Category Archives: Trust Board Directors

A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades

We need investment in buildings, plant and people. The crisis is here and now. A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades.

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Nick Triggle for BBC news 13th December reports: Every major A&E misses wait target for first time

and BBC produced a report on the “Accident and Emergency crisis”.

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The search for waiting time failures in A&E reveals an epidemic of failures.

New builds, particularly under the PFI initiative have been catastrophes of long term mis-management and perverse incentives leading to perverse outcomes. These are exposed by Louise Clarence-Smith in the Times 17th Jan 2020: Soaring costs and delays expose lack of scrutiny at Carillion hospitals and “Beware the real costs of Hospital Failures”

one of which is demand for Private Treatment centres….

In The Guardian opines that A&E wait times matter. But the key issue facing the NHS is investment

 

The costs of hospital failures extend to morale in all areas of the 4 health services.

All hospitals are now failing. Just because we hear about some (Like Bury St Edmunds) does not mean the rest are clean. The endemic failure to provide sufficient people is compounded by insufficient new builds, old plant needing replacement and inadequate imaging facilities, and of course the professional radiologists to read these images. Wales has avoided PFI but all its buildings and equipment, with a few exceptions, is stone age. Its people will be asked to travel further than ever to get help, and choice is absent. The complaints alone are epidemic, and the costs set aside for future litigation are enormous. The costs of hospital failures extend to morale in all areas of the 4 health services.

Alistair Osborne opines 17th Jan 2020 in the Times: Beware real cost of hospital failure

evolutionary zeal is not a trait typically associated with the Conservative Party. But at least Boris Johnson is promising an “infrastructure revolution”. What it entails is anyone’s guess, apart from spending £100 billion over five years. So, it’s lucky that the National Audit Office has popped up with a handy guide — on how not to do it.

It’s had a poke around the Midland Metropolitan and Royal Liverpool University hospital projects: a duo as sick as you might expect given they were being built by the now bust Carillion under the similarly kaput private finance initiative. Naturally, the patients are still waiting to see either hospital.

The 646-bed Liverpool scheme, due to open in 2017, is now running at least five years late, costing £1.06 billion to build and run: not the budgeted £746 million. Meantime, the 669-bed Midland Met, due to start operations in October 2018, will cost at least £988 million, up from the initial £686 million. It opens in July 2022.

Not the finest advert, then, for injecting private capital and expertise into the delivery of public projects. Except for one thing: the NAO reckons the taxpayer is barely out of pocket — because “the private sector has borne most of the cost increase”. It’s lost £603 million, shared between investors in the PFI companies, Carillion and insurers. Indeed the NAO believes that the taxpayer will be 3 per cent worse off with Midland Met and 1 per cent better off with Liverpool. And that includes the 30-year running costs.

It seems barely credible, given what’s gone on. After Carillion keeled over in January 2018, the health trusts and government wrongly assumed that “the PFI companies would complete the hospitals, as contractually required, by replacing Carillion”. Instead they had to terminate the PFI schemes and “use public finance to complete the hospitals with new contractors”. Consulting engineer Arup then found that the Liverpool work was so shoddy that the new contractor “had to strip out three floors of the building” to reinforce its structure.

So, how come the taxpayer’s no worse off? Simple, really. Because the government held the PFI investors to their contract — not paying for hospitals they’d failed to deliver. It then inherited two half-built hospitals that taxpayer funds are finishing off. True, the health department coughed up £42 million to avoid a “lengthy contractual termination process” in Liverpool: a sum it could have dodged given its rocketing costs. But that’s hindsight.

Does it all prove, then, that PFI works? Well, not really. The real cost is that both hospitals are years late. And there’s still a risk that the final price will exceed NAO estimates. Moreover, the affair says much about the government’s addiction to picking the lowest cost contractor. As the NAO notes over Liverpool: Carillion’s pricing may have been “too low to meet the required specification”.

Still, at least there’s a lesson here for BoJo: infrastructure revolutions are harder than they look.

Sensible rationing of dementia drugs – a lead from France

The first country in Europe to act on concerns over limited effectiveness In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state.

