Category Archives: Trust Board Directors

Will YOUR local trust be candid (honest and truthful) in a timely manner? No way….

In an epidemic of plague managers and bureaucrats have to draw a line between complete honesty, which might lead to anxiety and panic, and modified truths, which reassure and support the population through difficult times. But is this against HMG and GMC rules since 2013, which obligates a “duty of candour”.

It is unlikely that your local trust will be entirely honest and truthful, and this may be in your best interest. Unfortunately, the track record means that their honesty and decision making has been questioned so much in the past few years, especially in rural areas, threatening to close the local DGH, that the public will likely be dissatisfied whatever they are told. 

I was in favour of a new build hospital, but in Pembrokeshire. All hospitals are out of date almost as soon as they are built because of advances in science and technology. So we should only build hospitals with a short life expectancy, and there should be twice as much ground space as needed, so that the replacement can be built alongside, while the cardboard and plastic of the first one is demolished. But a new build out of the area will distance patients from loved ones, lose the community support, and because of poor infrastructure lead to loss of lives.

At present there is a problem if you have a coronary or a stroke, as increasing covid-19 admissions may mean home is safer, and yet the old fashioned thrombolytic, (treatment before stent) is not being encouraged. It could be given at home…. This would be appropriate rationing… And of course, we are being told rationing will have to take place – as if it never happened before!

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The BMJ leader, by Fiona Goodlee ( Covid-19: weathering the storm: BMJ 2020;368:m1199 ) gives a good indication of the way we are now, our focus oon immediacy and avoidance of blame until its all over… My post on Scapegoating was not meant to be political, as it showed all parties to be at fault. 

Fiona’s text is below:

The UK is at last in near lockdown. While further measures may be needed, the government’s announcement on Monday 23 March has brought the country nearly into step with its European neighbours. If we are indeed only two weeks behind Italy, the peak of the covid-19 pandemic is on its way. There is an eerie calm, as when the sea recedes before the tsunami. Few of us can imagine what lies ahead.

For some, especially in London, the wave has already hit. Intensive care units are full, and hard decisions are becoming harder. On BMJ Opinion Daniel Sokol hopes that hospitals will establish “ethical support units” to help clinicians choose which patients to prioritise (https://bit.ly/2WIlTsI). In our rapid responses David Barer makes a stark call for people aged over 60 to prepare for a lack of ventilatory support and to express their preferences for palliative care until WHO declares an end to the pandemic (bit.ly/3bqvubU).

Every aspect of the NHS is being reorganised to meet the increased demand, say John Willan and colleagues (doi:10.1136/bmj.m1117), but 20% of its workforce is either ill or in self isolation. Healthcare workers are at higher risk of infection, and personal protective equipment is still lacking, despite government assurances. The waiting and workload are worsened by fear and fatigue. Staff, already stretched, are now scared.

Could some of this have been avoided? Many think so. Over the years, opportunities to research influenza-like illness have been missed and money squandered on ineffective antiviral drugs (doi:10.1136/bmj.m626). The NHS has been stripped of resilience by years of attrition compounded by lack of investment in social care. Public health services have been systematically decimated and dismantled. The UK’s idiosyncratic response to the pandemic has been guided by questionable modelling rather than by long established fundamentals of communicable disease control (https://bit.ly/2UzRZnI).

David Oliver counsels against political point scoring: there will be time enough for that when this is over, he says (doi:10.1136/bmj.m1153). So we should for the moment focus on things that will help us weather the impending storm. An urgent return to community contact tracing, says Allyson Pollock (bit.ly/2ULmgAj). Testing of frontline healthcare workers, says Julian Peto (bit.ly/2QJLjCx). Lowering the baseline of underlying illness, say Robert Hughes and colleagues (bit.ly/33PhNRa). To these, like Mary Black (bit.ly/2JcjiiF), I would add three more necessary things: candour about the scientific and political uncertainties, kindness to ourselves and each other, and courage.

