Category Archives: NHS managers

Patients “hurt by hospitals that merge”…..

The Times printed a piece by Kat Lay which will stir the embers of injustice in the Welsh Valleys. On 5th Feb she writes: Patients “hurt by hospitals that merge”, but the article is not “on line”. Choice has been limited within Wales for a few years now, and different CCGs in England take differing approaches. A second opinion in Wales can be sought easily if its within ones own trust (where all specialists in a department meet regularly and think the same) but to get a genuine second opinion is not possible without private means.

Merging hospitals will improve standards, but it should not exclude choice and second opinions in a liberal society. You might argue that our 4 Health Services are in such a parlous state that the restriction to individual liberty is justified by the gain to the population as a whole. John Stuart Mill argues that this is the only justification for such restriction of liberty. Hence taxation is justified, health and education are mutualised, and social safety net has moved on from the poor house or the workhouse.

In areas where travelling time is significant, transport systems are relevant to quality of care.  There is a big difference between A&E attendance (speed, access) and cold referrals  (quality, choice). A government that put its money into prevention should then focus more on cold referrals if you are unlucky enough to get a “black swan” condition, or need A&E. 

I happen to live in a rural area, with a soon to be closed teaching hospital. I live in an area with poor and slow transport. The road east can be blocked by dozens of agricultural or industrial HGVs. My chances of a stent to save my heart attack, or clot busting treatment for a stroke, of killing me, will be much greater that those who live within 20 minutes of a merged facility….  depending on where it is located. Air ambulance is a charity, and we cannot depend on helicopters as the numbers are too large.

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Patients “hurt by hospitals that merge”. 5th Feb 2019, Kat Lay in the Times.

Hospital managers harm patients because they reduce competition, according to a watchdog report.

A typical merger plan costs the NHS more than £2.5m a year as a result, the Competition and Markets Authority found.

The report said that falls, pressure ulcers, blood clots and Urinary Tract Infections could almost treble if a merger created a local monopoly. It also estimated that deaths could increase by almost 500%.

Health policy experts said that the findings were interesting but questioned the watchdog’s conclusions. Nigel Edwards (Formerly policy director of the NHS England), chief executive of the Nuffield Trust, told the Health Service Journal: “The conclusion that a merger will increase death rates is completely illegitimate and an over-extension of the analysis because there are other factors driving this”. They included whether a hospital was in a rural area or used for teaching, he said.

The study used NHS statistics from 2013-15 across eight hospital specialities that covered about two thirds of admissions. Since 2006 patients ( In NHS England, not Wales or Scotland) have had the right to choose the hospital where they receive treatment.

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GP pension boost may halt exodus: why when “the NHS ….is the least national health service in the developed world, an insult to the memory of Aneurin Bevan.”?

The idea that successive governments bear responsibility for the manpower crisis has not occurred to the media it seems. Whilst the stressed out GPs, denied access to quick diagnostic tests, have a choice: they can “live with uncertainty” in an increasingly litigious world, or refer. Which choice they make determines the efficiency of the 4 health services. Most inexperienced GPs have higher referral rates, and the more experienced live with more uncertainty, and use time as a diagnostic tool. They play the odds…  When Ed Conway opines, in the same edition of the Times as the report below, he is correct that the “Rules ( of the game ) and red tape make the NHS second best”, and he is right that “..the NHS ….is the least  national health service in the developed world, an insult to the memory of Aneurin Bevan, whose goal was that the miners of Tredegar would have the same quality if service as London stockbrokers.”

He is right that AI could be more useful, right that IT has been badly used, right that some services and follow ups could be done by people other than doctors. He however misses the point that doctors are the only people who make a diagnosis….  He does not comment on the missed waiting targets and other performance indicators, or who is responsible for the manpower crisis. Changing them is an admission of defeat, and a time horizon for the extra 5000 GPs that cannot be met. Indeed, since the announcement of the extras 3 years ago we have 1000 less…

In West Wales we have no tertiary hospital in our area, and we have lower standards and survival for acute coronary events, and we suspect from many other conditions. We pay the same taxes, and although not Tredegar, we suffer from the same inequalities as b=the miners did before the old “N”HS.

