Category Archives: Trust Board Directors

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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Alan Milburn thinks the penny has dropped…. Money alone will solve nothing for the UKs health services.

We cannot expect a former health Secretary to admit we need to ration health care, but this is the nearest we will get. NHSreality does not think the penny has dropped with a majority of the politicians as yet. ….. One of the signs of inefficiency is readmission rates, which are rising fast. There may well not be a bed for YOU when you need one… Rationing is happening but we are all denying it, and as it is covert, Commissioners get away with it where they can.

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Alan Milburn opines in te Times 1st June 2018: The government can gift the NHS time as well as money

The penny has dropped. The Prime Minister has come to realise that the NHS — indeed the wider care system — needs more money. An announcement, perhaps to coincide with the 70th birthday of the NHS in July, is apparently imminent.

It has become obvious to government that demand and supply are out of kilter. Hospital admissions have risen by one third in a decade but resources have failed to keep pace with NHS funding rising at less than half the rate of the 4 per cent historic average.

The arguments are now raging in Whitehall about how much the NHS needs to be sustainable. History seems like a good guide — 4 per cent is surely the minimum needed.

But here I have a health warning for the government. Increasing the volume of cash is only one leg of the three-legged stool on which a stable NHS needs to sit. The second leg is visibility over-resourcing.

The NHS needs long-term line of sight — 5 to 10 years — over resources so that it can plan with certainty to transform local services so they meet future demographic and disease challenges.

It will take time to change services so that they are less fragmented and more integrated, less dependent on hospital care and more more community-based, less focussed purely on treatment and more on prevention. The government can gift it time as well as money.

Thirdly, reforms must accompany resources. People working in the health service know that the current structures are no longer fit for purpose. Structural reforms since 2010 have led to unprecedented confusion and uncertainty.

The reforms were intended to introduce more competition but the thrust of The Five Year Forward View — the NHS’s reform plan — is about encouraging greater collaboration, not least between health and social care.

Today the NHS is in an organisational no-man’s land. In particular there is a misalignment between the ambition of creating integrated, place-based and outcome-led care and the operation of the current financial system. Money talks in the NHS. Not just the volume of money but how it is used, deployed and how it moves around the system. I know that from my experience as Health Secretary in the Blair government.

When we put record resources into the NHS, at first hospital activity levels stalled and waiting times continued to rise. One of the key things that changed that was the introduction of incentives on hospitals to increase activity and reduce waiting.

The more they did, the more resources they got. That change led to unprecedented reductions in the times patients had to wait for an operation. But today, although reducing wait times remains important, the biggest priority for the NHS is to tackle chronic diseases like diabetes and improve population health outcomes. That needs a different set of financial incentives.

The current financial system is caught in a time warp and needs to catch up. Without reform there is a risk that that the government simply won’t get the most bang for the buck out of the new resources it intends to invest in the NHS. That would mean too many of the extra resources would be wasted.

What is more, if left unreformed, the financial system will be a stumbling block to the service transformation that is so desperately needed. According to a new report drawn up by PwC with the help of the Healthcare Finance Management Association, 76 per cent of NHS finance professionals feel the current funding structures in the NHS are not fit for purpose.

I agree. To make sure that the extra resources are put to the best use, reforms are needed. Health and social care budgets need to be brought together at a local level. How providers get paid should be changed to reward improvements in health outcomes rather than increases in the number of people treated — so helping the drive towards prevention rather than activity.

Channeling NHS resources through local systems rather than single institutions would speed care integration. And banning capital to revenue transfers — which have robbed the NHS of billions of desperately needed infrastructure spending in recent years — would provide more investment in out-of-hospital care. These changes would put extra resources to work for the benefit of patients.

Today the NHS has reached an inflection point. Without change, it will not be sustainable as a universal service providing care according to need regardless of the ability to pay. The promise of more government investment is welcome. but it must be accompanied by reforms.

There is a huge opportunity to better optimise resources, better empower patients and better improve health outcomes. Change is always hard in the NHS but there is a big prize on offer — not just to sustain the system, but to transform it.

