Category Archives: Rationing

NHSreality response to the RCGP Questionnaire into the future of Welsh health and social care

This is NHSreality (my own) response to the questions asked by the RCGP in Wales:

1. What matters most to you about health and social care services, and what should we concentrate on to make things better?

An honest language in health and social care rationing. We need to make it clear to citizens what is not available. This might be different for people of different means, but it needs to be overt. (We also need exit interviews conducted by an outside and independent Human Resources body, reporting both to the WG and to the Media in a depersonalised way.)

We need more doctors and nurses, physios and psychologists, all trained in the UK.

2. What do you see as working well?

Very little. Every service is under strain. What continues to work well is the denial of politicians and administrators, the gagging of staff, and the inability of the press and media to sustain a debate on a complex subject.

3. Can you think of any new ideas and good practice you have seen, that could be copied more widely?

I was in the habit of offering “open access” to psychiatric patients before I retired, on a Friday afternoon. I believe all practices would reduce their suicide attempt rate if this was accepted as normal practice. In hospitals I found that Friday afternoons were inadequately staffed (Flexitime?) and so if I was a CEO I would ask that all departmental meetings were ion a Friday afternoon, and have random phone checks on staff to see if they were present.

4. What problems are there in the current systems, and how do they show through in the services people get?

Everyone educated knows that the health systems of the Uk are unsustainable. What they do not know is the different rights of patients, outcomes, mortality and complication rates. These will become more evident over time as the WHO reports on 4 rather than one health system. Devolution has failed for Wales. Free prescriptions discourages autonomy. These problems show through in a disengaged staff, gagging and bullying, lack of exit interviews, particularly for consultants, top nurses and trust board members, but in general for all staff.

5. What do you understand by integration of health and social care and what do you think a fully integrated service looks like in practice?

There are risks in integration. These are made worse if rationing is not overt. Whilst the average citizen feels that he is covered for “everything for everyone for ever”, we will not get progress, or reality. I think that if we continue down the way we are, civil unrest is likely as systems fail, and important treatments are unavailable. Elderly, terminal, palliative, and mentally ill people are politically soft targets compared to those who will vote for many years.

6. What do you think stops improvement from happening and how could this be overcome?

Dishonesty and lies. Top officials unable to lead by articulating the truth. Disengaged staff who realise the whole of their health safety net is founded on sand, and holed.

This can only be overcome by new leadership, an honesty which is seen as a summary of the “hard truths” of a society where the technology is advancing faster than our ability to pay for it. This needs p[political permission and a long term approach to subjects such as manpower provision. The long term means longer than one or even two terms of office. Giving the people of Wales the opportunity to vote on reversal of devolution, returning to England and Wales, and having more money for health and education might help.

7. What more can people do to look after their own health and well-being?

Bring back prescription charges. Introduce ID cards with tax status on them, and a scale of fees related to income. This means waiting lists will have to be mush better/shorter and therefore such a  system can only be introduced once there is an “excess” or overcapacity in trained UK doctors. (preferably graduates)

8. What improvements can be made to information and advice to help patients make decisions with professionals about care?

The rules of the game need to change.. Look at NZ and Scandinavia.. for sustainability.

A limited list of drugs. if patients prefer off the list they pay. Many more therapists as an option instead of (not as an adjunct( to drugs. More public health consultants. One IT notes system in Wales, starting with General Practice, and then expanding into A&E, etc. It will spread like a cancer.

9. Please tell us about any ideas you may have that you think could deliver real improvements to services.

Focus on Friday afternoons. Have a Full Time service until 17.00 at least, and until 22.00 hrs for Psychiatry. Allow GPs to escape from QOF. Performance related pay is all very well for a short period of time (2-3 years) but after that it demotivates.

10. What do you think should be covered by national rules and what should be left for local managers and professionals to decide?