What a sensible approach. Without the expensive drugs we can have more carers. Trust Boards and Commissioners take note. The trouble is that these drugs are effective in some people, but the utilitarian approach taken by France is correct. 

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France removes state funding for dementia drugs | The BMJ 30th December 2019 and 18th January 2020 BMJ 2019;367:l6930

The first country in Europe to act on concerns over limited effectiveness

In May 2018 the French minister of health announced the delisting of drug treatments for dementia; payments for memantine and the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine would no longer be reimbursed by the state. The decision followed a long campaign by the French therapeutics journal Prescrire, which subsequently declared, “The days are over when support for patients and their struggling caregivers was based on drugs raising false hopes.”

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The following month, the National Institute for Health and Care Excellence (NICE) published updated dementia guidance.2 This recommended combination therapy for the first time, advised not stopping drugs simply because the condition progressed, and relaxed regulations on primary care prescribing. In short, drugs for dementia would no longer be supported in France but would be further promoted in England and Wales. France is the only European country to take this step,3 although authorities in Belgium are considering following suit.4

Acetylcholinesterase inhibitors inhibit the breakdown of acetylcholine, a key neurotransmitter involved in memory, attention, and sleep that is often depleted in adults with dementia.5 Memantine works on a different and less well understood target thought to be involved with cognitive decline, blocking N-methyl-D-aspartate receptors to prevent toxic overstimulation and subsequent neuronal damage.6

Alzheimer’s dementia is the only licensed indication for these drugs, but NICE recommends off licence use for adults with dementia with Lewy bodies.2 No other drugs are available for any of the common dementia subtypes, and disease modifying agents remain elusive.7 These drugs are therefore the only available pharmacological treatments for dementia.

The French health authorities cite several reasons for their decision, including concerns about the clinical meaningfulness of their effects on cognition, no proved benefit for behavioural symptoms, quality of life, or time to institutionalisation, and real world indications of a rare but increased risk of bradycardia requiring hospital admission.8

Little benefit

Broad consensus exists that drug treatments for dementia produce statistically significant improvements in cognition for at least six months, but these improvements are small. A 2018 Cochrane review of donepezil trials9 reported a mean difference between treated and control groups of just 2.7 points on the cognitive section of the Alzheimer’s disease assessment scale (ADAS-Cog, scored out of 70), and 1.1 points on the mini-mental state examination (maximum score 30) at six months, favouring treatment. Cochrane reviews of the other drugs have reported cognitive benefits of similar magnitudes.101112

Whether these changes are meaningful for patients remains unclear. Researchers have attempted to quantify a threshold for a clinically important difference by triangulating changes in cognition scores with changes in clinician assessment and functional outcomes.13 But this assumes that any improvements in clinician assessment or functional outcomes equate to meaningful benefit for patients and their families, which remains debatable. Nevertheless, the authors concluded that a benefit of ≥3 on ADAS-Cog was clinically important. This uncertain finding on cognition is consistent with Cochrane reviews reporting similarly small, albeit statistically significant, changes to functional outcomes and clinician assessment.

Frustratingly, there are few qualitative or quantitative studies reporting quality of life (for patient or carer) or patient reported outcomes. Uncontrolled observational studies have suggested that drug treatment can delay nursing home admission by at least several months, although these study populations are likely to be skewed by indication bias.14

Change of emphasis

To justify depriving patients of the only available drugs when they are well tolerated and known to produce benefits (albeit of uncertain clinical relevance), there must be a clear idea of what is to be gained. The French health authorities argue that these drugs divert the attention of clinicians, researchers, and policy makers away from non-pharmacological approaches to dementia care. They expect that the decision will shift priorities from a drive to ever earlier diagnosis and treatment, to a more person centred approach, more research on non-pharmacological management options, and increased scrutiny of policy makers and commissioners to ensure adequate support for patients and their caregivers.15

They believe these changes will lead to overall benefits, although the potential merits remain hypothetical. What should the UK do now? Following France’s lead would require careful consideration of the best way to manage wholesale deprescribing, alongside a systematic evaluation of the effects. A more pragmatic approach is to “watch and wait” to see whether the hoped for benefits are realised in France.

