Category Archives: Trust Board Directors

170,000 victims, and nobody takes the blame!! Typical of a nationalised health service…

Just as we need to change the onus of proof on Agricultural products, we need to do the same with non drug medical products. The licensing of the mesh repair products is a case in point, and all 4 health systems should be ashamed of not reporting side effects and complications systemically (all together). The reporting of such problems is just one reason for a large mutual in health. Devolution means smaller numbers and lower standards. The commissioners and the Trust Boards are all to blame, but so is central government. Will any careers be finished? They should be.. Mesh is a foreign body, and as such the default is rejection, and possible infection.

See the source image

Hernia mesh complications may have affected up to 170 000 patients, investigation finds ( BMJ 2018;362:k4104 )

Up to 170 000 patients who have had hernia mesh operations in the past six years could be experiencing complications, yet NHS trusts in England have no consistent policy for treatment or follow-up with patients, an investigation by the BBC’s Victoria Derbyshire programme has found.

Around 570 0000 hernia mesh operations have taken place in England over the past six years, figures from NHS Digital show. Leading surgeons think that the complication rate is between 12% and 30%, meaning that between 68 000 and 170 000 patients could have been adversely affected in this period.

Patients who had had hernia mesh operations told the programme about being in constant pain, unable to sleep, and finding it difficult to walk or even pick up a sock. Some patients said that they felt suicidal.

The Department of Health and Social Care and the Medicines and Healthcare Products Regulatory Agency (MHRA) continue to back the use of mesh for hernia repair. The use of surgical mesh for stress urinary incontinence is under ongoing review after it was suspended in July in response to pressure from campaigners and MPs.1 Campaigners are calling for a similar review into the use of hernia mesh.

Owen Smith, a Labour MP who chairs the all party parliamentary group on surgical mesh implants, said that he feared the UK could “potentially have another scandal on our hands.”

He added that the MHRA was not doing enough to listen to the experiences of patients affected. “It reflects the flawed system we have in place,” he said. “Neither the regulators nor the manufacturers have to follow-up on problems.”

Ulrike Muschaweck, a private hernia surgeon, told the programme that she used a suture technique instead of mesh for most hernia operations, but this method was dying out because young surgeons were rarely taught it. She said that she had performed 3000 mesh removals because of chronic pain—after which only two of the patients had not gone on to become “pain-free.”

Suzy Elneil, a consultant urogynaecologist who was a leading voice in the campaign to halt the use of vaginal mesh, said that the mesh used in hernia was the same product. She estimated that treating those who have had complications with hernia mesh would cost a minimum of £25 000 (€28 000; $33 000) a patient—a similar amount to that predicted for vaginal mesh complications. This includes the removal of the mesh, a further operation to treat the hernia, and follow-up care. She said that the manufacturers should be covering the cost rather than the NHS.

The Royal College of Surgeons pointed to a 2018 study, which found that both mesh and non-mesh hernia repairs were effective for patients and were not associated with different rates of chronic pain.2

A spokesperson for the college said that “complications range dramatically from minor and correctable irritations to the more serious complications highlighted [on the] programme. Complications can also occur with non-mesh hernia repairs and by not operating on a hernia at all.”

They said that the college and regulatory authorities would continue to listen to patients’ experiences. “It remains vital that surgeons continue to make patients aware of all the possible side effects associated with performing a hernia repair,” the spokesperson said.

Kath Sansom from campaign group Sling the Mesh told the programme that a lot of the studies into complications were flawed or had short follow-up times. Quality of life questionnaires, for example, asked only about whether the hernia was fixed and not about new onset pain or other complications.

In a statement, the MHRA said: “We have not had any evidence that would lead us to alter our stance on surgical mesh for hernia repairs or other surgical procedures for which they are used. The decision to use mesh should be made between patient and clinician, recognising the benefits and risks in the context of the conditions being treated and in line with NICE guidance.”

An MHRA spokesperson added, “We encourage anyone—patient, carer, or healthcare professional—who is aware of a complication after a medical device is implanted, to report to us via the yellow card scheme, regardless of how long ago the implant was inserted.”

… following hernia repair with an Ethicon Proceed patch have resulted in a product liability lawsuit against the manufacturer
This was caused by what should have been a simple 45-minute operation to fix a hernia … of patient filed lawsuits. “For the ..
Advertisements

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…

Image result for fraud in health cartoon

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 ..

Image result for fraud in health cartoon

A new West Wales Hospital – an inevitable utilitarian decision. Today’s children are going to live shorter lives than their parents. Todays West Wales adults could also live shorter lives than their parents.