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Chris Smyth reports 11th Jan 2019: GP pension boost may halt exodus

GPs could get more generous pensions to prevent so many leaving the NHS.

Matt Hancock, the health secretary, is pressing Philip Hammond, the chancellor, to change pension tax rules that are said to encourage GPs to retire early.

The Treasury believes that the change would be unfair, unnecessary and costly. The pensions of other high-earners in the public sector, such as senior army officers and High Court judges, would be boosted as well.

It is also unconvinced that pensions are a significant cause of a shortage of GPs. A Treasury source said: “The secretary of state for health has just inherited the biggest single cash injection the health service has ever had. He can now put that money to work supporting NHS staff and frontline services.”

Mr Hancock is prepared to push for changes after being told that a worsening shortage of GPs threatens efforts to improve local care and keep patients out of hospital, ideas that are at the heart of the ten-year, £20 billion plan for the NHS announced this week.

GP numbers have fallen by 1,000 since a government pledge to recruit 5,000 four years ago, and doctors complain that they are overworked coping with an older, sicker population.

They argue that the loss is worsened by a cap of £1 million on the tax-free amount that can be accumulated in a pension pot. Many doctors hit this limit in their fifties, making it less attractive to carry on working.

Some complain of being hit with annual tax bills of tens of thousands of pounds because of related rules that limit the amount that can be contributed to a pension each year. GPs earn an average of £92,500 and the average age at which GPs retire has fallen by two years since 2011 to 58.

Mr Hancock told the GPs’ magazine Pulse: “The biggest concern I have raised with me [on GP retention] is around the tax treatment of pensions.”

Richard Vautrey, chairman of the British Medical Association’s GP committee, said that doctors “had been unfairly hit by complex regulations and tax changes. “At a time of plummeting morale, and amid a deepening recruitment and retention crisis, such charges make taking on extra work, or continuing to work full-time, an extremely unattractive prospect,” he said.

Boosting GP and other local care is crucial to the success of the ten-year plan, which promises that budgets for such services will rise faster than hospital spending for the first time.

Simon Stevens, chief executive of NHS England, has also blamed the pensions rules for driving doctors in their fifties out of the NHS.

Ed Conway: Rules and red tape make NHS second best

Don’t drop NHS waiting targets, doctors plead

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Can the NHS be saved? Only with different local and global thinking, and changing the “rules of the game”.

All of us in the caring professions know the answer to this question, and indeed that there is no “N”HS any longer. The Guardian knows the answer….. Iain Robertson Steel, a retired medical director acknowledges the problem (But suggests no answer/solutions), but on 26th April  in the Western Telegraph I suggested a “fourth option” for people in Pembrokeshire.  This last is only for local needs, and a letter suggesting a global rethinking was in the Western Mail 25th Jan 2018 is at the bottom of this post. What can save the 4 health services is not clever reorganisations, but an honest debate on overt rationing, and making it clear to everyone what is not available free, for them. ( Changing the rules of the game )

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Can the NHS be saved? The Guardian – Dennis Campbell – 

…the Guardian’s health policy editor Denis Campbell spent a day in King’s College hospital in London. He found staff and patients who are devoted to the NHS but who can also clearly see what is needed in order to sustain the service for future generations.

A long-term plan designed to secure the future of NHS England has been delayed once again by Brexit. But as Britain’s health service heads into its annual winter beds crisis, the Guardian’s Denis Campbell visits King’s College hospital in London to find out what staff and patients need for the future – and how much it will cost. 

“The Welsh NHS and social care is a shambles and no longer sustainable or fit for purpose.” Dr Iain Robertson Steel in the Western Telegraph 7th December.

Health service needs to be remodelled Western Mail 25th January 2018

From the perspective of west Wales there is no British health service.

