Category Archives: Rationing

The advantages of mutuality are being shunned. Purchasing power in small regions is little. Choices are disappearing.. Hammond is unlikely to help ..

The breaking up of the old “National” health service into the 5/6 different health services (If we include London) is a form of self harm in many ways. The benefits of a large mutual in health, where we cannot predict our future diseases, or our own “lottery of life” ticket, were fully understood by Aneurin Bevan.

The NHS Executive (England) announced 26th October: NHS ahead of schedule for procurement savings but this is still small savings in relation to the potential. The Logistics Manager, Supply Chain reports 30th October: NHS Supply Chain delivers £250mn of savings, nearing £300mn …But the “Public Finance” site 9th November reveals the truth in its concern to compare: DoH to rank NHS hospitals in ‘procurement league tables’. You have to believe in the power of the mutual to understand the reduction in risk, as well as the potential savings. Devolving powers is all very well, and “liberal”, but if it reduces life expectancy by increasing risk, reducing choice and purchasing power, and makes a Regions (such as Wales) bust then it is not a public good.  Imagine if we were so “liberal” as to give each citizen a health budget of their own? The benefits of mutuality are lost as those lucky enough to avoid disease choose to lead hedonistic lifestyles at the expense of the unlucky. The post-code lottery is reality, but nobody knows it until they are a victim. Dead patients don’t vote.

With the inefficiencies in mind, one wonders why London has been approved as the 6th health system in the UK? The only explanation I can believe is that it muddies the water even further: it allows more comparisons, and less choice. Politicians of course, with access to London will always have access to the best! For the rest of us it will be second rate care or a private plan/ purchase option.Image result for the mutual health cartoonI wonder if the youngsters understand the principles behind a mutual organisation? It is not hard to find examples which we revere such as the John Lewis partnership. The question of “what is the John Lewis Model” was addressed in the Guardian. If you want to read and then answer questions on a “business case study” the opportunity is here.  In Insurance, such as the old NHS, the advantages are clearer still…

Oliver Wright reports in the Times 20th November 2017: No cash bailout until you make savings, Hammond tells NHS ( a reality warning before the budget ).

Health service leaders have failed to keep their promise to save billions of pounds to spend on frontline services, Philip Hammond claimed yesterday, as he ruled out a budget bailout for the NHS.

The chancellor rejected calls by Simon Stevens, the chief executive of NHS England, for a £4 billion funding boost, saying that people running public services often claimed “Armageddon” if they did not get the money they wanted from a budget.

He warned that although the government might find some money for “particular pressure points” in the NHS it would not be at the scale demanded by Mr Stevens. The chancellor is understood to be prepared to find the money to fund limited pay rises for nurses and some capital investment programmes but there will be no significant increase in total NHS revenues.

Mr Hammond’s comments came after Mr Stevens said that the government should honour the pledge of the Vote Leave campaign and hand some of the money “saved” by Brexit to the NHS…….

Drawing on analysis by the Health Foundation, King’s Fund and Nuffield Trust charities, Mr Stevens suggested that the NHS needed about £4 billion more next year to prevent patient care from deteriorating.

Mr Hammond said that the government had already agreed to provide the NHS with an extra £10 billion by 2020 — a figure requested by Mr Stevens in his five-year plan.

“That plan is not being delivered,” Mr Hammond said. “We need to get it back on track.” He added: “In the run-up to budget, people running all kinds of services come to see us and they always have very large numbers that are absolutely essential, otherwise Armageddon will arrive.

“I don’t contest for one moment that the NHS is under pressure. We have been doing some very careful work with the Department of Health, with the NHS, to look at where those pressures are, to look at the capital needs of the NHS, to look at where the particular pressure points around targets are. And we will seek to address those in a sensible and measured and balanced way.”

His remarks about the five-year plan irritated NHS England, which sent out a series of tweets shortly after Mr Hammond was interviewed on The Andrew Marr Show on BBC One, citing “evidence” that Mr Stevens’s reforms were working. The shadow health secretary, Jonathan Ashworth, described Mr Hammond as out of touch. Mr Ashworth said that an extra £6 billion was needed to avert “Armageddon”.