The decision to commit to a new hospital in West Wales has been inevitable – since the WG has no intention of combining Hywel Dda and Abertawe Bro Morgannwg (ABMU) and providing a sensible solution, a mistake is being made. Recruitment to West Wales has been poor at the best of times, and now that the rationing of medical school places over the last 30 years is coming home to roost, the Hywel Dda board have no other option. There are not enough professionals ready and willing to work in West Wales, and not enough money to fund them if there were. There is an ethical argument, from a population perspective, that rationing covertly )whereby nobody knows what is not available until they need it) is better than rationing covertly (whereby citizens know in advance what is not available in their post code). But from a liberal and individual perspective, this is unethical, as it discourages autonomy and choice. It seems some choices have to be planned for by saving money, and of course this option divides us into the haves and the have nots. Exactly what Aneurin Bevan tried to avoid. Medical professionals accept that the pace of advance of medical technology is faster than any states’ ability to pay, and that rationing is inevitable and endemic already. Politicians deny the need to ration, and until this becomes honest and overt, the hearts and minds of the caring professions will be disengaged from the politics.

It has been a “least harm for the greatest number” decision that Hywel Dda has been asked to make. It will please nobody. It will satisfy nobody. It may lead to more emergency deaths. As the population ages and the demographic suggests this will be for several decades, the problems of type 2 diabetes and dementia will become worse. The Welsh Health Service costs more per capita than the English because of poverty, and yet the WG takes more from the overall budget by top slicing. When dealing with a population as low as 3 million, this really matters and adversely affects the options in devolution. That is just one of the reasons devolution has failed.

Aberystwyth finds it even harder to attract staff, and the longer term prospects for their people are worse. Llanelli and Carmarthen citizens have speedy access to Swansea, and NHSreality, and most GPs in Pembrokeshire, feel that joining the two boards would be best. The decisions to build relatively new A&E and Renal units at Withybush in the last decade now seem very strange.

Is the fact that every county wants the new hospital the opposite of NIMBYism?

Image result for nimby cartoon

Today’s children are going to live shorter lives than their parents. Todays West Wales adults could also live shorter lives than their parents.

…Babies of both sexes in Scotland and Wales and baby boys in Northern Ireland are even projected to live shorter lives than their parents do after average longevity dropped slightly in parts of the UK.

Experts said that the government must investigate the reasons behind the stalling of life expectancy, which some have blamed on cuts to public services.

Between 2015 and 2017 the average life expectancy remained at 79.2 years for men and 82.9 for women, the Office for National Statistics said. There were falls in Scotland and Wales for both men and women, and among men in Northern Ireland, averaging 0.1 years.

Greg Hurst September 26th in the Times: Today’s children set to live shorter lives than parents

Nicola Davis in the Guardian 25th September: Children becoming physically weaker found team who measured handgrip, arm-hangs and sit-ups in Essex children

Western Mail (Walesonline) 26th September: Hywel Dda Board in shake up decisison

May 4th 2018: The agony of Damocles sword hangs over West Wales..

The fourth option for West Wales? Do we want “soft lies and gentle indifference”, until we realise the safety net is failing for us personally?

February 2018: A bigger and bigger deficit in West Wales…… Now at £600 per head……

January 2018: The West Wales options.

West Wales Health has to have a future – somewhere in the “middle” ground… Back to 2006 and reversing the wrong decision taken then not to build a new Hospital.

Leimyoscarcoma treatment options unfair…. in west Wales where choice is anathema.

Banal and sanitised Drakeford interview shames the local press in West Wales

Image result for nimby cartoon

 

Hospital job vacancies top 100,000 due to bad planning. NHSreality adds political short termism, & high sickness and absenteeism..

The bad planning is built into the system it seems, as successive and different administrations under ministers of health of many different persuasions have fallen into the same trap. Undercapacity. The 4 health services reports their staffing levels on different sites. It is accepted that the health services combined are the largest employer in the country, and have the highest absenteeism.

England, WalesScotlandN Ireland

The total full time equivalent workforce is unknown as so many are actually in the GIG economy, work part time, or are part of a  sub-contracted service. It is not all due to bad planning. Some blame must fall on our first past the post political system whereby no elected MP considers any problem solving with a time horizon longer than the next election. It is made worse by the largely female workforce, the part-time working, and the high sickness levels. 

Image result for workforce crisis cartoon

Kat Lay reports “on line” with a different heading on September 12th in the Times: National emergency risk as NHS vacancies top 100,000

More than 100,000 NHS jobs are unfilled and vacancies are increasing, according to the hospital regulator.

Experts said that there was a risk of a national emergency because of “a long-term failure in workforce planning”. The figures are part of a performance report from NHS Improvement in which it said that the underlying deficit in hospitals was £4.3 billion.

Some 11.8 per cent of nursing posts were not filled between April and June, a shortage of nearly 42,000. In London, which had the highest vacancy rate, the figure was 14.8 per cent. In England 9.3 per cent of doctor posts were vacant, a shortage of 11,500.

At the end of June there was a total of 107,743 vacancies, up from 98,475 at the end of March.