I do not have access or choice to anywhere outside my own rural trust (Hywel Dda) unless the service needed is not available here. Even a second opinion has to be within the same trust.

There are four, and possibly five health services if Manchester is included. The WHO has said it will no longer report on an “NHS”.

The lack of choice, the covert rationing, and the unequal access to tertiary centres, primary care, and palliative care threaten to bring on civil unrest.

A Welsh mutual of three million people cannot offer the same quality of healthcare as one of 60 million. Even if the Welsh Government has tax-raising powers, there are not enough taxable earners to rise above the decline.

We seem to have forgotten the power and improved health outcomes in large mutuals. Since the UK’s health service has to be refashioned, now seems a good time to unify again, and re-establish the same rights across the country.

Increasing taxation to pour more into a holed bucket should not appeal to most taxpayers.

We need a new health insurance system (the original NHS was insurance based) and the caring professions will remain cynical until what replaces “in place of fear”, avoids bringing it back.

Dr Roger Burns

Haverfordwest

Pembrokeshire GP urges a “fourth option”. Western Telegraph 26th April 2018

The finances are in such a mess, that local post code and unexpected rationing is everywhere… The “Rules of the game” need to be changed…..

Changing the rules of the game

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The rising trend in fraud in the UK health services.

My calculation for a population of 70 million is that this “fraud” costs us all around £16 each. The known parts are £5 loss to staff, £1 loss to patients, and £10 the professionals.  How can an organisation be run by administrators and leaders so much in the dark? We know purchasing power is reduced in smaller Health Services (Wales, Scotland and N Ireland), and now we know more about what they have been unable to correct due to the perverse incentives in the system. How many families have crutches, walking sticks and other accessories no longer needed? A small co-payment, is needed, with partial refund when returned undamaged. The managers need a breakdown at the touch of a button, of all missing items. Can you imagine a company like Screwfix or Argos not knowing what was where? Whilst the figures are not high, the rising trend shows it might become a real problem in future. 

Fraud is also a concern in other countries, especially the USA. Some comfort…

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Kat Lay reports 8th October 2018 in the Times: Fraud in the NHS could have paid for 40,000 nurses

Fraud costs the NHS £1.29 billion every year, according to the health service’s anti-corruption watchdog.

The money would be enough to pay for more than 40,000 staff nurses or buy more than 5,000 frontline ambulances, the NHS Counter Fraud Authority said in its annual report.

The organisation was established on November 1 last year. The new figure is higher than the £1.25 billion identified at its launch. The estimated total loss includes £341.7 million from fraud by patients and £94.2 million by staff.

Fraud by dentists adds up to about £126.1 million, the watchdog said, and opticians £79 million. Fraud in community pharmacies is estimated at about £111 million and in GP surgeries it is worth £88 million. People accessing NHS care in England to which they are not entitled is thought to cost the health service £35 million. The rest included fraud involving NHS pensions, bursaries and legal claims.

Simon Hughes, the authority’s interim chairman, said: “Ensuring public money pays for services the public needs and doesn’t line the pockets of criminals means we all benefit from securing NHS resources.”

Sue Frith, its interim chief executive, said: “Fraud always undermines the NHS, with every penny lost to fraud impacting on the delivery of vital patient services. If fraud is left unchecked, we believe losses will increase.”

The report said there was “no such thing as a ‘typical’ NHS fraudster”. It noted that there were barriers to tackling the issue, including a lack of understanding of the problem in many NHS services. It added: “There is also sometimes a mistaken assumption that reporting fraud casts the organisation involved in an unfavourable light.”

At the end of March there were 45 criminal investigations in progress, the report said. In July a neurology nurse from London was jailed for 16 months for fraud by false representation. Vivian Coker, 53, from Camberwell, took sick leave from August 2014 to May 2016. During this time she received pay of £32,000 from St George’s University Hospitals NHS Foundation Trust, but had also registered with two agencies and worked shifts. Coker initially denied the charges but changed her plea at Kingston crown court.