Alan Milburn is chairman of the PwC Health Industries Oversight Board and a former health secretary

Chris Smyth reports 1st June: Millions return to hospital after only a month

Is NHS rationing a possibility? – BBC News

Sarah Page reports for West Susses County Times 1st June: Vital eye surgery rationed across the county despite calls for rationing to stop


There is advantage in enhancing choice by enlarging trusts. And it will improve outcomes… Good news for Devon: bad news for Wales.

Apart from economies of scale, and reducing overhead, there is advantage in enhancing choice by enlarging trusts. And it will improve outcomes…

Hywel Dda and ABMU trusts in West Wales need to merge. The politics of Wales may prevent this but in England there is a utilitarian precedent in Devon. Exeter and Barnstable trusts are combining. Good news for Devon: bad news for Wales if the option is not taken.

Sarah Howells for the North Devon Gazette reports that “North Devon MP welcomes move to share health care bosses with Exeter”.

North Devon’s MP has said a new collaboration between Exeter and North Devon’s healthcare trusts could increase the services available in Barnstaple.

Peter Heaton-Jones released a statement reacting to the news Northern Devon Healthcare Trust (NDHT) and Royal Devon and Exeter (RD&E) will be working in collaboration.

If agreed by both trust boards, Exeter’s chief executive and chairman will take over the running of NDHT as well.

Mr Heaton-Jones said: “Last week I met the acting chief executive of the Northern Devon Healthcare Trust, Andy Ibbs, and the board chairman, Roger French, to discuss these new arrangements.

“I sought and received assurances that the collaboration has a single purpose: to ensure that all acute services can continue to be delivered in Barnstaple.

“Last year, the NHS England review concluded rightly that all services should be retained at the NDDH, but set the challenge of doing so in a sustainable way.

“This new arrangement does just that, and means we can share resources and expertise to our long-term advantage.

“In fact, I have been told that some procedures currently not available in Barnstaple may be able to be delivered here in future as a result of this collaboration..

“The local community is passionate about our hospital, and I will soon be meeting the new chief executive to hear more about the collaboration and how it will safeguard the future delivery of services in Barnstaple.”

Hospital campaigners have welcomed the move, and a spokesman for Save Our Hospital Services said the group hoped the new management would ensure the retention of acute services in North Devon.

As part of the draft agreement, a senior management team will be based at both North Devon and Exeter hospitals, and an appraisal will look into a long-term solution.

However, Devon County Councillor Brian Greenslade, said he felt the move could cause concern for those already worries about a loss of services in North Devon.

He said: “For the people of North Devon the critical thing is to protect the delivery of acute services provided in the NDDH.

“This is my key objective and where I will focus my scrutiny attention.

“I will also be probing to see whether this proposed collaboration gives the opportunity to repatriate some acute services from the RDE to Barnstaple.

“I also believe with the increasing population in North Devon there is a case now to look at growing the facilities at the NDDH.

“We have been very lucky to have such a good hospital in North Devon with such dedicated staff.

“Let us remember that had it not been for former MP Jeremy Thorpe and the 50,000 signature he presented to Parliament, we probably would have not had this facility in our community.”

Jennifer Howells, regional director South West for NHS Improvement and NHS England, said the two trusts were ‘determined to do the right thing’ for the community.

She added: “Working with the RD&E through this agreement, and with ongoing support from NHS Improvement, I am confident that NDHT will have the best possible support to make the necessary, sustainable improvements that will enable them to provide the quality of services patients expect from the NHS.”

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…

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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Trials of personal budgets will have long term perverse outcomes in an ageing society. Health costs are rising, and geographic variations will become greater….

Health costs are rising. Even in Australia, a relatively rich 1st world country, citizens are “struggling to afford their cover”. The safety net afforded by the current 4 health UK services may be holed, but it is not yet “absent”. In London, where it costs most to live, but where people earn more, residents who can afford to pay for private health Insurance (PMI) are being charged more than others around the country. This simply reflects the general inflation in health costs, and the likelihood of a claim. If less people are paying for PMI, then those that pay up are going to be those more likely to make a claim. As the population ages, the same is true. Each individual is, on average, going to cost more…Imagine a country where everyone needed “personal health budget”: what happens when the emergency operation is needed and the budget is spent? The Times leader  16th April supports individual budgets..(see below) .

The only virtue of personal health budgets for chronic conditions is that it is part 1 of over rationing.