He told Sunday With Niall Paterson on Sky: “It’s incredibly serious and if I may say so I’ve seen Philip Hammond doing interviews today, being dismissive of the calls for more money for the NHS, saying well you know it’s not going to be Armageddon.

“This is happening now, today, in the NHS, and if he doesn’t realise that, he’s completely out of touch. We are calling on the chancellor to put aside an extra £6 billion in this budget.”

NHS England declined to comment but is understood to reject suggestions that the plan it set out for NHS efficiency savings is not working.

 

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The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

Devolution of health to Wales was a mistake?

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.

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….

Stroke survivors ‘are dumped by the NHS’. Dead patients don’t vote, and those near death don’t appear to count…

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

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American rationing – an opinion from the Sun Journal

It is not only the UK with it’s 5 medical systems, (soon to be six) but the whole world that has to address rationing. The politicians are ducking the issue in the UK, but NICE has opined on the Life-Year-Value below which the state should intervene. In the USA the vitriolic debate on socialised care and mutual funding is still active, but the US needs to be reminded of the duty of government to treat populations. It is the duty of doctors to treat individuals within the “rules of the game” as defined by government and private insurers, and within the law. An example such as this one rightly makes us think …. The reality is that all health systems are rationed. (What would the world’s best health system look like? NHSreality’s book review of “In search of the Perfect Health System by Mark Britnell) Free prescriptions, as in Wales, means more covert rationing, and less patient autonomy. Te health service itself will die if we cannot address this truth.

March 4th 2017 and the Sun Journal in the USA opined: Do we ration health care? without doubt.

For those who fear the government is about to start rationing health care in America, there many examples of how we already do.

Here’s one.

Each year, about 115 high school athletes across the U.S. die from undetected abnormal heart rhythms.

And, for years, some have argued that an electrocardiogram, or ECG, could, if administered to all student athletes, prevent many of these deaths.

However, after studying the issue in 2007, the American Heart Association concluded it would cost about $2 billion to screen and evaluate ECG results for the 10 million students competing in high school and middle school sports.

That means it would cost about $17 million per life saved, if indeed every death could be prevented.

What’s more, trying to screen every student in the U.S. would put a tremendous burden on the health care system. Some questioned whether there are even enough physicians, technicians and machines in the U.S. to handle the load.

Then there is the issue of false positives. About 16 percent of the tests show a problem where there is none, so those students would have to undergo expensive retesting and evaluation.

So, a national testing program has not been adopted.

While it seems callous to say so, the medical community applied a cost/benefit ratio to the problem and decided that 115 deaths is acceptable compared to the massive cost and difficulty of testing every young athlete.

That implies there is a point — a dollar value — at which a life, even a young life, is not worth saving.

But that point isn’t fixed forever. As the result of its own research, Harvard University, has decided to give ECGs to student athletes, according to a story in Monday’s Boston Globe. Italy also tests all competitive athletes between 12 and 35.

And a new Stanford University study says the cost is actually less than previously estimated, perhaps as little as $43,000 per life saved, according to the Globe.

Now, is $43,000 worth saving a single young life? That’s now in the same range as mammograms and pap smears.

But, as you can see, this is sort of rationing at work. At one price, the procedure seems outrageously expensive and it is not performed. At another price it seems like a bargain.

We are simply choosing among various alternatives in order to spend our health-care dollars as effectively as possible?

The real question is who sets these standards and makes the decisions, particularly when it comes to publicly funded programs.

Right now, insurance companies decide which drugs and procedures are available to those with insurance.

The federal government decides for older citizens.

And the uninsured have their health care severly rationed. If they can’t pay for it, they don’t get it.

In some countries, like Canada and England, public panels of scientists, researchers, doctors, patients make the decisions based on established criteria. Of course, those would be labeled “death panels” here.

Still, as health care costs mount, and pressure to contain them grows, we will need some rational way to making these difficult choices.

Mark Britnell – In Search of the perfect Health System. 