Medworm: Re: France removes state funding for dementia drugs

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Prudent healthcare reforms and a suggestion for GP recruitment

The numbers of GPs have increased, but the number of Full Time GPs, (Which means 9 sessions a week) has reduced because more and more are taking options to mix and match their portfolio careers.

The first letter below is correct: GPs need portfolio careers to survive themselves, and for the local service to survive. Changing the shape of the job…. In the festive season (see below ) doctors cannot be expected to behave like turkeys in their voting… Ask around and I expect you will find demoralised people who did not know who to vote for, but in a PR system would have voted Liberal.

The Times letters 18th December 2019:

Sir, Libby Purves makes some very good points about the crisis in A&E departments in many NHS hospitals (“Don’t just throw money at the NHS, be smart”, Dec 16). She suggests a return to convalescent homes or cottage hospitals, with both staffed by nursing auxiliaries and overseen by local GPs. Patients who did not require the “high tech” care provided by the acute hospital but required good nursing and general care before returning to their home or other long-term care could be transferred to one of these units. I was a GP and we had a 100-bed unit that did just this. The patients were well cared for and many were able to return home. Like many other units, however, it was closed; all we have now is a 600-bed acute hospital some miles away.

I met another retired GP this morning. He had been away: his wife, who is disabled, had suffered a serious injury to her face and he had taken her to the acute hospital A&E. They were there for about ten hours; the place was chaotic, being full of people suffering from minor ailments whom in the past we as GPs would have dealt with. When she was treated by the medical staff the care was first-class. We both agreed that it was time that the problem of GP out-of-hours care was sorted out; the pressure on A&E departments would then reduce.
GBR Fisher

Cononley, W Yorks

Sir, Libby Purves makes an important case for new convalescent homes but creating them will take time. A quick interim fix would be for the government to seek bids for building basic accommodation modelled on budget hotels over hospital car parks. Hotel operators and some house builders would respond quickly, a standard brief could be produced and a new permitted development right or development order could avoid planning delays.
Brian Waters

Chairman, London Planning & Development Forum

Sir, In her article Libby Purves makes many good points about the medium-term future of the NHS. A further core problem is unscheduled care. Until there is more integration between GPs and emergency departments problems are likely to continue. It is a pity that the so-called internal market of 1990 widened this chasm and that budgets within the system still drive change. The royal colleges of both the physicians and GPs advocate generalists, and some emergency departments have innovative ideas. There is, however, a need to devise a qualification for interested GPs to integrate seamlessly within emergency departments, thus allowing patients to see the most appropriate person on arrival.

Who knows, perhaps by offering a dual base this could help to solve the problem of GP recruitment.
Dr Michael Houghton, FRCGP, FRCP

Preston, Lancs

Sir, I went to my local surgery last week. The person before me was a “no show”; the nurse told me that there had been four “no shows” the day before. Last year I had knee replacement surgery. I was given an ice machine to take home after the operation. I didn’t want it and didn’t use it, preferring the flexibility of using frozen peas. I tried to return it but it was refused on the grounds of cross-contamination. I was also unable to return the crutches for the same reason. Throwing money at the NHS is not the answer to all its problems.
Ann Hadingham

Alton, Hants

Times letters: Prudent reform of the NHS and social care

Don’t throw money at the 4 health services. Put the plug in first, and then concentrate on recovery in 10-15 years time…

 

Honest and pragmatic solutions to Social Care are ignored – by all parties. ( And the media )

Ever since Mrs May tried to sell what the press deemed a “dementia tax”, all the parties have conspired to duck the hard truths of social care, and its linkage with medical care. the one is means tested, and the other is free. They should both be handled in the same way in order to avoid perverse incentives to classify in order to exclude. so either they are both free ( impossibly expensive ) or they are both means tested. The pragmatic solution…

David Aaronovitch opines in the Times 4th December 2019: ‘NHS for sale’ nonsense ignores a real crisis – Labour and the Tories are happy to keep distracting us from the fact that neither has grasped the nettle of social care

At what point does the repeated appearance of the surreal mean that it becomes the new real? Answer: when Donald Trump hits town.