The whole idea of a National Health Insurance scheme is to mutualise risk. Once rationing is overt and honest, each citizen and family can plan for what is excluded. It should be possible to make different thresholds for exclusions based on wealth/means. This would be fair. If we keep wriggling on the various hooks that try to avoid rationing, we will get perverse behaviours and outcomes.  These have yet to be seen, but they will bankrupt us whilst we remain in denial. Trust boards and commissioners should wait for the long term effects of these “trials” before following..

Londoners will consider having their knees replaced in Wales, or India, more frequently. Paying directly seems the answer. Is it more important to pay for a very large mortgage in London, or to have good affordable health treatment? By this means, the rich can subsidise the poor. Where health insurance is cheaper, so people are poorer.

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Ruth Emery reports in the Sunday Times 16th April 2018: Sick of the rising cost of health cover

Londoners are paying almost twice as much for medical insurance as policyholders in other parts of the country

When Stacie Coates received a letter from her healthcare insurer, Vitality Health, saying her premium was rising by 11% to £148 a month, she decided it was time to do something about it — especially as it followed a hike of 15% the previous year.

Coates, 43, of Chelsea in southwest London, turned to a broker, who found a similar policy with the healthcare giant Bupa that cut her monthly payment to £124 — plus she got two months free.

“I’d been with Vitality Health for three years but never claimed,” she explained. “It’s not right they kept putting up my premium.”

Coates works for herself, running the Chelsea Windowbox Company, and believes health cover is important. “What if I had an accident? I can’t afford a long wait on the NHS, such as having to wait for a knee operation for six months. The NHS is so squeezed right now. If you can afford it — and you find a reasonable price — health insurance makes sense.”

However, Coates may not be pleased to find out that, even with her new deal, she will be paying substantially more for her cover than people elsewhere in the country…..

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Christopher Knous for the Guardian reports 29th March 2018: Three-quarters of Australians struggle to afford private health insurance – Choice

Premiums cited as second greatest cost-of-living expense concern after electricity

Chris Smyth in the Times 18th April 2018: Patients will decide how they spend NHS money

Huge expansion of personal health budgets…

Money Well Spent – Personal health budgets can transform nightmares into lives worth living – The Times leader 16th April

When Jackie Kennedy developed epilepsy as a result of an assault at work, for a while things looked very bleak indeed. She lost her mobility, could no longer work as a police officer, went into a severe depression and considered suicide. Fast-forward to the present and her life looks rather different. She has a full-time canine helper (a highly trained black lab called Kingston), two part-time human ones and part-time voluntary work of her own. She’s thinking of going back to university.

The transformation has been made possible by a personal health budget of £50,000 a year arranged by an initiative called NHS Continuing Healthcare. For now only 23,000 people in the country have personal health budgets funded by the state. That is set to expand more than tenfold to include several new categories of people, among them those with mental as well as physical illnesses, dementia sufferers and military veterans.

There have been stories in the past of patients using money meant for their care on holidays and games consoles. There will be more. Jeremy Hunt, the health secretary, and Simon Stevens, head of the NHS, will have to take them on the chin. They are supporting the expansion of this scheme on the sound basis that as long as experts are also involved, no one is better placed to decide what to prioritise in complex treatment programmes than patients themselves. That principle can be taken a step further: who honestly is in a position to tell a recent amputee that a season ticket to his or her favourite football club, or indeed a holiday, might not be the best defence against depression?

There is evidence that personal health budgets improve long-term outcomes and bring overall cost savings. The plan is that they will also merge NHS and social-care spending, accomplishing on an individual scale exactly what is needed on a national one. From such acorns, oak trees grow.

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Update: The Times letters, on this issue, 17th April reveal a Liberal minister unwilling to see further than the ideology of Liberalism, to the benefits of utilitarianism. In this case the two conflict, and the latter takes precedence. This is exactly the sort of idealism, and lack of pragmatism which keeps the middle party out of office.

Sir, The idea of increasing “personal budgets” to manage health and social care may look politically attractive but it will not benefit everyone, particularly older people who have complex health care needs (report and leader, Apr 16). Indeed, lessons will need to be learnt about why they have not been a success to date.