The Health Services in “Reality”: even the chief says it’s broken

How on earth did we get here, to this point in denial and lack of long term thinking. Now, if we employ GPs directly from overseas, we will be negating years of training and Improving standards. Teaching Hospitals and Deaneries will be irate. In the longer term the places filled from overseas will be blocked to UK trained doctors. History repeating itself from the pressure in the 1950s? The Health Services are in “Reality”: even the chief says it’s broken. More money will not make more qualified doctors and nurses. The options outlined do not include rationing health care overtly. A knee jerk response tells me it may happen suddenly and unfairly, and without a national debate on the best way to achieve fairness within rationing.

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Chaand Nagpaul, in the BMA Blog in the BMJ opines: A crisis acknowledged and a political choice

Last week, in a speech at the NHS Providers conference, Simon Stevens – chief executive of NHS England – broke ranks from his political masters and laid bare the full extent of the crisis in the health service.

Far from the ‘we’re spending more than ever in the NHS’ rhetoric, or the illusory mantra of politicians promising world-class convenience on second-class funding, Mr Stevens was unequivocal that the NHS was broken, declaring that the current budget ‘…is well short of what is currently needed to look after our patients and their families at their time of greatest need.’

He was openly critical of the impact of austerity on the NHS, describing it as ‘the exceptional choking back of funding growth of the past seven years.’

He mirrored the BMA’s own analysis of the NHS being woefully underfunded compared to European counterparts, arguing: ‘If instead you think modern Britain should look more like Germany, France or Sweden then we are underfunding our health services by £20bn to £30bn a year.’

Indeed I felt a sense of ‘at last’ in hearing language that could have been lifted from the BMA’s own NHS at breaking point campaign.

And as Mr Stevens made patently clear, we are not arguing simply about a number here but about the impact on the health of millions of lives, including explicit government priorities, saying that ’on the current funding outlook it is going to be increasingly hard to expand mental health services or improve cancer care’.

He went further to state it was a ‘duty of candour’ – relating to speaking up when patients were at risk – to ‘explain the consequences’ of this starvation of funds to the NHS.

He also spoke of the impact of inadequate resources on workforce: ‘On the current budget, far from growing the number of nurses and other frontline staff, in many parts of the country next year hospitals, community health services and GPs are more likely to be retrenching and retreating.’

And instead of the usual DH pronouncement of a wishful 5,000 more GPs he was candid: ‘GP numbers over the last seven years have actually fallen but their workload has risen’ – exactly what the BMA GPs committee have been warning of repeatedly.

Mr Stevens also argued for the ‘clinical and the financial logic for integrated care rather than fragmented competition’ – in doing so he reflected 25 years of BMA lobbying opposing the market-driven purchaser provider split.

I hope that he will now go one step further and unequivocally call for an end to competition law enshrined in the Health and Social Care Act – only that will put an end to fragmented care and the billions wasted in the transaction costs of competition.

It is these procurement rules that allow private companies to provide cherry-picked services in the NHS, and also mean that the future proposed accountable care organisations could be sold off to multinationals.

Mr Stevens speech crucially reinforced what the BMA has always argued – that with the UK being a leading health economy globally, the level of funding of the NHS is a political choice by Government. He said: ‘No-one disputes that these are choices that a chancellor could make.’

More specifically he claimed that next year’s funding gap is likely to be £4 billion, citing the analysis of three leading think tanks (the King’s Fund, NHS Providers and Health Foundation).

He asserted this should not be a challenge for the politicians, since it would only bring the NHS back to historic norms. ‘[The independent analysts] show there’s nothing out of the ordinary about needing such a sum. In their words, it would just be a return to the average increases of the first 63 years of the NHS’ history.’

Mr Stevens also rightly reminded government of the promise to the nation of an extra £350m per week paid into the NHS to leave the EU – at a time when indications show the antithesis that Brexit is likely to act as a further drain on NHS resources.

He called on the Government to meet this funding pledge on the fundamental matter of not undermining public trust: ‘You voted Brexit, partly for a better funded health service. But precisely because of Brexit, you now can’t have one.’

It is probably no accident that Mr Stevens’ comments came ahead of next week’s budget; so it’s over to the chancellor, health secretary Jeremy Hunt and the prime minister. The case for investment is overwhelming, as is the daily experience of an NHS that is failing patients, doctors and other NHS staff.

