were, at least, taken by surprise at the last moment. It seemed at times that, apart from the BBC, the Welsh media boycotted our campaign. This, despite the fact that the “No, to a Welsh Assembly” vote in the 1997 referendum received 552,698 votes.

That was 49.7% of the votes cast when only half the Welsh electorate actually voted. So, only a quarter of us actually voted Yes to the Assembly. Hardly a mandate for fundamental change.

I urge everyone to consider the possibility that the Welsh Assembly was not designed for the benefit of the Welsh people, but for the benefit of the career politicians.

They get big salaries, expenses and pensions. What do we get? The bill.

Issues that are perhaps best devolved can be made the responsibility of our local authorities and their 1,265 councillors. That really would be power closer to the people.

We think the Assembly just gets in the way while costing far more than it would take to keep Port Talbot steelworks operating.

We consider our result in this election to be a foundation stone for the fightback. We have drawn a line in the sand.

We will keep this movement going.

James Cole, St Thomas, Swansea

wh-15-46

A campaign to abolish the Welsh Assembly will continue

Spokesman David Bevan claimed the assembly benefitted “career politicians”, not the Welsh people.

He said the election result was “a foundation stone for the fight-back”.

The Abolish the Welsh Assembly Party put up candidates on the regional lists, claiming abolition would save the taxpayer £500m a year.

Further info below from the party website

“The cost of running The Assembly is very difficult to estimate. We are tempted to think this is deliberate as the figure would, no doubt, be truly shocking. Now we find that Welsh Assembly members are going to see their salaries increased to £64,000 in 2016. Assembly Cabinet ministers will get £100,000 p.a. The First Minister’s salary is due to increase to near the level of Prime Minister David Cameron, £140,000 pa. The First Minister is only in charge of devolved issues covering Wales.” from the abolishthewelshassembly website

Welsh Assembly Final Budget 2016-17

 20101030_brd001

Components of the Welsh Budget £000s
MAIN EXPENDITURE GROUP
Departmental Expenditure Limits Resource Capital Total
Health and Social Services      £7,004,269
Local Government  £3,370,622
Communities and Tackling Poverty  £ 707,323
Economy, Science and Transport  £988,747
Education and Skills £ 1,756,578
Natural Resources £ 376,575
Central Services and Administration  £311,897
Total Welsh Government MEG Allocations

Resource 13,159,112 Capital 1,356,899  TOTAL £14,516,011

The amount of funding allocated to Welsh Government Main Expenditure Groups (MEGs) for 2016-17 is £15bn.

Abolish the Welsh Assembly Party

Seats0 Net change in seats Votes 44,286 Vote Share4.4%  

 

 

 

On a turnout of 45.3% Letters Walesonline May 10th  , but no candidates fielded in the constituencies.

The Abolish the Welsh Assembly Party put up candidates on the regional lists, claiming abolition would save the taxpayer £500m a year.

Devolution of health to Wales was a mistake?

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

Patients and the professions are ready to ration health care strategically, without devolution. It’s the politicians and the managers who won’t hear of it because the strategy might mention rationing.

The State of Wales: we should all rage against it dying

Trainee’s portfolio ‘used as evidence against them’ in legal case

The real man smiles in trouble, gathers strength from distress, and grows brave by reflection. Thomas Paine
Article from Pulse magazine once again the opportunity to learn from mistakes will be lost in order to satisfy the thirst for cash for claims bonanza that is going on in the UK. Good luck retaining doctors with this  sort of thing  going on …. We will become the dumping ground for the worlds worst practitioners , man can only learn through experience. LINK TO FULL ARTICLE BELOW

“If you want a vision of the future, imagine a boot stamping on a human face – forever.”  Could be a quote from any tory politician …. but alas not their actions speak far louder than words …

 

Trainee’s portfolio ‘used as evidence against them’ in legal case
|15 April 2016 |By Alex Matthews-King

GPs must provide ‘honest explanation’ to patients if something goes wrong, says GMC
03 Nov 2014
A trainee’s ‘written reflections’ on an incident in their training development portfolio was used against them in a legal case, which GP leaders have said illustrates the medico-legal ‘minefield’ that GPs are having to operate in.

Health Education England bosses in London and the South East have warned that a recent legal challenge saw a trainee release their reflections – a vital part of a trainee’s portfolio – which ‘was subsequently used against the trainee in court’.

But in a letter to postgraduate deans and training supervisors, HEE said trainees should continue to make particular note of cases where ‘things do not go well’.

It highlights that for trainees the reflection process is exactly the same as for GP appraisal, and that these should avoid patient-identifiable information and focus on the positive lessons learned.

RCGP’s guide to revalidationGP leaders warned that GPs need to take all precautions to not incriminate themselves

The letter from HEE, which was shared by doctor and medical educator Dan Furmedge on Twitter, said: ‘Recently, a trainee released a written reflection to a legal agency, when requested, which was subsequently used as evidence against the trainee in court. This has resulted in questions about whether trainees should still provide reflection about incidents in their portfolios.