Local rationing of services has to come, and should apply to high volume low cost items. National rationing should be about (as few as possible) high cost and low volume services. In this way there is local “choice”, but as little post code rationing differences of important and fearful conditions as possible. Co-payments according to means could work once waiting lists are short and there is an oversupply of doctos. If patients are on the lowest possible income and unemployed they should still pay something for everything, but get it back in their next Social Security payment. the cost of all services should be on the obverse or at the bottom of the paper. Eg Out patients, Scans etc.

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Instead of talking therapies, lets shock them: Rise in electric therapy for treating mentally ill – Driving staff away.

The Health Services of the UK are understaffed in many (all?) areas. Nurses, Psychologists, Counsellors, Radiographers are considering their positions… Some may move abroad.. Rationing by deliberate undercapacity and restricting their income drives staff into the private world, or abroad.

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Kat Kay reports in The Times 19th April 2017: Rise in electric therapy for treating mentally ill

The NHS is increasingly turning to electroconvulsive therapy to treat patients with serious mental health problems.

In 2015-16, 22,600 ECT treatments were carried out, a rise of 11 per cent from the 20,400 in 2012-13. The number of patients treated also rose — to more than 2,200 — as did the average number of treatments per patient, from 9.6 in 2012-13 to 10.1 in 2015-16. The data, obtained by The Guardian, covers 44 NHS health trusts in England.

“I think [ECT] should be on the increase because it has been underused for years,” Tim Oakley, of the ECT Accreditation Service and a clinical director at the Northumberland, Tyne and Wear NHS trust, told the newspaper. “There are some patients who would respond very well to ECT who perhaps don’t get it as quickly as they should or don’t get it at all for various reasons. In terms of getting people better, particularly for depression where everything else fails, it is still the best treatment.”

A 2014/15 survey of patients found that 91.5 per cent improved after treatment and 1.7 per cent became worse. However, Mind, the mental health charity, warns that the therapy, which involves passing electricity through the brain, can have side effects including memory loss, poor concentration and dizziness. The National Institute for Health and Care Excellence advises that it should be used as a last resort.

Nurses vote on strike action after NHS pay cuts leave staff ‘struggling to make ends meet’ – The Independent

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When will public anger over the NHS reach a political tipping point? More NHS mental health patients treated privately…

It seems we are a long way from the tipping point whilst “most” services are up and running for the articulate and coherent. NHSreality has opined that “civil unrest” is not far below the surface, but whilst the Regional Health services can hoodwink their populations, and whilst citizens (mainly healthy) can remain in denial as their elderly and mentally infirm get a “rough deal”, and whilst the media and press, including Toynbee, fail to grasp that “overt rationing” is a pragmatic necessity, post coded and covert rationing will drive more and more into private care, and result in a two tier service. Harry may have had “counselling” but I expect it was private, unlimited, and done by a fully trained psychology counsellor. In the Health service it would be limited to six sessions, provided by a Nurse Counsellor who has done an extra short course, and terminated when the allowed sessions expired.

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Polly Toynbee in the Guardian 13th April asks: When will public anger over the NHS reach a political tipping point?

here is an ebb and flow in reporting on the NHS as Trump, Syria and Brexit dominate front pages. But the pressure-cooker state of the entire service still worsens. This morning’s latest figures are just a snapshot of deterioration – but every target is missed: for A&E, ambulance response times, for treating psychosis within a week, for cancer waiting times, blocked beds and diagnostic tests.

“Demand” is rising, the government says, as if serious illness were a choice, though the pressure comes from well-predicted, rapidly increasing numbers of old, sick people: this February’s A&E figures are, as ever, better than deepest winter January, but worse than February last year, as this crisis ratchets up.

Major A&E centres are treating 81.2% of patients within four hours, against a target of 95%, which used to be hit before 2010. The government likes to blame frivolous users of A&E, but those are easily triaged to on-site GPs. Serious delays are because of very ill people needing to be admitted with no empty beds: bed occupancy is at dangerous levels, as Chris Hopson of NHS providers warns, where doctors often have to decide “one in, one out”, discharging those who still need more care too early.

Take the temperature in virtually every part of the NHS and the wonder is how the heroically overstretched staff keep the wheels on the trolley. Take this week alone: the Royal College of Physicians says 84% of doctors have to cope with staff shortages and gaps in rotas.