The Government has a choice, of whether to acknowledge the evidence it faces and whether to heed the clear message from the boss it appointed to run the NHS. And a choice between punishing patients or belatedly properly funding the health service this country needs, deserves and which the government itself has promised.

Chaand Nagpaul is BMA council chair

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Disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

We are facing disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

Emma Forde for the BBC News 12th November 2017: ‘I’m dealing with life-threatening situations – but I’m not a clinician, I’m a mum’

Hayley Smallman’s 15-year-old daughter Holly has a series of complex, life-limiting health conditions.

Her cerebral palsy, chronic lung disease and epilepsy mean she needs 24-hour care at their home in Liverpool.

It is estimated there are 40,000 children like Holly living with life-limiting and life-threatening conditions in England alone.

Many of them need palliative care round-the-clock, which is largely provided at home by their families but with the support of community children’s nurses and community paediatricians.

‘Alone and scared’

Hayley says: “I have a community matron and a community physio. They work Monday to Friday, 9am till 5pm. They are great.”

But when it comes to out-of-hours and weekends, Hayley says she is left without any support…..

On the same day: ‘Postcode lottery’ for dying children’s care, report finds

Families of dying children lack support because of a “postcode lottery” in palliative care services, according to a report.

The Institute for Policy Research says 49,000 children have life-limiting or life-threatening conditions in the UK.

The report says Scotland is “leading the way” in ensuring the right care is available to all, but the rest of the UK must follow suit.

The government says it is committed to tackling end of life care variations.

The IPR, based at the University of Bath, blamed a “piecemeal” approach to polices around palliative care and helping the bereaved for a wide difference in services across the UK – notably for children.

According to children’s charity Together for Short Lives – which contributed to the report – seriously ill children are “being forgotten or ignored” by nearly one in ten clinical commissioning groups (CCGs) in England as important services are not being made available.

Only 73% of CCGs provide palliative children’s nursing out of hours and at weekends, meaning children have to go into hospital rather than be treated in the community, the report found…..

…James Cooper, public affairs and policy manager at the charity, said: “The way in which children’s palliative care in the UK is planned and funded represents a postcode lottery.

“The current policy and funding environment has failed to adequately acknowledge the needs of these children, their families, or those that work to support them.”

He said families of children with life-limiting conditions have to co-ordinate a “vast array of professionals and agencies” for the care their children rely on.

“While a number of positive policy initiatives are being developed by the UK’s governments and other agencies, more work is needed to make sure that they bring about more joined-up plans, assessments and services with children and families at their centre,” he added.

The IPR report praised work in Scotland where the government is investing £30m following a pledge to provide palliative care for all who need it by 2021, “regardless of age, gender, diagnosis, social group or location.”

But it criticised the rest of the UK for being “ill-prepared” for the ageing population, and left with “disjointed policies” for people of all ages.

The report’s lead author, Dr Kate Woodthorpe, said: “For too long we have been complacent about death’s social and economic consequences, and our policy responses.

Government can no longer ignore the many, many challenges outlined in this brief.”

Other issues highlighted in the report

  • Only one in six employers have policies in place for employees providing palliative care for someone with a terminal illness
  • Growing funeral poverty – 45,000 people annually seek help from the state to meet the cost
  • A lack of burial space and concerns regarding crematoria capacity
  • One of the lowest rates of organ donation in Europe, while more than one in ten people die in the UK before they get the transplant they need
  • Nearly two-thirds of the UK population do not have a will

The report said the example of the devolution of powers and resources to Scotland offered a framework to tailor services to local populations and allow best practices to be shared.

“National and regional devolution is showing early indications that innovation and modernisation is possible, and Scotland is arguably leading the way with ambitious targets and re-organisation of key policy areas,” added Dr Woodthorpe.

“It is up to the rest of the country as to whether they wait to see how well Scotland fairs, or whether they use this as an opportunity to review, consolidate and improve how they support dying, death and bereavement.”