March 2020: Many governments and many ministers of health have made mistakes… They should be candid.

May 2019: Whistleblowing protection is important, but exit interviews that prevent the need for whistleblowing are more important.

Jan 2017: Candour and Transparency? – what a farce

April 2016: National NHS whistleblowing policy published. Doomed to fail. The duty of candour will be outgunned by fear of reprisal.

March 2016: Stephen Bolsin – Bristol Scandal Whilstleblower mock interview in BMJ confidential. The duty of candour shows no sign of overriding the culture of fear and bullying.

Dec 2015: The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..

Nov 2015: Constructive deconstruction – of the ischaemic bowel in the UK Health Systems.. Politicians need a duty of candour like Mr Smallwoood

March 2013: No more covering up errors, NHS told. (A new “Duty of Candour”.)

March 2020: Doctors will ration health care if they have to. But the situation that led to the under capacity- shortage of staff, equipment, beds, plant and then morale, needs an independent enquiry

CV19. Lets see who we can scapegoat for our unpreparedness…? The magnificently ( unlucky ) 13

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Reverse the devolution of health.. Now is the time to combine the 4 health services to give us efficiency, equality and unity.

The 3 smaller health services should be closed down, and decisions made by England should apply to all. Its clear to NHSreality that Now is the time to combine the 4 health services to give us equality and unity. Why have Public Health Wales when the English administration is fit for purpose? NHS Health Scotland is fine and dandy, and it sometimes comes out with advice earlier than England, but the duplication of expensive resources cannot be justified. How many more incubators, respirators, and hospital beds could we fund with this money? So not only equality and unity, but also efficiency would result from unification of health services.                                                                                                                  BBC Wales news emphasises the difference and independence of its health service 25th March 2020

The democratic and opportunity deficit in health will become apparent, especially in the retrospectoscope, after this pandemic. Watch for different death rates, infection rates, and survival rates. The fact is that devolution has failed greatest in N Ireland, whose parties and public remain in a repressed civil war, and secondly in Wales, where the population is only a little larger, and non violently, but multiply tribal, and more successfully in Scotland because they have a separate budget. Certainly reversing health devolution should be considered carefully.

Unfortunately politics and media conspire to forbid pragmatic and unemotional discussion of any change to devolution. Indeed, the mood amongst these two conspirators is for independent taxation and then what: fiscal independence as well?

The pandemic has shown us that unity helps. Big mutuals do better. In defence and armaments bigger stronger countries can defend themselves better, and weaker ones least. The same is true for a pandemic. Reverse the devolution of health. Thee shock of this virus will either bring us together more, or tear us apart. Europe is at risk of the latter.

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Poor state of Welsh health. The experiment with devolution has failed….

Wales is bust, and cannot pay for its citizens care. Devolution has failed. This is the thin end of a very large wedge..

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

The democratic deficit. Applies to health as well as devolution, and to leaving the EU. The first honest party should get public support.

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The shock of coronavirus could split Europe – unless nations share the burden

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Many governments and many ministers of health have made mistakes… They should be candid.

If doctors have a duty of candour, then how about politicians? Many successive governments and many ministers of health have made mistakes… They should be candid about the reasons for poor manpower planning, fewer beds, fewer hospitals, fewer consultants, fewer nurses, fewer GPs, and fewer imaging diagnostic facilities than almost any other country in the G8.

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Rajaratnam Jeyarajah, consultant physician opines in a letter to the BMJ 14th Jan 2020: True candour about mistakes means full disclosure of system failures ( BMJ 2020;368:m104 )


BMJ 2020368 doi: https://doi.org/10.1136/bmj.m104 (Published 14 January 2020)Cite th

I agree with Maskell that we should be honest and volunteer all information to people harmed by provision of services.1 But why should we stop at doctors’ honesty about mishaps during patient care? Why shouldn’t we make the public aware of the shortages nearly all hospitals face and the stress and unrealistic demands this places on staff?