GPs? Two years after a government promise of 5,000 more GPs, numbers are still falling. They dropped by 400 just in the last three months of last year: as doctors find the workload unmanageable some escape abroad, take earlier retirement or become locums. Too few new doctors want the burden of running a GP partnership, so 92 practices closed last year, tipping hundreds of thousands more patients on to already overloaded neighbouring GP lists.

Today the Royal College of Nursing, traditionally most reluctant of unions to take action, starts consulting its members on whether to hold a strike ballot. But with public sector pay frozen yet again at 1%, when inflation will shortly hit 3%, nurses are departing – as are doctors – for less stressful, better-paid work. Recruitment from the EU is plummeting, as predicted…..

…This is the dismal background to the reorganisation that the head of NHS England, Simon Stevens, is attempting, almost undercover. His state-of-play review of his five-year forward plan passed hardly noticed, announcing a first tranche of England’s 44 STPs, (sustainability and transformation plans) to reconnect local services fragmented by the Lansley 2012 act.

Most observers think it the right way to go, putting the NHS and social care under a united structure with one finance hub, ending destructive and expensive competition and tendering of services. But hardly anyone thinks this can be done with no new money: every STP calls for capital for new beds and units. Virtually all involve closures and mergers stirring a local political outcry.

Jeremy Hunt, who always presented himself as the patient’s ally, rooting out poor quality, wallowing in the Labour disaster at Mid-Staffs, has fallen uncharacteristically quiet. He has nothing much to say about patient safety in A&Es or elderly patients turned out of beds too soon. Not even deaths on trolleys in A&E corridors in Worcester roused his usual righteous ire.

Concern about the NHS has risen high in recent polling: what no one knows is when public anger will reach a political tipping point. Theresa May and Philip Hammond stay iron-clad adamant: all this is NHS shroud-waving and there will be no more money. Lack of any opposition helps, but can they really tough it out where Margaret Thatcher, John Major and Tony Blair all bent in the face of NHS crises?

Chris Smyth in the Times 18th April reports: Sick children ‘denied drugs to save money’ and Spendthrift NHS regions face big cuts. This is the reality of todays health services, and which/what quality of service depends on which. post-code you live in. You cannot plan for the deficit, because the “priorities” change from year to year.

George Greenwood for BBC 18th April: More NHS mental health patients treated privately


Appalling and shameful: Huddersfield and Cumbria Trusts in disgrace..

This exposes inappropriate and immoral rationing. If true, it is appalling and shameful: Huddersfield and Cumbria Trusts are in disgrace..

Sophie Borland and Rosie Taylor report 17th April for the Mail: GPs ‘bribed’ to NOT send patients for cancer tests: NHS pays millions for rationing hip ops, heart checks and even tumour scans

  • GPs are being paid millions to not refer patients for a variety of important tests
  • In a bid to reduce patient numbers doctors are being deterred from referals
  • The incentives mostly cover non-urgent referrals but some include cancer tests
  • Patient groups have deemed the payments ‘profoundly wrong’ 
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Doctors warn NHS is rationing best drugs to cut costs

Far better to have fairness in rationing so that all of us know what is excluded, wherever we live. Devolution and GP Commissioning have ensured inequality, and covert rationing of fearful conditions. Remember, drugs do not improve the health of populations… This is an issue for public health consultants, but are there any left?

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Jon Ungoed-Thomas in the Sunday Times 16th April reports: Doctors warn NHS is rationing best drugs to cut costs

Hospital doctors have revealed how some of the best available medicines are being rationed by the NHS in a cost-cutting drive.

Doctors including gastroenterologists, rheumatologists and dermatologists say they are being prevented from prescribing the most appropriate drugs by their local clinical commissioning groups (CCGs).

CCGs are already reducing the number of hip and knee operations by using pain thresholds to ration procedures.

Now a survey of 200 clinicians, commissioned by the drugs company UCB and conducted by ComRes, has found that seven out of 10 clinicians claim NHS funding pressures have restricted their ability to prescribe approved medications.

