Category Archives: NHS managers

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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Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

It is hard to recruit to West Wales. The “little England beyond Wales” is culturally very different from Welsh speaking Carmarthenshire. I used to think Whitland would be near enough, but no longer.

Doctors choose centres of excellence in cities rather than rural areas to work in.

There is an under capacity in diagnostic physicians, and this will remain the case for 10 years.

Reconfiguring West Wales services gives an opportunity to raise standards, reduce infections, accelerate discharge and improve choice.

The medical model is changing, and teams of specialists raise standards fastest.

There has not been the investment in infrastructure that there should have been to speed transport.

Choice for patients needs to be encouraged by the system. A larger Trust ( preferably all of Wales – why not?) will give greater choice.

If a rural area such as Pembrokeshire wishes to recruit consultants and GPs easily, it needs to recognise the drivers for change in the medical profession. New doctors want to have access to new technologies, tests, and treatments. The medical model now involves large teams of specialists raising their standards together. Access to such centres is meant to be “equal” but in effect, especially in Wales, it is dependent on post code. Choice has been restricted to “within your own trust”, and outside referral restricted unless there is no service within your trust. Consultants and their juniors like to have access to specialist investigations, a complete set of treatment options, and research and teaching opportunities.

So why did I move to Pembrokeshire. I enjoy an independent mind-set, and the challenge of working in remote areas. But I saw the possibilities were better where there was a DGH (District General Hospital), a postgraduate centre and teaching opportunities. All these will go if my local hospital closes, or moves outside of the “little England beyond Wales”. I feel cultural affiliation, and when I seek medical care the first language should be one I understand. (English). Consultants arriving in the area were offered subsidised accommodation in a hospital house whilst they looked for a home. New physicians arriving felt they were cared for …

Within GP, the clinical variety and opportunities have reduced, and there is much less room for manoeuvre in todays group practice experience. The shape of the job has changed, and the people in it have changed too. Now it is 80% female reflecting the underperformance of males at age 18 when applying for medical school. It may change even more, because with too few diagnosticians, digital consulting, without an examination may expand, with resultant litigation risk. ( Murray Ellender GPs must embrace digital future – The Times 23rd April 2018 )

The threat to move our hospital outside of our county, and into another tribal area, will not be taken lying down. So we need a solution that allows consultants all the things they want, and our, mainly female, GPs to get what they want. With a 10 year deficit and shortage of diagnostic doctor skills, we have to centralise in some way or other. ( Patients want all services as close as possible, and many would choose local access instead of lower death rates. They will also demand it is all free, for everyone, everywhere, for ever. )

If we take out the hospital we take away part of the culture. House prices will fall further as professionals leave, and choose to live near tertiary care centres. The already dilapidated and sometimes empty heart of the county town will get even more squalid and forgotten. Yes, we can replace one culture with another, more cynical one. People are already disillusioned in the shires, where the vote went against staying in the EU, even though the people there had more to lose. Taking away their hospital without persuading them that it is for the greater good could lead to civil unrest…. and they will also have a Welsh language school they never asked for.

In the end we have to make the new solution attractive to medical applicants, and that means combining Hywel Dda with Swansea so that hospital jobs are rotated, the educational and research opportunities are there for all, and the important services; stents, stroke and radiotherapy are all provided on site. Without Swansea the new hospital needs more money to have the facilities needed to help recruitment and even then it may not be enough.

Dirty surgery such as gut emergencies should be treated in on of the old DGH theatre suites, and the rest of old DGHs become community care recovery centres. The funding must also be changed, so that all the country, patient and professionals, realises that financially, it is founded on a rock rather than sand. This will win hearts and minds.. but it is tough love.

My personal belief is in means related co-payments, scaled and managed centrally. I have some concern about how to deal with citizens who have cash flow poor, but are asset rich, but this can be debated once we agree to ration and use co-payments.

The three options are all reasonable, given the under capacity and recruitment problems described, and NHSreality goes for a new build in Pembrokeshire, along with new roads. If this were done, and/or the trust combined with Swansea, there would be a great improvement in services for West Wales patients. The finances are a different matter, and I expect continued denial all round.