I suggest hospitals put a board outside the entrance, like those outside car parks, stating the number of staff shortages, vacant beds, and patients waiting on trolleys in the emergency department. As well as the number of scanners that aren’t working, and the delay in discharge because of the shortage of community care and nursing home beds. Also the number of staff who are absent because of stress or involved in appraisals and revalidation.

Then, some may decide that their hospital visit could wait another day or may even decide to have the investigation done elsewhere, and others may decide to take their loved one home and bridge the gap before care starts. This will make the public more appreciative of the care provided under difficult conditions in a constantly overstretched system. They will also be more understanding when unintentional errors are made. And less demanding.

I am in total agreement with the principles of the duty of candour. We need to be open and honest, not only about mistakes made but also about the contributory factors and the unreasonable demands imposed because of a shortage of resources.

Above all, staff should feel supported and their sacrifices appreciated. The public should realise that the NHS is the envy of the world but is giving way at its seams. If we don’t support NHS staff—the service’s greatest asset—we are in danger of losing our national treasure.

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Standards were falling anyway, so what better opportunity than to stop rankings.. The Minister’s denial will cost us all.

NHSreality has explained how standards are falling several times. The Corona virus outbreak gives politicians and administrators a chance: Standards were falling anyway, so what better opportunity than to stop rankings.. The opportunity is there to ration overtly, but the minister of health (England) lost the opportunity when he only half grasped the nettle recently.. He actually denied the need to ration for certain high cost and emotional areas – like IVF. His denial will cost us all. 

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Katherine Hignett reports in the HSJ 17th March 2020 (Health Services Journal) that:  Trust rankings put on hold over ‘unprecedented’ covid-19

Acute trusts have been told not to submit efficiency data to NHS England/Improvement until at least May amid increasing supply pressures.

Preeya Bailie, director of commercial and procurement at NHSE/I, told trusts not to share certain procurement metrics in an email sent late Friday afternoon.

She wrote: “Due to the complex, challenging and unprecedented situation we are facing as a result of the covid-19 virus, the NHS is having to make some tough decisions on where it prioritises its resources at the moment.

“I am conscious of the additional pressure on you and your teams, and as a result have decided to ask you not to submit your procurement metrics for the next couple of months. I will review the situation in May 2020 and communicate the process for submission, once the impact on operational activity is understood more fully.”

The next two procurement league tables, which rank trusts quarterly on several efficiency metrics, will be delayed until further notice. The latest table, which used data from the second quarter of the current financial year, was released earlier this month.

Mrs Bailie wrote: “We will ensure you have a revised timetable for retrospective data submission and league table publication, once the landscape we are currently working in becomes clearer.”

A Health Care Supply Association spokesman told HSJ the trade body “strongly supported this sensible decision” which would allow procurement teams to focus on the current challenges.

HSJ has approached NHSE/I for comment.

The global demand of supplies like face masks and hand sanitiser have soared in recent weeks because of the spread of covid-19. Factories in China — the original epicentre of the disease — have focused on supplying protective equipment domestically, putting a strain on the global supply.

HSJ understands some Chinese manufacturers are now exporting face masks, but countries including the UK still face significant supply pressures.

NHS Supply Chain, which procures common consumables and medical devices for NHS trusts, has been “managing demand” for increasing lines of personal protective equipment and infection control products since the end of February.

The body recently told customers it was implementing “controls on excessive order quantities” of a range of personal protective equipment to make sure stock was managed “fairly”. A spokeswoman from the Department of Health and Social Care denied this amounted to rationing…….

NHS Supply Chain announced last week it would begin distributing FFP3 respirators from national stockpiles to NHS customers. It has begun hosting daily webinars for its customers.

“We have stock on order from the UK and European countries in addition to suppliers based in the Far East to continue to secure a pipeline and replenish the stockpiles to help ensure the uninterrupted supply to the NHS”.

Grasping part of the nettle, but not the whole rationing genus.. So what are the criteria for the services that will not be rationed, and for those that can be. How will we do it?