The Breast Cancer Now charity revealed last year that some women were missing out on a potentially life-saving drug that costs 43p a day. Bisphosphonates cut the risk of cancer spreading to the bone, but many CCGs have blocked their use.

Dr Thomas Sheeran, a consultant rheumatologist at the Royal Wolverhampton NHS Trust, said bureaucratic hurdles and financial restrictions were hampering clinicians. “It’s frustrating that the people we have to try to persuade are accountants and the CCGs,” he said.

In one case last year he said a woman at risk of going blind was turned down by her local CCG for £2,000 of drugs to save her sight. The woman was admitted as an emergency patient so the trust could pay for treatment.

The drug in question, infliximab, is approved for use by the National Institute for Health and Care Excellence (Nice) for some conditions, but the treatment for this patient was considered experimental.

Sheeran said another drug used to treat arthritis and approved by Nice, abatacept, was not being permitted by Wolverhampton CCG for some patients.

He said there were concerns that patients who were not given the most suitable drug were more likely to be readmitted to hospital, so the drive to cut the drugs budget was in fact not cost effective.

Patients are entitled to drugs approved by Nice for specific conditions, but there is often no national guidance and CCGs make their own funding decisions.

A spokesman for NHS England said: “As the NHS goes into the most financially challenging few years in its history, it is right that we strive to ensure maximum value for patients from every penny available, but ultimately these are legally decisions for clinical commissioning groups, informed by best evidence and national guidance where appropriate.”

A spokesman for Wolverhampton CCG said that although it could not comment on individual cases, “a number of individual funding requests have been approved for the prescribing of abatacept”.

NHS managers still growing as GP posts fall

The Observer reports 15th April 2017: Number of NHS managers still growing as GP posts fall again – Doctors say ministers’ ‘bureaucracy busting’ shakeup has failed to switch resources and manpower to the front line

The number of NHS managers has grown by almost 18% in the four years since the government introduced a “bureaucracy-busting” shakeup of the health service, according to the latest official data.

The rise of about 4,650 in total management posts since April 2013, when the controversial Health and Social Care Act came into force, contrasts with an alarming fall in the number of GPs over recent months at a time of unprecedented demand for health care. The figures have drawn criticism from the British Medical Association (BMA), who say ministers are failing in their central objective of shifting more resources and manpower from back-office posts to the front line….

Managers are at odds over rationing, and management recognises the case, but the “rules” don’t allow them to speak out.


Two tiers of access to important diagnostic testing: the future through a glass darkly?

There are too many tests done in Medicine, but these are done partly to exclude a sinister condition when this is a possibility, partly owing to the doctors anxiety not to miss something, and partly due to patient expectation. In the free “Everything for everyone for ever” medical care that pretends to exist in the UK, it is no wonder that anxious patients, aware of the possibilities (as opposed to probabilities) expect and demand access to investigations.

Early diagnosis often means the difference between life and death. This is why all these tests exist.

The waiting time(s) recommended in Wales and other UK regions is a maximum of 6 weeks. So if you can get a test in a day or two, this may well improve your chances.

The European Scanning Centre has just opened new equipment in Cardiff, and has sent a letter to all GPs in Wales. The letter from the European Scanning Centre is here, and courtesy of a colleague.

If you go for an early scan, and are found to need treatment it will be interesting to hear the interpretation of the Health Trusts as to where you should be placed on the waiting list for operation/treatment. According to the “rules” there should be no advantage in going privately. If you get one test / part of a process for a symptom privately, you should follow up and pay for the remainder. However, what if you have not got the policy/means to continue? Does the state put you to the back of the waiting list as if you waited the normal time, and only then operate? The patients you might be put ahead of may or may not have a diagnosis needing surgery, but you definitely do.

So this is just one aspect of a two tier health service, and with Wales having the longest waits and poorest outcomes, it is no wonder that a private company has seized the opportunity offered by an imploding Health Service.

What happens when there are private A&Es, and private GPs? Are we prepared, looking through a glass darkly, for the two tier future?

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