At Independent Age we hear about the immense difficulties that older people face trying to access healthcare and support and it is questionable whether personal budgets will make life easier. The vast majority of older people want health and care provided through the NHS and social services in their area. They are not experts in brokering care packages, negotiating contracts or assessing quality. Personal budgets may also create an external market that is driven by price and profit, rather than meeting the diverse and complex health needs of an ageing population. Although some people will benefit from personal budgets, it is not a silver bullet. No one should be disadvantaged by not taking them up, but crucially the government must also address the funding crisis in the NHS and social care, and end the disjointed fragmentation of support across the two systems. Personal health budgets should not be seen as a substitute.
George McNamara

Director of policy, Independent Age

Sir, The chief objection to personal health budgets expressed in your report was that feckless patients might spend their money on world cruises and football tickets. The real risk, however, is that they will use their budget to fund so-called alternative medical treatments that have been proven to be ineffective or even dangerous. I fear this is yet another gimmick on the part of the government to divert attention from their underfunding of the NHS, but the effect will be to increase the funding shortfall.
Dr Bob Bury


Sir, Plans to expand the use of personal health budgets should be welcomed by all those who believe in the liberal principle of giving people more control over the public services they use. As health minister I extended the right to a personal health budget to everyone receiving NHS continuing healthcare. There is evidence linking these with better outcomes for patients, while concerns that the system would be open to widespread abuse have proved unfounded.

However, the government’s commitment rings hollow when many patients already report having their personal budgets trimmed without any medical justification. This includes people with debilitating progressive conditions such as spinal muscular atrophy, who have been left unable to pay for the level of support they need. Personal budgets have the potential to transfer power to patients, but that potential will only be realised if there are sufficient resources for people to exercise that power effectively.
Norman Lamb, MP
Care and support minister 2012-15



Will citizens be wise to move away from under-resourced areas of the country?

Where should you live to get the best health care? The demise of rural area DGHs, such as my own, where recruitment is a recurring problem, are compounded by the shortage of GPs. There is an irony, that as more and more beds are blocked, the hospital trusts demand more and more money, and expansion. Mr Stevens does not encourage this, and feels resources should be directed to the community and GPs. A letter in today’s Times lucidly exposed the dissonance. The result of too few doctors, and downsizing of all hospitals in West Wales, is that none of them are good enough. Once the penny drops,  more private care, including A&E  services, and more travelling are inevitable. Those that can may choose to leave… In the last week I have heard of children being sent on a round trip of 80 miles with a minor illness even thought he Out of Hours service was manned by a GP. Presumably one with stress overload.. I have accounts of patients with stroke not getting treatment because it was a Bank Holiday, and waiting lists are impossible, both for hospital and GP appointments. We may need beds, but not in hospitals..

The Western Telegraph 27th March 2018

The Times letters: Dr Stephen Mann: 

Sir, Jeremy Hunt promises a new hospital every year (News, Mar 28). In his “Next Steps” plan Simon Stevens, the head of NHS England, correctly recognises that the solution to challenges in A&E and hospitals is in the provision of joined-up health and social care based in our communities. The current provision of services is based on hospitals, with every issue prompting a “political” reaction to invest more in hospitals.
Dr Stephen Mann

Stourbridge, W Midlands

Chris SMyth in the Times 29th March 2018: NHS needs 10,000 more beds say chiefs

The NHS is more than 10,000 beds short of what it needs to look after older people properly, hospital leaders have said.

NHS Providers, which represents hospitals, said that it was impossible for waiting time targets to be met this year and warned that the government’s pretence that they would be met created a “toxic culture” similar to that which led to the Mid Staffordshire scandal.

This week Theresa May promised that a long-term plan for NHS budget rises would be agreed within months, and will be under pressure to agree increases of up to £20 billion over five years.

However, Jonathan Ashworth, the shadow health secretary, said that “a nod and
wink from the prime minister” was not enough for patients.

The NHS has not hit any of its main targets for more than two years. Chris Hopson, chief executive of NHS Providers, said: “The levels of performance expected and the savings demanded for next year are beyond reach. While we strongly welcome the prime minister’s commitment to increase long-term funding for the NHS, it makes no immediate difference to the tough task facing trusts for next year.”

Mr Hopson’s report estimates that 3.6 million patients will not be treated within four hours at A&E over the next year and 560,000 will be denied routine surgery within 18 weeks. He said that hospitals could make £3.3 billion in savings next year but that ministers had demanded 20 per cent more than this.