The title assumes that there will be rationing: always denied until now. So exactly how will Mr Hancock choose those services not to ration? Just because he appreciates the post code imbalance of the different commissioners to IVF, does not mean he has grasped the whole nettle. Grasping part of the nettle, but not the whole rationing genus.. So what are the criteria for the services that will not be rationed, and for those that can be. How will we do it? One thing is certain. It is not up to doctors. These are political decisions.

Gareth Iacobucci in The BMJ reports that: Hancock vows to stamp out “absurd” rationing of some NHS services (BMJ 2020;368:m804)

The health secretary Matt Hancock has vowed to stamp out what he described as the “absurd” and “unwarranted” postcode variations in access to certain clinical services on the NHS.

In a keynote speech at the Nuffield Summit 2020 setting out his future priorities for the system, Hancock said that one of two key goals for the NHS—alongside increasing healthy life expectancy—was to increase public confidence in the service.

As part of this, he called for an end to rogue rationing decisions that deviate from national guidance and deny some patients access to treatments that people in other parts of the country can receive.

He cited the example of IVF, where access varies depending on the policies of local clinical commissioning groups (CCGs), leaving patients in parts of the country unable to access it or only being permitted one cycle.

Hancock said, “In the 2020s we must make it our mission to put the ‘national’ back into the national health service.

“At the patient facing end of the service that means levelling up across healthcare and ending some of the postcode inequalities so, for instance, your chance of seeing a GP doesn’t depend on where you live.”

Turning his attention specifically to inappropriate rationing of care, Hancock said, “Being a national service means having consistent standards that patients can expect. We want less unwarranted variation in both commissioning and delivery of services.

“Why should three cycles of IVF be allowed in some parts of the country while some other parts offer none? A local part of the NHS deciding it’s okay not to offer IVF with no accountability is absurd. It’s unacceptable in a national system.”

He added, “It’s not for a CCG to decide whether you should have one, two, or three rounds of IVF available. They are a local body that does not have democratic legitimacy.”

Our local debate: Debate Rationing final

NHS rationing – by Julia Manning

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A deficient NHS bill for a sinking and near moribund service…

When 3 eminent people write  a letter to the Times letting the readers know that the NHS bill is “deficient”, they are putting it mildly. They really agree with Richard Smith (see below) and they are pointing out the “denial” of our politicians. These privileged people live mainly in London, and can get access to the free quality health care, or to all the private options, that exist in London. Choice is part of their lives, unlike the rest of us living in the shires. The 4 health dispensations re sinking – fast. The authors of this letter are experienced and eminent…. They are in charge of the “think tanks” that provide background research and evidence to the health services. They are unwilling to mention rationing, as is Richard Smith, but that is what is needed, and it has to be open. What would help is releasing the CEOs and Trust Board members to say what they feel in public, withiout losing their jobs, and to have exit interviews for all board members which should be done by an outside agency (not hospital HR) and feedback should be at intervals that allow depersonalisation of the comments.

DEFICIENT NHS BILL 04/02/2020
Sir, Today MPs will pass a bill to enshrine in law promised funding for everyday NHS services in England. The investment is an important signal but it does not include areas of funding crucial to the government’s election promises to provide more hospitals, nurses and GP appointments. The bill does not cover investment in buildings and equipment. Yet capital spending in the NHS is well below comparable countries; for example, we have only a third as many MRI or CT scanners as Germany. The government has announced some money for hospital upgrades but it is not enough to address the NHS’s crumbling infrastructure or fund new technology to improve care.

The NHS is facing a workforce crisis but the bill does not cover education and training budgets that would help recruitment and retention. Nor does it offer any relief for the public health and social care services that help to keep people healthy and independent.
Dr Jennifer Dixon
, CEO, the Health Foundation; Nigel Edwards, CEO, the Nuffield Trust; Richard Murray, CEO, the King’s Fund

Spin doctors? Richard Smith isn’t buying it. “The NHS doesn’t need more money, it needs a radical rethink”.

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