In March the authority helped to jail Andrew Taylor, a locksmith employed by Guy’s and St Thomas’ NHS Foundation Trust. He was sentenced to six years for defrauding his employer of £598,000. He had charged the NHS mark-ups of up to 1,200 per cent.

Taylor, 55, from Dulwich, was found guilty at Inner London crown court of fraud by abuse of position. Financial investigators “established that Taylor was leading a cash-rich lifestyle beyond his legitimate means, which included paying for his son to attend a private school whose fees were £1,340 a month and purchasing a brand new Mitsubishi L200 vehicle at a cost of £27,400”, the report said.

It also described the case of Paula Vasco-Knight, 53, chief executive of South Devon NHS Trust, who made fraudulent payments of more than £11,000 to her husband, Stephen. She admitted fraud by abuse of position in March 2017 and was given a 16-month prison sentence, suspended for two years, and ordered to do 250 hours of unpaid work by Exeter crown court.

The couple said that they did not have sufficient assets to repay the money but investigators found that they had access to personal pensions that could be surrendered.

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

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A disingenuous report on closing A&E. Some lives will be saved in densely populated Trusts, but lives will also be lost..

What about choice? What if patients in rural and distant parts prefer to live shorter lives and have more convenient services? The whole basis of “mutuality” is being challenged by the current financial crisis. Does the utility value for the whole of West Wales trump the utility value for each individual part? There are four DGHs and three A&Es, and this is why we have a “trusted?” board to make decisions. But the people don’t trust them – do they?

This is a disingenuous report on closing A&E. Some lives will be saved in densely populated areas, but lives will also be lost..

TRUST: ‘Are you telling me that none of you knows what it means?’

Kat Lay reports august 20th: NHS saves 1,600 lives by sending ambulances on longer journeys

Controversial A&E reforms under which ambulances can bypass their nearest hospital have saved the lives of more than 1,600 patients since their introduction in 2012, according to research.

Designating some hospitals as major trauma centres concentrated expertise in dealing with emergencies such as gun and knife wounds, serious road traffic accidents or terrorist attacks.

However, it led to claims that other A&E departments had been downgraded, putting them at risk of closure.

The new research, from experts at the universities of Manchester, Leicester and Sheffield, calculated that an additional 1,656 people had survived major trauma injuries since 2012, when they would previously have died.

The reforms have also meant that patients are more likely to be treated by an experienced doctor at the roadside who, working alongside paramedics, can help to stabilise them before they get to hospital.

The odds of surviving a severe injury among patients reaching hospital alive have increased nearly a fifth since 2012, the researchers calculated. Patients have also spent fewer days in hospital.

Trauma is the most common cause of death for under-40s in England. According to National Audit Office estimates, there are 20,000 major trauma cases a year, with 5,400 deaths.

Researchers looked at data on more than 110,000 patients admitted to 35 hospitals between 2008 and last year. They found that results for major trauma patients were flat between 2008 and 2012 but improved rapidly after the introduction of major trauma networks.

Timothy Coats, professor of emergency medicine at the University of Leicester and a consultant in emergency medicine, said: “These findings demonstrate and support the importance of major trauma networks to urgent care with figures showing there were 90 more survivors in 2013 rising to an additional 595 in 2017. Over the course of the five years 1,656 people have survived major trauma injuries where before they would probably have died. It’s a fantastic achievement.”

He said that it could take up to ten years for this kind of system to reach its full potential, with the number of additional survivors greater than predicted by NHS England at this stage.

He added: “With changes to the way patients are treated from the moment doctors and paramedics get to them, with pre-hospital intubation, improved treatment for major bleeding and advances in emergency surgery techniques, there has also been a significant reduction from 31 per cent to 24 per cent in the number of patients needing critical care, and their length of stay on critical care wards reduced from four to three days on average.” The study is published in the online journal EClinicalMedicine.