“This creates a toxic culture, based on pretence, where trusts are pressurised to sign up to targets they know they can’t deliver and then miss those targets as the year progresses,” his report said.

“The NHS is probably somewhere between 10,000 to 15,000 beds short on a bed base of about 100,000.”

One hospital chief executive suggested that hospital overcrowding pointed to deep social problems. He said: “As a country we don’t look after old people well. We have too many people living by themselves in houses that are unsuitable . . . In the end they get really unwell and call 999.”

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?”

Jenni Russell reports in the Times 8th Feb 2018: Wise doctors will retreat from the front line now

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians for their long term rationing, denial, and collusion of anonymity. Other countries and their leaders cannot understand us, including Mr Trump. (Stephen Glover in the Daily Mail)

Overwork and the risk of negligence cases make safer specialisms preferable to acute medicine

I was once responsible for a patient’s death. Or that’s how it could have been seen. It was years ago, in a gap year job, but the experience was so searing I can relive it with terrible clarity.

I was working as a nursing auxiliary on a hospital ward. At 9pm all the nurses were gathered in the sister’s office, two doors and 30 metres away, handing over to the night team. A physio was with an elderly asthma patient when she threw open the curtains around the bed and shouted: “Resus! Nurse, get the resus trolley!”

She meant me. I was the only person in a nurse’s uniform in sight or earshot. I ran. The heart resuscitation team was bleeped. I dragged the trolley, which was new on the ward that month, to the bed. I unwound the electric cable, seized the plug, looked around for a socket. And looked. And looked.

This was an old ward in a crumbling outbuilding and there was nothing logical about its power points. As the newest and most junior person on the team, no one had thought it necessary to show me where they were. While I hunted, with rising panic, ducking between beds, the old lady’s heart began to fail. The heart team arrived, a nurse grabbed the plug from me, the old lady died.

Was this my fault, or the system’s? If I had been faster that woman may have lived. Is someone who tries their best when they don’t have adequate backup the guilty party, or is the system around them also responsible, for not providing the support they need?

Any sane person would think the latter, but thanks to the punitive decisions of the GMC and the High Court in pursuing the striking-off of Dr Hadiza Bawa-Garba after an error which led to a child’s death, every doctor and nurse in the country now fears that they may lose their jobs, futures and reputations for a single serious mistake.

The doctor was under extreme pressure, covering for an absent registrar while overseeing six wards on four floors, on a relentlessly demanding twelve-hour shift. It was her first day back after maternity leave and she had had no induction training. The nursing rota was understaffed and the IT system was down for hours, meaning blood test results were critically delayed. Her consultant wasn’t present. All the evidence given testified to her being a committed, above-average doctor, and yet she has been thrown out of the profession.

The chilling lesson of the Bawa-Garba debacle is that context, character, remorsefulness and a good record will be no defence.

The unintended consequences of this hardline decision by the GMC are going to damage the NHS, not protect it. Doctors across the country are aghast, feeling, as an editorial in the BMJ said, that “there but for the grace of God go I”. Furious senior doctors are reporting themselves to the GMC for long-ago errors, to make that point. Newer doctors are now afraid to admit to theirs in case it backfires on them. And the devastating practical effects are now unfolding, unseen.

“I’m practising defensive medicine now,” one doctor told me. “We all are. I’m not taking risks. If someone turns up with a non-specific lump, I might before have used my judgment, said wait and see. Now I’m sending them for scans, second opinions, follow-ups, blood tests. Lots of that will be unnecessary, the NHS is already overloaded, and I’m adding to that. But I feel now I’ve got no protection, I’ve got to watch my own back.”

His fears are widely shared, an A&E consultant tells me. It’s going to cut the numbers willing to work in areas of acute medicine that are already routinely understaffed, like paediatrics or emergency medicine. If doctors know, as they do, that those are the jobs where they must take what are now career-threatening high-risk decisions, while covering rota gaps, fewer people will apply. “They’ll retreat to safer options — dermatology, genito-urinary clinics, specialisms like that.”

He warns that it’s going to mean a rise in staff going off sick in high-pressure disciplines, as people assess the new pressures of being conscientious. Instead of putting the patients first, many doctors will choose caution. “If you’re feeling a bit off, why would you risk putting yourself in the firing line? It’s going to be a lot safer to stay at home.”

