Category Archives: Rationing

Doctors are being asked to play God…….. The FT thinks it has the solution…

Philip Stevens in the FT reports: Doctors are being asked to play God – The coronavirus pandemic is presenting hospitals with a terrible choice about whose life to save

web_Nursing coronavirus balance
So who decides between life and death? As the Covid-19 outbreak threatens to overwhelm healthcare systems, it also presents a harrowing human dilemma. We have caught a glimpse of this in Italy. Distilled to its essentials, it can be expressed more or less as follows. Doctor A has one ventilator and two patients in the grip of the coronavirus. Arriving first at the hospital, patient B, a 65-year-old retiree thought to have only a slim, albeit still measurable, chance of survival, is being kept alive on the ventilator. Patient C, a 35-year old teacher who arrived later, is deteriorating fast, but is judged to have a high chance of recovery if transferred to the ventilator. ….

And the FT then opines that it has the solution: How to avoid rationing urgent healthcare during the Covid-19 outbreak

But I’m afraid you will have to buy or register to get the answer.

Ruling political parties will never plan for long term health in our FPTP system. The political parties need to take away the gag from the mouths of their politicians.

Ruling political parties will never plan for long term health in our First Past The Post ( FPTP ) system. Countries that were nearest to the SARS and other viral epidemics, have planned best. Most countries, even those with various PR systems have planned inadequately. Singapore has had a plan, and even there a second wave is possible, but they have far fewer first wave cases. Thus their medics will be much more able to cope. But any form of PR must give a better opportunity to plan than the current UK system. The planning extends from viral epidemics, to manpower, and to financial stability. It is also evident that the “Honest Debate”, asked for by Mr Stevens in 2014, has not been able to take place. Rationing is now common parlance in the media, but not amongst politicians. 

The political parties need to take away the gag from the mouths of their politicians. Their failure has led to a deep abscess in a root canal of a rear molar. If its not removed the whole body will get worse…

See the source image

March 2020: Hardship…? Lets seize the opportunity for more much needed change..

May 2015: Setting sail in a boat already holed. The new government will fail unless it rations health. Proportional representation would be better than the inevitable mess to come..

Dec 2019: A toxic amalgam of 4 “health and social care” services

Nov 2019: A curse on all their houses. Banal debates omit the really important questions. Entertainment has come before long term politics and unity..

and Health services and elections.. PR will give fewer changes in philosophy and bring back trust.

June 2018: How did we get to this? What manpower planning failure. Please let Health Service visas be dependent on good language and cultural awareness.. and integration

and  Jan 2018: Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

Nov 2017: We are creating a “caste” of doctors – by neglect. Neglecting to change our electoral system is equally crass..

Apr 2017: The contestants – who will promise the most irrelevant package? Listen and (later) read their prospectus.

March 2017: The UK Health services are facing a “dead end” – both literally and figuratively if we don’t accept rationing.

Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

See the source image

A changing opportunity for the four UK health services.. Solution: avoiding paternalism, for rationing, and for financial probity.

This type of social revolution brings some good thoughts from our media correspondents. Whether their thoughts are translated into action is another matter. Populism, embraced by leadership in the UK, is aware that by changing the services so that they are founded on a rock will be traumatic, controversial, and lose them votes because the opposition will pounce on them. Co-payments – no way. Rationing – never happens, Standards – always rise! These are lies that need to be exposed and debated in an open society.

Lets start with standards. In a short article hidden in a small side column on the Times 4th April, and not on line, :

Medics’ Extra Insurance: Doctors have been given extra government assurance for lower care standards and a commitment that regulators will be lenient on failures at the height of the pandemic. In a letter to medics, seen by The Times, health authorities acknowledged that satff may “need to work in different ways”, adding “We do not want indemnity to be a barrier to delay to such changes”.

Well let me tell you that not only hospital doctors, but also GPs are taking extra risks. For a start not examining the patient and relying on phone and video calls raises the risk. I wonder if GPs, already in meltdown before the crisis, are going to be absolved if they make the inevitable error. We should go the whole way and have no fault compensation.

Co payments. Well Janice Turner  on 4th April in the Times in This fad for fitness could last a lifetime – All the generations are coping with their fears by trying to improve their health, which will be good news for the NHS

….The one notable downside of the NHS is it leads to physical complacency. If we get obese, diabetic, develop joint problems or high blood pressure we just see a GP and are treated “for free”. No need to change your lifestyle: pop a statin. An NHS physio told me patients expect to be fixed in a single appointment, rarely doing the therapeutic exercises at home. Writing about diabetic amputations, I met nurses begging high-risk patients not to live on chocolate bars, and a surgeon who eventually cut the limbs off patients who’d carried on smoking even after losing several toes.

Ms Turner exposes the achilles heel of the paternal society that is the 4 UK health systems. One that even Anneurin Bevan recognised, but felt he had to put up with to get his bill through. We do not encourage people by stick, as well as carrot, to look after themselves.