Chris Moran, NHS England’s national clinical director for trauma care, said: “Patients suffering severe injury need to get to the right specialist centre staffed by experts, not simply the nearest hospital.

We are confident that we will continue to see further increases in survival rates for this group of patients.”

“Major trauma centres deal with the victims of stabbings and acid attacks as well as car and motorbike accidents. We have all seen the terrible increase in knife crime in our cities and there is no doubt that the new trauma system has saved many lives as these patients receive blood transfusion and specialist surgery much quicker than before.”

The changes were made after a 2007 report identified serious failings in the NHS’s care of trauma patients, which was poor in almost 60 per cent of cases.

We need tax and fiscal policies that upset some!..”The role of a leader is to persuade voters of the need for reform, rather than just to follow public opinion.” but we have no leadership, and no honest debate ..

We need tax and fiscal policies that upset some!..”The role of a leader is to persuade voters of the need for reform, rather than just to follow public opinion.” but we have no leadership, and no honest debate .. The media find health too complex, and in a media led society this is part of the collusion of anonymity and denial. Where the author mentions priorities – rad rationing.

June 5th in the Times: Theresa May should stop tinkering and start spending

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To solve the crisis in health and social care, the PM must come up with tax-raising policies that risk upsetting people

Politics is a bit like playing Monopoly. Leaders start the game with a pot of political capital that is gradually eroded by power. As they go around the board dealing with events, they spend more to build up a property empire of popular support. There must be an element of risk-taking and ruthlessness, as well as responsibility. Luck is required, but also the wisdom to know that you must create your own good fortune. The winner is the person with the most capital left when the country goes to the polls, even if everyone is almost bankrupt.

……There is a chance for the prime minister to play a winning hand on the NHS in the year of its 70th anniversary but it will require a courage that she has so far lacked. Jeremy Hunt, who yesterday became Britain’s longest-serving health secretary having fought off No 10’s attempts to move him at the last reshuffle, is pushing hard for more money and he knows reform is also required. Boris Johnson is piling in with demands for a “Brexit dividend” for the NHS, while Sajid Javid wants to overturn the “hostile environment” of immigration and relax visa restrictions on foreign doctors. Philip Hammond understands the need for resources to cope with an ageing population. If the settlement is to be more than a sticking plaster that falls off at the first hint of rain, however, leadership from the prime minister is needed to win some difficult arguments.

The NHS crisis is also a social care crisis in which nearly one in ten hospital beds are taken up by patients who are well enough to go home, a situation that is traumatic for families and damaging to the health service. There needs to be much greater integration between the health and social care systems, with budgets reallocated people in the community. That will mean closing hospitals or reducing the number of wards — a political taboo for many MPs — but if Mrs May is serious about reform it is a row worth having.

It costs about £250 a day to keep somebody in hospital and only £100 for a domiciliary care package, so rebalancing the system would save money and be better for patients. In six areas where the NHS is piloting a scheme to send doctors and nurses into care homes, emergency hospital admissions have fallen. Wakefield reduced ambulance callouts by 9 per cent and the number of days spent in hospital by care home residents by 26 per cent, while in Sutton there was an 18 per cent drop in bed days.

The prime minister also needs to make the case for tax rises, including on the elderly. According to the Institute for Fiscal Studies, spending on healthcare will have to increase by an average of 3.3 per cent a year over the next 15 years, and social care funding by 3.9 per cent, just to maintain current provision. In other words, the NHS needs an extra £2,000 from every household to continue functioning properly. On top of that, the government must introduce a cap on care costs to end the unfairness that some people who have to spend years in residential care end up with crippling bills while others pay nothing. That would cost about £6 billion a year. Such sums cannot be raised by trimming budgets or cutting costs — there needs to be a public debate about priorities.

Mrs May is understandably nervous about engaging in this discussion after the fiasco over the “dementia tax” during the last general election campaign. That policy, however, was fatally flawed because it increased the amount that many people would have to pay for social care without spreading the risk. It therefore created a political problem without solving the policy dilemma.