Scotland’s Health Secretary Shona Robison, said it was “extremely heartening” to be recognised by the report, adding: “It is a tribute to the compassion, commitment and dedication of those working across our health and social care services.

“To achieve our aim it is essential we create the right conditions nationally to support local communities in their planning and delivery of those services and support – to help ensure that the unique characteristics of each individual and family are met.”

The Department of Health said it had made a commitment to address variations within end of life care, including investing £11 million from NHS England into funding for the Children’s Hospice Grant.

A spokeswoman said: “We want all children and their families to receive high quality, compassionate and tailored care at the end of their life, regardless of where they live. That’s why we have committed to improving care in all settings.”

Update 12th November – And I forgot to mention child and adolescent mental health. A letter from an exasperated mother in the Sunday Times reads:

Psychiatry crisis takes toll on young anorexics

The woeful provision for young people with eating disorders led to my daughter being transferred in March to Edinburgh — even though we live in Hampshire (“Crisis in child psychiatry as vacancies soar”, News, last week).

It is totally unsustainable and she cannot build a life outside while she receives care. In early summer she was ready to move on but beds and/or funding were not available, so she has relapsed and lost hope.

This happens to patients time and again; hence the cyclical nature of anorexia. As a mother, I feel I am fighting on all fronts every day to get the right treatment for my daughter — with her condition and her daily or future care — while also dealing with grief and sadness for all that has been lost for our daughter and family, and the fears over what lies ahead for her.

There is a desperate need for more inpatient beds and a variety of treatment settings community, acute or inpatient and step-down) in which there is a greater range of therapy options to enable all the complexities of the illness to be addressed. One size does not fit all.

Incentives to train more psychiatrists, mental health nurses and support workers, plus a specialist eating disorders pathway for therapists, are essential.
Jemma Perkins, Andover

Private health care variations in price, access and quality… as the safety net fails

Anna Hodgekiss dramatizes for the Mail with the headline: Scandal of private health sharks overcharging their patients by up to £12,000 but it is evident that, as the safety net fails more frequently, that those who have the means will use them to get better treatment. Speed (avoiding waiting lists) and choice (consultant not junior) and fewer complications (less infections in private hospitals) mean we are morphing to a two tier system. Differences in outcomes between those with means and those without could well lead to civil unrest. Exactly what Aneurin wanted to avoid. Bringing back fear?

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Patients who pay for private surgery are falling victim to massive price variations of up to £12,000 for the same procedure.

A report by medical industry experts shows that depending on the provider and location, the quoted price of a total hip replacement ranges from £8,945 to £14,880, while a commonly performed varicose vein procedure can cost anything from £1,995 to £4,340.

However, a Mail on Sunday investigation has found that patients are often being charged several times this amount, with one woman quoted £15,000 for a vein operation.

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A Mail on Sunday investigation has found dramatic differences in the costs of private health treatment with a £1,500 difference in the bill for a simple back operation

There can even be a near £1,500 difference in the cost of simple back pain injections, and the bill for cataract surgery can almost double from one place to another.

The figures relate to the amounts that self-pay patients – rather than those having procedures covered by private insurance – are having to fork out for treatment

An increasing number of desperate Britons are being forced to self-pay as NHS rationing cuts deeper and waiting lists grow ever longer. More than four million people are currently waiting for NHS surgery – the highest figure since 2007 – according to NHS England.

And in October it was revealed that patients in Northern Ireland are waiting up to three years for an initial consultation about having surgery, following a GP referral.

The report, published by Private Healthcare UK, predicts that the self-pay market will surge over the next five years.

The Mail on Sunday also reported last month that record numbers of Britons are shelling out up to £15,000 for vital operations after being told they must wait for months by NHS hospitals.

In total, patients are forking out £623 million a year for self-pay treatment. They are cashing in ISAs or pensions, taking out loans and even ‘maxing out’ credit cards to fund treatment they should have had sooner on the NHS.

Experts are urging private patients to shop around after the report – which gathers data that providers are now obliged to publish – found alarming differences in prices. For example, the bill for an injection of local anaesthetic and steroids for back pain ranges from £950 to £2,370, while a knee replacement can cost anything from £8,750 to £15,410. Meanwhile, the quoted guide price of cataract surgery for one eye varies across the UK from £1,850 to £3,350.