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

Who wants to be a Hywel Dda board member? “Hywel Dda health board looks at hospital closure options”. The obvious solution is to promise a new build at Whitland, and a dualling of roads west.

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

A poisoned chalice. Advertisment for Chairman of Hywel Dda…

Hywel Dda Health Board chief executive Trevor Purt to leave his post

Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

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A sign of falling morale (and standards), and lack of “buy in” to the health service philosophy…?

Doctors don’t go on strike easily. Junior doctors are 80% women, and they strike less easily than men. The strikes of 2017 have been replaced by “legal action”. Is this not a signal to politicians, of falling morale, and lack of “buy in” to the health service philosophy…? In other countries, Germany, USA, Canada etc. the doctors work harder and longer hours. So this case may be a proxy for general discontent. Who amongst them has had an exit interview, and who would trust an HR department to report feedback dispassionately. Only this week I heard of a consultant offered (rare event) an exit interview, and he is thinking hard about it. Could he be punished when he is a patient (downside risk)? Will he be taken seriously? Is anything likely to change as a result? He would certainly tell them standards were falling..

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Junior doctors take trust to court for denying them breaks every four hours (BMJ 2018;360:k852 ) Clare Dyer

A junior doctor has accused her former employer of breaching her contract by not allowing breaks every four hours, in a High Court test case with reverberations throughout the NHS.

Sarah Hallett is acting on behalf of herself and another 20 junior doctors who trained with Royal Derby Hospitals NHS Foundation Trust in 2013-14, when she was in her foundation year. In a case supported by the BMA they argue that they did not receive the breaks they were entitled to.

At the Royal Courts of Justice in London, where the four day case opened on 20 February, John Cavanagh QC, representing Hallett, said, “This case is of general public importance . . . It is a test case which is of significance across the NHS.”

He told Mrs Justice Simler that NHS trusts were obliged to allow junior doctors a 30 minute rest period after every four hour working period. “If they do not have the opportunity to take these breaks, this affects their safety and welfare, with consequent effects on patient safety,” said Cavanagh.

NHS trusts that did not comply with the rules had to pay juniors double their normal rate for missed breaks, he told the court. But Hallett’s primary objective was not money, he said, but to make sure that NHS trusts met their contractual obligations.

“It is the responsibility of trusts to make sure that they do not run overly fatiguing or unsafe rotas,” he added. “Junior doctors who have to work for many hours in very stressful and high pressure conditions without even a short break will be exhausted, and this will potentially lead to risks to patient safety.”

If Hallett, who is a deputy chair of the BMA’s junior doctors committee, wins her case and the 21 doctors claim compensation for the lost rest periods it could cost the trust £250 000 (€283 000; $349 000). Richard Leiper QC, representing the trust, said, “The potential cost to the trust, let alone to the NHS as a whole, would be dramatic.”

A trust spokesperson said, “This trial is simply about how Derby Teaching Hospitals monitored junior doctors’ working hours back in 2013. The approach we took mirrors that taken by a significant proportion of NHS trusts up and down the country.”

Junior Doctors strikes had significant impact on patient care – Paul Gallagher 19th February 2018 I news who also reports 18th March 2018 on the increasing death rate “Stunning figures reveal more than 10,000 excess deaths”…

 

Standards “Going into reverse”….There is no button to push… we need tens of thousands of staff

Chris Smyth reports in the Times on the reality of the staff shortages, which are worsening as those who failed to move on to pastures new fail to manage the brutal workload. “100,000 job vacancies as  NHS pushed to limit” in the Times 22nd of Feb 2018. Stories of leaderless dysfunctional consultant teams spread over wide regions, of GPs who take sabbaticals being shocked that even after a break they cannot cope, and resulting early retirements are legion. There are only politicians to blame, as the administrators are only doing their behest. There is a risk of anger, walkouts, burnouts, and serious mistakes through a collusion of denial and disengagement. Exit interviews conducted by an outside and independent HR department are now an essential and emergency need.