There is growing cross-party support among MPs for working pensioners to pay national insurance. At the moment a 64 year old and a 66 year old doing the same job take home different amounts because pensioners are exempt from the deductions, which is illogical and unfair. The levy could be turned into a dedicated health and social care tax, which could be put up or down each year in line with demand. Billions more could be raised by scrapping the planned cut in corporation tax and abandoning the now-annual fuel duty freeze. There may also need to be adjustments to property taxes to ensure those with the greatest assets contribute more. None of this will be popular with everyone but the role of a leader is to persuade voters of the need for reform, rather than just to follow public opinion.

The rumour in Whitehall is that the government is heading towards a promise of a 3 per cent boost for the NHS. Tory MPs have been told it is “not helpful” to ask for more than that. As one senior backbencher puts it: “That would be treated with dismay because it doesn’t even keep the health service at standstill.”

To govern is to choose. If she wants to have a legacy beyond Brexit, Mrs May should approve a proper funding settlement for health and social care, involving radical reform, rather than tinkering around the edges with a package that pleases no one.

One senior Conservative MP says that the prime minister has “to a quite extraordinary extent no leadership in her DNA”. It is time to break with the habit of a lifetime and roll the dice if she wants to get another chance to pass Go on the political Monopoly board and collect £200.

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You have been warned…. No genetic secrets will remain ….

We already ration infertility treatment, in most commissioning groups, and we also restrict the use of pre-embryonic blastocyst selection to avoid inherited disease to one child in most commissioning groups. This is despite the cost (long term) of looking after an individual with HD or CF. The result is that affluent families pay for the embryo selection, but poorer families are faced with either having one child, or taking the risk and having more. If the state wishes to construct a data base of risk, and the potential is there, we will have to let rationing become as overt for everything as it is for infertility.

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The Economist has pointed out in 2003 (jan 23rd) No hiding place – The protection of privacy will be a huge problem for the internet society and now more recently. In Science and Technology May 5th “No hiding place” (Genomes and Privacy) reports: Police have used genealogy to make an arrest in a murder case – The did so by tracing the suspect via distant relatives’ DNA

….If a serial killer really has been caught using these methods, everyone will rightly applaud. But the power of forensic genomics that this case displays poses concerns for those going about their lawful business, too. It bears on the question of genetic privacy—namely, how much right people have to keep their genes to themselves—by showing that no man or woman is a genetic island. Information about one individual can reveal information about others—and not just who is related to whom.

With decreasing degrees of certainty, according to the degree of consanguinity, it can divulge a relative’s susceptibilities to certain diseases, for example, or information about paternity, that the relative in question might or might not want to know, and might or might not want to become public. Who should be allowed to see such information, and who might have a right to see it, are questions that need asking.

They are beginning to be asked. In 2017 the Court of Appeal in England ruled that doctors treating people with Huntington’s chorea, an inherited fatal disease of the central nervous system the definitive diagnosis of which is a particular abnormal DNA sequence, have a duty to disclose that diagnosis to the patient’s children. The children of a parent who has Huntington’s have a 50% chance of inheriting the illness. In this case, a father had declined to disclose his newly diagnosed disease to his pregnant daughter. She was, herself, subsequently diagnosed with Huntington’s. She then sued the hospital, on the basis that it was her right to know of her risk. Had she known, she told the court, she would have terminated her pregnancy.

That is an extreme case. But intermediate ones exist. For example, certain variants of a gene called BRCA are associated with breast cancer. None, though, is 100% predictive. If someone discovers that he or she is carrying such a variant, should that bring an obligation to inform relatives, so that they, too, may be tested? Or does that risk spreading panic to no good end?

It may turn out that such worries are transient. As the cost of genetic sequencing falls, the tendency of people to discover their own genetic information, rather than learning about it second-hand, will increase. That, though, may bring about a different problem, of genetic snooping, in which people obtain the sequences of others without their consent, from things like discarded coffee cups. At that point genetic privacy really will be a thing of the past…..

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