The report highlights that the cheapest providers are specialist centres – day surgery centres for procedures such as steroid injections, veins and optical surgery – as opposed to private hospitals offering a range of services.

Some providers, including Spire and Nuffield Health, have prices that vary so much that they are often listed as both the cheapest and most expensive option, depending on the location of their centre.

For example, the highest bill for cataract surgery is found at Nuffield’s hospital in Exeter, where the procedure costs £3,350 for one eye. Yet the cheapest provider in the South East is the company’s Chichester hospital, where the same operation costs £2,090.

Keith Pollard, chief executive of Private Healthcare UK, said the figures emphasised the need for stringent research before committing to any hospital or clinic. ‘There has always been a wide variation in pricing,’ he explained. ‘But companies are now being ordered by the Government to publish their prices on their websites.’

When asked about the huge disparity in pricing, Nuffield Health said: ‘Our prices vary according to surgeon and anaesthetist fees and local market conditions.’ Spire Healthcare refused to comment.

Mr Ian Eardley, vice-president of the Royal College of Surgeons, said many desperate patients who did not fit the criteria for NHS treatment were now opting to go private if they could afford it. ‘There are some elective procedures, such as hip and knee replacements, where patients are being denied access due to local NHS policy. They may be told to go away and lose some weight before they are eligible,’ he said.

‘With procedures such as varicose veins, cosmetic appearance is no longer enough to get surgery. You must be at risk of developing other symptoms, such as painful ulcers, in order to be considered eligible on the NHS.’

Six things every self-payer needs to know

1 Mr Ian Eardley, vice-president of the Royal College of Surgeons, says: ‘Ask a potential surgeon how frequently they operate and what their results are.’ Details of how many procedures a surgeon has done and what their results are can be found on the NHS Choices website.

2 ‘If you are offered a new procedure, approach it with caution,’ urges Mr Eardley. ‘Don’t be afraid to get a second opinion or ask to speak to other patients who have had it.’

3 If you are going to be in hospital for a few days, stay in one with low infection rates. ‘Every hospital will have been assessed by the Care Quality Commission and you can read the report on the CQC website,’ says Mr Eardley.

Lower prices don’t always mean lower quality: clinics that specialise in a limited number of procedures can offer savings.

Check the Private Healthcare Information Network (phin.org.uk), which compiles information such as hospital performance, patient satisfaction and CQC rating.

Ask about hidden extras. What happens if something goes wrong? Is follow-up care covered? Make sure you and the surgeon are on the same page in terms of what you consider a successful outcome. For example, improvement in variables such as pain, movement and quality of life.

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Suicide clinics a preserve of middle class A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

Sarah Kate-Templton reports on a form of inequality and class division in the Sunday Times. The division extends to the preservation of wealth, as planned deaths can save many thousands of pounds of family savings. These are then distributed amongst the children after inheritance tax. Have you, reader, made out an advanced directive yet? Is this rationing by wealth?

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The Sumday Times 112th November 2017: Suicide clinics a preserve of middle class – A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

Margaret Wicks was quiet as she ate her final meal with her husband, son, brother and nephew. The family had booked a table at a fine hotel overlooking the Rhine in Basel, Switzerland, but Margaret’s husband, Tony, admitted that “it didn’t go very well; too much hanging over us. There was a cloud.”
Tony Wicks often ponders what his wife was thinking during that Sunday lunch in November 2015. Margaret, 83, had multiple systems atrophy, an incurable neurodegenerative disease.
The retired company director and former chairwoman of her local Conservative association could not walk, had trouble swallowing and was unable to speak properly. She could not join in the general conversation.

The next day she had an assisted death at Lifecircle, a clinic in Basel. She took an intravenous sedative by pressing a lever as her family watched.

Tony, 83, a retired engineer from Hampshire, said: “Margaret did not want to leave this world or me, but repeatedly said that the alternative would be worse as the deterioration continued.