Siva Anandaciva, chief analyst at the King’s Fund think tank, said: “Widespread and growing nursing shortages now risk becoming a national emergency and are symptomatic of a long-term failure in workforce planning, which has been exacerbated by the impact of Brexit and short-sighted immigration policies.”

The report said that trusts had had to use bank and agency staff to ensure that posts were filled, spending £805 million on bank staff and £599 million on agency staff in three months, £102 million and £32 million over budget respectively.

Those costs were partly responsible for hospitals missing their savings target by £64 million, the regulator said, although it added that the plan had been “ambitious”.

The way vacancies are recorded has changed, but in 2008 the vacancy rate for nursing staff was 2.5 per cent and for medical and dental staff 3.6 per cent.

At the end of the first quarter of the financial year trusts in England were £813 million in deficit. The report included the sector’s underlying deficit for the first time, which reflects its financial position without taking into account one-off savings such as land sales or non-recurrent funding. That was £4.3 billion.

Sally Gainsbury, senior policy analyst at the Nuffield Trust think tank, said: “That means services were lacking the equivalent of 18 days’ worth of funding last year.”

The report said that A&E attendance was 6.23 million from April to June, 220,574 more than last year.

Image result for NHS workforce crisis cartoon

The NHS culture is sick – and so are its staff – But is there any “quick fix”?

Physiotherapy and counselling for NHS staff in drive to cut sickness rates

Waste in the Health Services. It;s mainly due to staff absenses…

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Do we want reduced access and less efficiency? GPs are self employed, and they take dividends. Salaried staff are far less value to the state. Politicians are uninformed and short termist..

Successive increases in the health budgets in Wales have not helped….. Brexit will make it worse… We all seem agreed, so why not change direction?

Image result for NHS workforce crisis cartoon

 

Orkambi and Yescarta are merely illustrating an ethical problem that will get bigger into the future… Political dishonesty and denial stall a solution.

It is self evident that we cannot afford everything. In health we only find this out when we need a non-funded treatment, such as Orkambi. There are other examples, such as Yescarta, Anticoagulant monitors etc. With drugs the perverse incentive is for authorities to decline them for as long as possible, so that they get as near to their patent expiry (12 years) as possible. Usually media pressure brings the state funding forward by a few years.. But in the intervening period the “health divide” means that only those who can afford it will get the new treatments. We could afford all these treatments once they were proven, if we agreed to ration out high volume low cost treatments. Indeed, for a disease like CF, the advent of CRISPR could ensure that fewer and fewer people need the drugs. This is the longer term solution, but shorter term our politicians need to ration honestly and overtly, large volume low cost products, so that those unfortunate enough to have an expensive disease can be treated. Even America is not covering Orkambi…

When will the debate on rationing take place ?

George Herd for BBC Wales: Cystic fibrosis mothers’ plea over ‘life-changing’ drug

Kimberly Roberts is the mum of three-year-old Ivy, who has cystic fibrosis – or CF – which is a genetic lung disease with no cure.

Along with her friend Alison Fare, who has two daughters with the condition, they want access to one of the most advanced treatments – the drug Orkambi.

But the manufacturer and NHS bosses have been locked in arguments over its £100,000-a-year price tag since 2015.

“Our children deserve to have it – deserve to live a healthy long life. Without that drug they won’t have one,” said Mrs Roberts, who lives near Conwy in north Wales.

Nice – the body which recommends whether a drug or treatment is available on the NHS – has said that the ongoing bills for the drug would be “considerably higher than what is normally considered a cost-effective use of NHS resources“….

Nice has said the cost for the drug would be “considerably higher than what is normally considered a cost-effective use of NHS resources“.

In July, NHS England made an offer of £500m for five years to have the treatment, with £1bn over 10 years.

But while that offer remains on the table – the deal has not been done.

Good News: Deal to freeze prices will allow NHS to use new drugs

First stem-cell therapy (for corneal epithelium) approved for medical use in Europe

Drug trails: how much obligation ha the state to support unproven treatments?

Anticoagulants to prevent clotting diseases.

Orkambi rationed for Cystic Fibrosis

Big pharma is taking the NHS to court this week – research is not “nationalised” for a reason..

More money needed… lets pour a little more into the holed bucket – and reduce the quality of care by rationing new treatments

Key cancer drugs to be axed from NHS fund – ITV News is updated by the Mail and Wales makes sensible decision..

The Times 29th August 2018: Yescarta cancer therapy ‘is too costly for NHS’

Kate Thomas for the NY Times 24th June 2018: A Drug Costs $272,000 a Year. Not So Fast, Says New York State. – New York’s Medicaid program says Orkambi, a new drug to treat cystic fibrosis, is not worth the price. The case is being closely watched around the country.

In PharmaTimes, Selina McKee, online 9th July 2018: Vertex, NHS England no closer to Orkambi settlement

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

Image result for dishonest politician cartoon

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.

Image result for dishonest politician cartoon