And rationing: In Paul Nurse opinion in the Times 4th April: ‘Boris knows he’s out of his depth. Suddenly experts are useful again’

…The country is, he warns, paying the price for ten years of austerity. “If you’re always strapped for cash, you will invest in what’s going to be needed next week, and not what might be needed in ten years.” Too often, the political debate about the NHS “focused too much on short-termism — what money can be saved here — and you do have to have a longer-term perspective,” he says. The calculation that “we’re tying up money in something that is unlikely to be used . . . is OK if you’re running a business, but it isn’t so OK if you’re running a healthcare system”.

The pandemic also, he argues, proves the importance of “left-field” scientific research that may not be immediately useful. “I work with yeast, and people think that’s utterly useless. But what we discovered some years ago is what controls how a yeast cell divides . . . and then we showed that’s the same in humans. That is absolutely critical for cancer.”

The next big challenge is to create a coronavirus vaccine.

It needs more money, resources, people and plant. But we cannot afford it if “Everything is free for everyone for ever”.

Kat Lay in the same paper thinks that the Pandemic is set to future-proof the NHS

but NHSreality would contend that is only if we face the issues above honestly.

…New ways of working, including centralised hubs co-ordinating cancer care, are likely to persist even after the pandemic has passed, experts say…..

…He estimated that even after the pandemic, up to half of GP appointments would be online or by telephone.

Efforts are focused on how GPs can access patient records securely from home, with many having to travel to surgeries to conduct remote appointments…

Hospitals, too, have moved outpatient appointments online. The move ties in with a pre-pandemic ambition to reduce travel and thus air pollution.

Pando, a communications app for healthcare workers, is being downloaded by more than 1,000 doctors daily.

Last week, Matt Hancock, the health secretary, wrote to all NHS organisations giving them legal backing to set aside the normal confidentiality for patients until at least September if sharing patient data was deemed relevant in helping the fight against Covid-19.

 

 

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!

See the source image

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

Image result for dishonest health cartoon

 

The NHS.. can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”).

How refreshing to read a correspondent who does not comply with the collusion of denial that most writers in the newspapers have with politicians. Perhaps Dominic Lawson can start the honest debate which Mr Stevens wants, and perhaps then we can debate if it should be covert or overt. I have a medical friend who genuinely believes rationing should be covert, and that citizens will only worry about what is rationed out. My answer is that rationing does not have to be of the same design for everyone. It can be means based, or income based, or a combination of both, but rationing by waiting list and post code is much worse. If this is agreed and is overt, we will have some sort of plan structure on which to base the new health service that emerges after Covid19. 

Dominic Lawson opines in the Times 29th March 2020:  All lives aren’t equal, but we still want them saved – Although the NHS favours youth, society will not abandon the old to Covid-19

The pathogenic micro-organism known as Sars-CoV-2 presents as an invisible but global Dick Turpin. Your money or your life. Here, opinion (in the media if not the nation as a whole) is fast dividing between those who think more of the loss of income and those who worry more about sparing lives.

This debate is intensifying as soaring unemployment (in America last week alone there were 3.3 million new benefit claimants) reveals the price of closing down all businesses dependent upon the interactions made impossible by anti-infection “social distancing”. In Britain, the astonishing measures of income support launched by the chancellor of the exchequer amount to a vast claim on future taxpayers (every pound of it is an addition to a national debt that must eventually be repaid).

But what amazes me is how few people seem to recognise that this dilemma — your money or your life — is a constant feature of the National Health Service. The coronavirus policy dilemma merely sheds a particularly harsh light on it.

As directed by the National Institute for Health and Care Excellence (Nice), the NHS will agree to fund non-palliative treatment for the seriously ill only if the drugs provided (for example) do not cost more than £30,000 in providing a further year of good-quality life. This is known as a Qaly (quality-adjusted life year). Since those with potentially terminal illnesses don’t have a good quality of life, that £30,000 limit would typically be cut to £15,000 per annum in their case — two of their years being regarded as of the same monetary value (in health accounting terms) as one year for an otherwise fit person.

As Sir David Spiegelhalter (who for decades ran the Medical Research Council’s Biostatistics Unit) put it to me: “It’s a myth that all lives are considered equally valuable in the NHS. The system already values years of remaining life given by treatment. So triage would be normal.” What Spiegelhalter means is that if the coronavirus crisis leads to a situation in which an older person is essentially left to die, in order to provide a scarce ventilator to someone with a greater life expectancy, that would be a graphic demonstration of the working model of the NHS.

This sort of calculation also governs expenditure on road-safety measures by the Department for Transport (DfT), under the formula known as the Value of a Statistical Life (VSL). The government will fund a new junction if it estimates that it won’t cost more than £1.3m per future life saved. Obviously, if your child gets killed because the DfT had worked out that the junction you and your neighbours had campaigned for was unjustifiable as it would cost more than £1.3m per likely life saved — well, you would not be consoled by the knowledge that they had dutifully followed the VSL guidelines.

But these calculations are the inevitable consequence of any system in which resources are centrally allocated according to need (rather than a market system in which individuals can pay any amount for what they want — which is not the same as need). This is especially true of the NHS, a centralised, free-at-the-point-of-use system unique in the western world, which can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”). Queuing is one form of rationing: on average, citizens are waiting four-and-a-half months for a hip replacement operation on the NHS. There is no measurable risk to their life expectancy with such a delay, even if the chronic pain of those on the waiting list may feel unendurable.