There is particular fury at the GMC’s attempt to cover its back by issuing guidelines telling doctors that if they are in understaffed, unsafe environments they must create a paper trail flagging that up. As one enraged doctor pointed out to me, hospitals already know exactly when their rotas are missing staff. And as a fine column in the BMJ by the consultant in geriatrics David Oliver points out, now we are ordering overworked doctors to spend more of the time they don’t have in documenting that they haven’t got it. It serves literally no purpose, since if nothing goes badly wrong on their shifts nobody cares that they were overloaded, and if something does go wrong, that record won’t protect them.

The NHS is clearly alarmed by what has been set in train here, with many hospitals declaring they stand by their staff and the health secretary Jeremy Hunt setting up an inquiry into the implications of the Bawa-Garba case. But warm words mean nothing laid against the cold legal danger doctors are now in. They need safer staffing levels and an absolute assurance that when they make mistakes their institutions will share responsibility too. Until they get that, the health service is going to be weakened by this cruel and foolish pursuit.

Laura Donelly in the Telegraph 6th February reports: Hunt orders review of Medical Malpractice and Doctors Outcry  over manslaughter case:

Dr Hadiza Bawa-Garba was struck off the medical register after she was found guilty of mistakes in the care of a six-year-old boy who died of sepsis.

The case has been met with a backlash among medics, with thousands sending letters of support for the doctor, saying the decision ignored NHS failings and staff shortages which contributed to the death.

Dr Bawa-Garba was originally suspended from the medical register for 12 months last June by a tribunal, but has now been removed from the medical register following a High Court appeal by regulator the General Medical Council (GMC).

The GMC said the the original decision was “not sufficient to protect the public”.

Mr Hunt had already expressed unease about the situation, saying he was “totally perplexed” by the actions of the watchdog.

In particular, he raised concerns that doctors would no longer be open about errors, and be honest in their self-appraisals.

In a statement to the Commons, the Health and Social Care said clarity was needed about  drawing the line between gross negligence and ordinary errors.

Speaking in the House of Commons today, Mr Hunt said Sir Norman Williams, former president of the Royal College of Surgeons, will lead a national “rapid review” of the application of such laws.

He said Sir Norman will review how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.

Mr Hunt said the review will also look at the role of reflective learning, to ensure doctors are able to open and transparent and learn from mistakes.

The review, which is due to report by April, will also consider lessons to be learned by the GMC and other regulators.

Charlie Massey, chief executive of the General Medical Council said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England. The issues around GNM within healthcare have been present for a number of years, and we have been engaged in constructive discussions with medical leaders on this issue.”

He said the watcdog was committed to examining the issues, and to ensure fair treatment of doctors working in situations where the risk of death is a constant and in the context of systemic pressure.”

“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure. We know that we cannot immediately resolve all of the profession’s concerns, but we are determined to do everything possible to bring positive improvements out of this issue,” he said.

The GMC is carrying  out its own review, and would endure the findings from the new review feed into it.

Dr Bawa-Garba was struck off over the death of Jack Adcock, aged 6, at Leicester Royal Infirmary in 2011.

The child, from Glen Parva, Leicestershire, was admitted to the hospital in February 2011, his sepsis went undiagnosed and led to him suffering a cardiac arrest. The courts heard Dr Bawa-Garba, a paediatrician, committed a “catalogue” of errors, including missing signs of his infection and mistakenly thinking Jack was under a do-not-resuscitate order.

But they also heard the doctor was working amid widespread staff shortages, with IT failures and delays in test results

At the time of the ruling, Jack’s mother, Nicola, said: “We are absolutely elated with the decision. It’s what we wanted.

“I know we’ll never get Jack back but we have got justice for our little boy.”

The Medical Protection Society, which represented Dr Bawa-Garba, said at the time: “A conviction should not automatically mean that a doctor who has fully remediated and demonstrated insight into their clinical failings is erased.”

An online appeal set up by concerned doctors has raised more than £320,000 to help pay the legal costs of Dr Bawa-Garba.

Agency nurse Isabel Amaro was also convicted of manslaughter on the grounds of gross negligence relating to the same incident and struck off by the Nursing and Midwifery Council.