“Margaret felt that she was becoming so limited in her abilities and had very little left of anything which she could enjoy that she decided to end her life while she could do so and she asked me to help her end her misery. She wanted out.” Her death is discussed in a report to be published tomorrow by Dignity in Dying, which campaigns for the law to be changed to allow assisted dying in Britain.

The report, How the UK Outsources Death to Dignitas, finds that an assisted death at Lifecircle or at Dignitas, the best known Swiss assisted dying clinic, is not available to all those who want it.

The average cost of an assisted death is £10,000 and most people cannot afford it. The report finds a lottery in the co-operation on offer from doctors, with some refusing to talk about an assisted death while others discreetly help to plan it.

The report also features Paul Smith, 59, who died from prostate cancer in September 2016. He desperately wanted to end his life in Switzerland.

Unlike Margaret, however, Paul, a steel worker from the West Midlands, was unable to get the medical records he needed from his GP or hospital consultants. In the end he gave up his bid for an assisted suicide and died in agony.

Paul was being cared for at home with the help of a hospice. His wife Julie, 47, said: “It was exactly as he feared. He was absolutely in agony. He really suffered. I was trying to give him more morphine. It just wasn’t enough. He felt like he couldn’t breathe, so was gasping for breath. He shot up out of the bed and collapsed. He was gurgling. He was frantic. He was wild-eyed and petrified and flailing around, and that is a terrible memory I have.

“It was horrific and about the furthest you could get from the peaceful death that he had wanted for himself.”

Julie recalled the palliative care worker holding his hand and saying: “Trust us. We’ll make sure you are not in pain.” She added: “They didn’t deliver on that.”

Dignity in Dying says the administrative process of arranging an assisted suicide overseas can be difficult. Obtaining the necessary paperwork by navigating the bureaucratic systems “requires knowledge and skills that favour the sharp-elbowed middle-class”.

The report also claims that the need to be physically able to travel to Switzerland to have an assisted death means people are ending their lives much sooner than they might otherwise choose to.

Kit Malthouse, Tory MP for North West Hampshire, who wrote the report’s foreword, said: “It’s time the UK stopped outsourcing its compassion to Switzerland.”

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.

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would the British public be happy to swap a shorter GP consultation time for a longer one that involved payment of it and additional services?

The quality of your GP appointment is important. This of course includes clinical skill, communication and cultural affinity, and understanding “where the patient comes from” or in RCGP terms their “ideas,concerns and expectations”. Older and more complicated patients need longer than 10 minutes, but the RCGP exam is predicated on this time for each consultation. Brutalising the profession is also brutalising the patient, but this is more likely when there is general and longstanding undercapacity. Sweden and New Zealand have shown that co-payments reduce demand. A pragmatic compromise thus encourages patient autonomy and self-sufficiency, allows resources to go further, and consultations to be longer. Should the price to ration appointments by co-payment be equivalent to two pints of bitter ad a packet of 20 cigarettes?

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Sarah Kate-Templeton reported 8th January 2017: GPs tell patients: Just one illness per appointment and then Chirs Smyth, also in The Times, reported 9th November Patients in Peru get more time with their GP than in Britain

LENGTH OF GP APPOINTMENTS – A Times letter from Annika Nestius-Brown 11th November 2017
Sir, You report that British patients visiting their GP are allocated half the time of people in places such as Sweden, where patients are given 22.5 minutes (“Patients in Peru get more time with GP”, Nov 9). What is missing from this information is the context. How and why can Sweden offer this superior service? Perhaps it is because patients in Sweden pay part of the cost of visiting their GP at each visit, and do so even if they are unemployed, a pensioner or a child. Patients in Sweden also part-pay for their stay in a hospital, such as in the case of my 76-year-old father, who received a nominal invoice for his week-long stay when he had a brain tumour removed last year. Moreover, some local authorities in Sweden also charge a small fee for transport to the hospital by ambulance or helicopter.

In Sweden, not even the chronically ill two-year-old child of a single unemployed parent is exempt from prescription charges, although these are capped at an equivalent cost of about £100 a month.

Which raises the question, would the British public be happy to swap a shorter GP consultation time for a longer one that involved payment of it and additional services?
Annika Nestius-Brown

London W14

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