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About 100,000 NHS posts are vacant and hospital deficits are twice as high as planned even after a winter bailout, according to official figures.

A rapid financial deterioration means that hospitals have overspent by £1.3 billion so far this financial year while waiting times have not improved.

Patient numbers continue to rise, with 5.6 million A&E visits in the three months to December, a quarter of a million more than in the same period the previous year.

Despite efforts to improve links with social care, patients spent almost half a million nights stuck in hospital over the quarter.

One in 11 NHS posts cannot be filled amid a shortage of doctors and nurses. In London, one in seven nursing posts is empty, rising to almost a quarter in the ambulance service. Overall 35,000 posts for nurses are vacant and 9,500 for doctors.

Janet Davies, chief executive of the Royal College of Nursing, said: “All the evidence shows that standards of patient care rise and fall as nurse numbers do. That was the lesson from Mid Staffordshire and we cannot afford to forget it.”

Nigel Edwards, chief executive of the Nuffield Trust think tank, said that the “dangerous” shortage of nurses was more worrying than worsening NHS finances.

“Shortages of nurses damage patient care and make working life harder for those who remain, potentially driving them away too,” he said. “We can bring back more money onstream if the will is there, but there is no button to push which will suddenly bring us tens of thousands of qualified extra staff.”

Hospitals warned that they were being “pushed to the limit” by rising patient numbers. “Having one in eleven posts vacant makes it much more difficult to provide high-quality care,” Saffron Cordery, of the lobby group NHS Providers, said. “There is an increasing feeling among frontline trust leaders of ‘We cannot carry on like this’.

carry on like this’.“The NHS has shown extraordinary resilience in sustaining performance in the midst of an unprecedented financial squeeze. We have managed to keep the show on the road. But the warning signs are now clear and in plain sight. The time to act is now.”

Officials pinned the blame for worsening finances on a minority of hospitals that were overspending by far more than planned. However, Richard Murray, director of policy for the King’s Fund, the independent health charity, said this “raises serious questions about how reasonable the financial targets were in the first place . . . these are not pressures that have sprung up in the last few months and [they] show no sign of abating.”

Ian Dalton, chief executive of NHS Improvement, the financial regulator that published the figures, said: “More people than ever before are going to emergency departments up and down the country at a time when providers are already having to tighten their belts. It would be unrealistic to assume the demand, which has been building for a number of years, is going to reverse.”

 

 

 

Good on you Mr Gavin Tait. Tell it as it is… and I bet you never got an exit interview.

The importance of a “utilitarian” approach in the restructuring for improved standards cannot be overstated. The debate in West Wales, although driven by financial constraints, should place it’s remedy on higher standards.  The planned 5 sites for 2.5 million people, in 2014, and not implemented, is too many – one site may be enough. Orthopaedic operations are the most common, give the most life-years quality gain, and are prone to infection if the conditions are less than perfect. There are short term temptations to try and make do, and to ignore the experts appointed to help us.

SURGICAL SERVICES – A letter in the Times 29th Jan 2018
Sir, I have recently retired from the National Health Service and have spent almost 20 years trying to have elective and acute surgical services geographically separated in my health trust. I support Alan Mackay (letter, Jan 25) and advise Eleanor Walsh (letter, Jan 27) that it is usually the public and politicians who are resistant. Any suggestion that orthopaedic surgery leaves an acute site is viewed in the public eye as a threat to A&E, and is resisted even with street protests.

Historically, elective orthopaedic surgery was always on dedicated sites until they were closed in the 1980s as they were considered to be unsafe. Waiting lists were never disrupted.

Surgeons who are prevented for months each winter from operating as the beds are taken by acute medicine become deskilled and bored, and trainees get little experience. The sooner we return to past arrangements the better.
Gavin R Tait

(Retired consultant orthopaedic surgeon)

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

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?