In London for the Nato summit, the US president was taxed with the non-issue that has dominated election discourse for a week. Was the NHS on the table? Trump decided to interpret the question as though he was being asked whether he would like to buy the whole of the NHS, ship it back to America and re-erect it in the Arizona desert. “Never even thought about it,” he replied. Americans already had “private plans that they absolutely love. We wouldn’t want it even if you handed it to us on a silver platter; we want nothing to do with it.”

But Trump’s absurdity was really only a twist on the absurdity of our own discussion. The Corbyn slogan “Not for Sale!” gives the impression of the potential hiving off of A&E wards to predatory Yankees who will find some way of charging us ten bucks a swab and 20 for a suture.

All we actually have, despite the 450 pages of documents brandished by Labour last week, is the US side of preliminary trade talks in which they say they’d like to discuss drug prices and patents and British civil servants not responding.

The Conservative manifesto shut off any such possibility by slapping down a couple of red lines: “When we are negotiating trade deals,” it said, “the price the NHS pays for drugs will not be on the table. The services the NHS provides will not be on the table.”

Fine. But it means, of course, that something else will be. Back in the summer when this matter came up Theresa May (remember her? Prime minister for a bit. Strong and stable.) stated the bleeding obvious in saying “the point about making trade deals is that, of course, both sides negotiate.” We set red lines, they set red lines. We say no to X, they say, then give us Y. That, and not the NHS being crated up for dispatch to the New World, is the issue.

This, of course, is just one element of Labour’s charge, going back to the days when Andy Burnham claimed the Tories were “privatising” the NHS. Nearly six years ago the shadow health secretary, serving in the catastrophic Ed Miliband team and deprived of the right to promise limitless billions for the NHS, began accusing the Conservatives of having “a privatisation agenda” that would mean the end of universal healthcare, free at the point of use.

If that was so, the Conservatives have manifestly failed. Not only has the basis of the service survived unchanged but, according to the independent health charity The King’s Fund, the share of revenue spent on services delivered by the private sector has stayed more or less static over the past few years. Not, incidentally, that people would be too bothered if it rose. As The King’s Fund puts it, “provided that patients receive care that is timely and free at the point of use, our view is that the provider of a service is less important than the quality and efficiency of the care they deliver.”

Amen. But these days not even Tories dare express such a view, leading to some pitiful denials of past opinions by Conservative spokesmen. Yet this sensible belief, once held by Labour but alas no longer, also turns out to be the conclusion reached by the substantial majority of our 100-voters panel after having the expenditure of the NHS explained to them.

So instead of any sensible discussion about how to improve healthcare in England, all we’ve had in this terrible election is the fraudulent “for sale” row and a bidding war. £20.5 billion in real terms plays £26 billion plays £7 billion per annum. 6,000 more doctors, 50,000 more nurses, 27 million more appointments and on it goes.

The figures are made to stand alone and no one gets to find out what they mean in the context of the real world. We have an ageing population. We need to shift resources into helping the population to age more healthily and to look after those who need care. That takes more money, more carers and new forms of delivery.

But the parties’ bidding war fails to take account even of the impact of their own policies on the requirements of the NHS. The Nuffield Trust think tank published a report this week on how, with NHS job vacancies at over 100,000 and social care worker vacancies at 122,000 and rising, both Conservative and Labour immigration policies to end freedom of movement from the EU are likely to exacerbate chronic staff shortages.

That’s just one. In addition Labour has promised a 5 per cent pay increase for all NHS staff in 2020 and “year on year above inflation increases” after that. This may help ease the recruitment problem a little, of course, but at huge additional cost.

And as if that wasn’t enough Labour has stated its ambition of moving workers, including all of those in the public sector, to a statutory four-day week. When the shadow health secretary, Jonathan Ashworth, attempted to exempt NHS staff from this promise he was effectively repudiated by John McDonnell.

There is a word for having a policy to significantly reduce staff hours at a time of chronic staff shortage. And it isn’t “clever”.

But above all Labour’s concentration of fire on the Conservatives over the false “NHS for Sale” controversy means that it fails to make the true accusation which should really damage the Tories.

For two decades the problem of inadequate social care has grown, and over time become a fug enveloping almost everything we might want to do to make our society that bit better. For almost the whole of the last decade the Conservatives have been in government.