These are, by and large, the same old people whose lives are now at greatest risk from the coronavirus. The average age of the thousands killed by it in Italy is 79.5 years. This is what is driving many to say to our Dick Turpin pathogen: I’ll keep the money, please, if it’s all the same to you. Of course, they don’t mean that they are happy to die from the coronavirus and keep their money: only that they don’t want to see the nation’s economy suffer a hugely expensive shutdown in order to save the lives of people they don’t know and with not that many years left anyway.

Or, as one American health economist put it to me: “If the shutdown costs the UK 4% of GDP, that is equivalent to $104bn. If you didn’t shut down, according to your government’s advisers at Imperial College, that would cost about 230,000 more deaths from the coronavirus. I estimate those people who were saved would need to live for another 15 years on average to meet the Qaly limit of no more than £30,000: and given that the life quality of the unwell over-seventies is considered half that of a healthy younger person, that means they would on average need to live for another 30 years to justify the $104bn hit to the economy. If you spent all that money on NHS treatment across the board, you would save millions more life-years.” Besides, he added, if the UK had not pursued an economically toxic policy of enforced social isolation, the majority of those most vulnerable to the virus would be among the 620,000 anyway projected to die this year, from all causes.

But, I pointed out to my economist friend, if social exclusion had not been enforced by the government, the economy would still have taken a colossal hit, not just because of what was happening in other countries but also because of the public’s autonomous response to the risks of infection. And the first opinion polls taken on the matter show a remarkable 93% backing Boris Johnson’s latest, draconian measures.

It is not hard to understand why. None of us are creatures of pure reason. Logically, we should not put a high value on the last years of seriously ill relatives (or our own). But as the authors of a 2013 BMJ paper on Nice’s end-of-life criteria wrote, in some perplexity: “In a choice experiment . . . a gain in life expectancy without a gain in quality of life was preferred to an increase in quality of life with no gain in life expectancy, suggesting that focusing on extensions of life, rather than improvements in the quality of life, may be consistent with societal preferences.”

The government, since it comprises politicians, gets that. What it also gets is the likely reaction of the British people if a less dictatorial policy — combined with a gross insufficiency of ventilators — led to a situation akin to Italy’s, where thousands of old people have been abandoned to a horrible end, in effect waterboarded to death by the coronavirus as their lungs filled with their own blood and fluids.

In short, Boris Johnson would not just be suffering with the virus himself. He’d no longer be prime minister. The voters will accept only so much health rationing.

Hardship…? Lets seize the opportunity for more much needed change..

There is now an exceptional opportunity afforded us to change the country. Our world is changing. Lets seize the opportunity for more much needed change.. A local family had their daughter’s advice: stay in and have plenty of vitamin C and Zinc filled supplementary foods. These are meant to help prevent or reduce viral load. They will find it hard to change their ways, self isolate, and survive. This elderly couple were born at a time when there was rationing, and when the country was emerging from hardship. We are entering a period of hardship again..

See the source image

Meanwhile, assuming a few of us survive, what opportunities are there in the post CV19 world? When I first started to compile this list I missed out health!

There is a great opportunity to reconfigure the health care system so that citizens are more autonomous, and responsible for themselves. The converse also applies, that the state should be less paternal, especially for cheap and cheerful conditions and services/products.

Make people more responsible for their own health

Make the state less paternal Be honest in saying what it will not provide.

Land Rental Tax – to replace Property Stamp duty, and inheritance tax.

Proportional Representation in two houses with staggered elections. Abolish the Lords.

Make towns and cities much more bike friendly (priority?). Make them less car friendly.

Universal Airline Fuel Tax ( more than highest domestic petrol tax)

Litter picking by Individuals in their areas..

Identity Cards

Shared car schemes

Community group support

Longer term planning and abandoning First past the post electoral systems

Over rather than under capacity in health.

More doctors and nurses

Asset and income related copayments for public services

Reassessment of the business model: more cooperatives owned by staff.

Increase price of food.

Increased appreciation of environment

And funding for it

Lower price of properties

A less unequal society

Bank reform: separate normal banks from investment banks

Make pension funds, including those for state employees, real .rather than Ponzi schemes

Make fund managers repay their bonuses.

See the source image

 

See the source image

Supply and demand: the gap has never been addressed

Rationing long term.

A former chairman of the GMC fitness to practice tribunals comments in the Times letters 23rd March 2020:

A matter of life and death
I am retired, but I worked through three large-scale flu epidemics, when the death rate was huge. This new virus means that, for the first time in several generations, the public, the government and doctors are being forced to confront the gap between medical demand and supply.

For decades there has been rough equivalence: if you have a disease, sooner or later you get treated. Now, suddenly, we must accept that for a whole section of the population, supply of care cannot meet demand.

Triage must happen, with treatment reserved for those who can survive. Those of us who cannot, or are unlikely to — and I am one of them — must take what comes.
Dr Tim Howard, Former chairman, General Medical Council fitness to practise tribunals