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

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites

Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

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When a crisis is the predictable outcome of poor policy making. It will take 10 years to begin to recover, and 20 years to recover completely from the politicians’ cowardice.

Perhaps the politicians (who go privately) think we the people deserve this. The falling standards, lengthening waits and lack of social safety net are now becoming evident. NHSreality started warning over 5 years ago, and even then it was 5 years too late….. It will take 10 years to begin to recover, and 20 years to recover completely from the politicians’ cowardice. … & The captains will NOT go down with the ship…

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Mary McCartney in the BMJ opines: When a crisis is the predictable outcome of poor policy making (BMJ 2018;360:k90 )

When is a crisis not a crisis? The “crisis” may be felt differently in the UK’s four NHSs, but these services are being pushed beyond reasonable capacity. I’ve little doubt that the coping mechanisms—corridor care, ambulance stacking, and a month’s worth of cancelled operations and outpatient appointments—are harmful. And these will contribute to burnout, sick leave, resignation, early retirement, and the cycle of even more rota gaps.

This is not a sudden explosive “crisis” but the predictable, and predicted, result of multifactorial choices over long periods that have made a mockery of evidence based decision making. This is winter: it’s a foreseeable annual event.

Yes, the NHS needs more money. But that money’s wasted if it’s spent on initiatives that don’t work and are driven by party politics, not patients. And it’s been spent on such initiatives repeatedly and avoidably. England has had the internal market and vast monetary waste from administering the legal framework,1 such that Virgin sued the NHS in 2017 in a dispute over tendering.2 This money should have been spent on direct patient care.

In Scotland a quarter of delayed discharges have been due to a lack of residential care beds.3 England has 43% fewer general and acute hospital beds than 30 years ago and fewer beds per head of population than any comparable country.4 People can’t get into hospital, but neither can they safely leave.

In 2013, management consultancies were telling us that technology would save us,5 when it couldn’t; and the government said that telehealth could save the NHS £1.2bn a year,6 before a randomised controlled trial found that it wasn’t cost effective.7 This was all money that could have paid for beds, hospital nursing, and community care.

Austerity has meant English councils cutting adult social care by 11% in real terms.8 The privatised, opaque process of carrying out medical assessments of eligibility for benefits has had a “substantial disadvantage” for the people it should have helped,9 while being associated with worsening mental health.10 This is avoidable harm done to patients and picked up by primary care, all while the provider turns a profit.

The origins of the current winter “crisis” have their roots in multiple places, all accumulating harm. Yet several campaigns aim to change behaviour by advising alternatives to visiting a hospital or GP.

These campaigns are untested and may not work—but they may harm. Patients, induced into guilt about “taking up resources,” may delay consultations and incur avoidable, expensive complications. Shifting problems we’ve failed to tackle onto the shoulders of ill people is unfair. This is a systemic problem that needs systemic change. If we can’t get the essentials of the NHS right we’re failing everyone, including the staff.

We’ve had our fill of short termism and party political policy making. We need to plan for the long term, seek cross party agreements, prioritise the basics, and have an “evidence desk” using expertise and systematic reviews, over which we can debate policy, disallow conflicts of interest, and stop wasteful nonsense in its tracks.

GP out-of-hours services struggle to fill shifts amid “intense” winter pressure –  2018; 360 doi: https://doi.org/10.1136/bmj.k97 (Published 08 January 2018)   (BMJ 2018;360:k97 )

Providers of out-of-hours GP services are struggling to fill gaps in their rotas in the face of “intense” pressure this winter, despite a £10m (€11.2m; $13.6m) cash injection to help cover indemnity fees that was intended to ensure full coverage.1

Simon Abrams, chair of Urgent Health UK, a federation of social enterprises that provide out-of-hours GP services, told The BMJ, “My colleagues generally have found it more difficult this year to recruit doctors to shifts. Pressure on health services has been intense this winter, especially over the bank holidays.”

Abrams believed that previous extra funding from government for winter pressure, such as the £335m announced in November,2 had been too focused on hospitals. “In the wider strategy, there hasn’t been that recognition of …

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