Three years ago the Tories promised a green paper in the summer of 2018. Then in the autumn of 2018. Then April this year. Then as soon as possible.

And here in December 2019, in the manifesto of the great “Just Get It Done” Johnson, is his proposal on arguably the third biggest issue facing the country: “We will build a cross-party consensus to bring forward an answer that solves the problem”. And that is pretty much that.

Now ask yourself these two questions whenever the two prime ministerial candidates declaim on the subject of leadership: first, why have the Tories so cravenly dodged this issue? And then, why has Labour been so happy to let them do it?

Dementia Tax & Theresa May | The King’s Fund‎

What is the “dementia tax”? – Full Fact

 

What the GP did best: used time as a diagnostic tool. The “failiing fiasco” of health care in the UK.

I was trained with and by the same teams as Nick Norwell whose letter points out the perverse incentives ever present in medicine. The dissonance is between over-treatment and investigation in the private system, or under-treatment and waiting lists in the state system. Elderly people are usually uninsurable, and so they have little choice. Thus they fall victim of any delay. The access to diagnostics is very important:

PET scans (positron emission tomography scans) are often done in conjunction with CT scans (computerized tomography scans) or MRI scans (magnetic resonance imaging scans). … An MRI scan can be used when your organ shape or blood vessels are in question, whereas PET scans will be used to see your body’s function.

But the relative number of these machines is very low in the UK, and often they are old and break down. There is not only a shortage of speedy access to imaging, but also a shortage of radiologists.

There will always be over-treatment, but what UK health service dependent patients are experiencing is slow, or under treatment, post code lottery of access, (even to private provision) and a failing fiasco of a broken down unfair system.

What better incentive to go privately if you know a delay could make your condition untreatable? Perhaps I need to drop the crusade? Legalising pot will be easier than reforming the (N) HS.

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INSURERS IN CHARGE – The Times 18th November 2019
Sir, The article on health insurers overruling consultants on the best treatment for patients (news, Nov 18) illustrates the fundamental problem with private practice in the NHS. In private health insurance, money (and profit) is king. In private practice money, if not king, is at least prince regent. The health insurers take the money and hope to do nothing, while private doctors take the money, and attempt to show patients that they are getting value for their money.

When I lived in France many expat Brits would tell me, with wide-eyed wonder, of the speed with which their various ailments were dealt with, surgically or otherwise, under the French mixed private/insurance/state-funded healthcare system.

As a retired doctor I could not help wondering how many ohttps://www.thetimes.co.uk/article/insurers-overrule-consultants-on-best-treatment-for-patients-5g0tdmdvtf those treatments were really necessary. I remembered the advice of one of my teachers at medical school: use time as a therapeutic tool. For all its faults, the NHS is good at doing this, albeit usually by default not design.
Nicholas Norwell
Newbury, Berks

The NHS does not have enough radiologists to keep patients safe, say three-in-four hospital imaging bosses  – Royal College of Radiologists

Andrew Ellson in the Times 18th November 2019: Insurers overrule consultants on best treatment for patients

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A night (or two) on a hospital trolley is better than living on the street. Asda type performance will not help…

Aneurin Bevan would not have accepted a night on a trolley as a compromise when he set up the former NHS. The cost of looking after overseas visitors is minimal, and not an important financial loss, but it does signify how we expect nobody to pay anything at all! Politicians have big salaries, good holidays, secure pensions, and access to London hospitals. If they want to they can avoid the A&E waits and mistakes and go privately. They usually do…. It will all get worse unless our managers and Trust Board Directors speak out honestly. Co-payments are not as bad as a failing service..

Cartoon 11.02.2017

Michael Sainato in the Guardian 14th November 2019 reminds us of why we live in one of four “Mutualised health services”. ‘I live on the street now’: how the insured fall into medical bankruptcy – Having health insurance is often not enough to save Americans from massive debts when serious illness strikes

Iain Williams on 14th Feb 2015 opined: £1 coin for your hospital trolley? The NHS’s supermarket-style makeover – cartoon

A government minister has said the NHS should be more like Asda. Should we expect bogof deals on hip replacements?