Category Archives: Rationing

The sticking plaster approach…. “….simply managing decline”.

We are going bust, and without rationing we will only dig a deeper hole. We face lower standards and continuing decline unless we address the reality that we cannot afford Everything for everyone for ever. 

The analysis at the bottom of the page in the Times is partly correct, and just needs to admit to failure if we fail to ration overtly. It is not on line, but the comments are worth attention as well, realising complexity. We already means test Social Care payments, so why not means test health payments? 

NHSreality is very concerned about the amalgamation of Health and SS into one budget, as this will make the need for rationing, currently covert, more evident. The health budget is beyond control, and growing exponentially…

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Joe Mellor writes in “London Economic”  18th June 2018: May’s NHS Brexit dividend is “tosh” & “a sticking plaster solution”

And this was also the approach of Rachel Sylvester: The timid and cowardly PM has ignored the urgent need for bold and radical reform of social care as well as health

….The Conservative splits over Brexit have left No 10 reeling from one political crisis to the next, rather than taking time to think of the country’s long-term future. “Every day is about survival,” says one former No 10 aide. “Theresa May was always cautious but her confidence and her political capital were completely destroyed by the election last year.” The row over the “dementia tax” during the campaign has created a neurosis in Downing Street about the funding of social care, but not dealing with this crisis will be more damaging for the country in the end.

On housing, prisons and immigration, the Tory leader is the “roadblock to reform” whose caution has become more entrenched with each Westminster disaster. Businessmen who visit No 10 find themselves repeating ideas that were received enthusiastically, but never implemented, on previous occasions. One compares it to Groundhog Day but leadership is about progressing rather than being stuck in the same place. “There are occasional flashes of radicalism — when she’s surrounded by the right people — but in her heart of hearts she’s a cautious person,” says one former aide. “It’s all about managerialism.”

On the NHS and social care, Mrs May must be bold rather than simply managing decline.

Kat Lay on June 19th reported in the Times: May prepared to reverse unpopular Tory NHS reforms

…Announcing a £20.5 billion annual increase to the NHS budget by 2023 the prime minister said that the government would “consider any proposals from the NHS on where legislation and current regulation might be creating barriers”. Last year’s Conservative manifesto had included a similar policy but change in this parliament had been thought unlikely.

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In a speech at the Royal Free Hospital in London she alluded to legislation introduced by the Health and Social Care Act 2012 that created hundreds of clinical commissioning groups, responsible for planning and purchasing health services, distinct from trusts that provided the care.

The reforms cost about £1.4 billion and were designed to to give GPs more power over the way money was spent on patients but they were criticised for being too complicated and disruptive. Mrs May said: “I think it is a problem that a typical NHS clinical commissioning group negotiates and monitors over 200 different legal contracts with other, different parts of the NHS.”

Chris Hopson, chief executive of NHS Providers, which represents hospitals, said: “The existing legislation continues to be a barrier to more integrated care and causes unnecessary bureaucracy, so we welcome the prime minister’s offer for NHS leaders to develop proposals for how the legislation may be simplified.”

Mrs May said that the structure of the NHS was too bureaucratic. She added: “Where legislation is making it harder for professionals from different parts of the NHS and different local authorities to work together we should be prepared to change it. Where it is resulting in overly bureaucratic processes we should be prepared to change it. And where it is making it harder to hold NHS leaders accountable for delivering better outcomes for people we should be prepared to change it. We must learn the lessons of the past and not try to design or impose change from Whitehall.”

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So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

Mrs May’s money will make no difference and will not create trained staff. If she admitted there would be no dividend for at least 10 years she would be more honest. 

What if she buys more scanners – where are the radiologists to report and where are the radiographers to provide, and the oncologists to define the treatment, and radiotherapists to treat?

Where is the plant to provide the projected radiotherapy needs?

So how will the money be raised, and how will it be spent, and over what time horizon does the government expect results?

….”to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

Without this no administration can win the hearts and minds of the professionals who man the system. They know the truth, which is that there has to be rationing; by exclusion, restriction, exception, reduction, prioritisation, etc. What we don’t like is unpredictable post-code rationing which differs for different people with the same condition.

Robert Colvile opines in the Times 18th June: Let’s talk about how NHS spends our money – An obsessive focus on funding ignores the importance of improving efficiency and results

Weeks — months — of furious speculation, and it all boiled down to a simple set of numbers. Would the settlement be closer to 3 per cent or 4 per cent? For five years or ten? Could Theresa May hit the magic figure of £350 million a week? Would Philip Hammond even let her?

Finally, we have some clarity. The NHS will receive, as its 70th birthday present, a real-terms annual funding increase of roughly 3.4 per cent. Not as much as some wanted, but more than many feared. And though it is being billed as a “Brexit dividend”, the prime minister ominously admits that “as a country” — by which she means as individual taxpayers, present and future — “we need to contribute a bit more”.

What has been almost completely buried in the coverage of this story, and was certainly overshadowed in her interview on The Andrew Marr Show yesterday, is an equally important aspect of the prime minister’s announcement: her insistence that the money must be spent wisely.

It’s often said that analysts at the Commonwealth Fund consider the NHS the world’s best healthcare system. It’s less often said that it actually came 10th out of 11 nations in terms of “healthcare outcomes” — in other words, the most important bit. Compared with its rivals, the NHS has far too many deaths from strokes and heart attacks, and our closest peers in terms of survival after a cancer diagnosis are Chile and Poland.

As the debate over the funding settlement reached its height, we at the Centre for Policy Studies carried out some simple analysis. It showed that as NHS funding goes up, productivity tends to go down: in other words, it does more with less, and less with more. The most notorious example of this was the great Blair/Brown splurge, which was, as the prime minister points out, misspent to a quite scandalous degree.

It’s not just about the headline figures. Talk to anyone in the NHS and you will come away with a laundry list of complaints about how the service works: the profusion of quangos; the targets and funding mechanisms that often incentivise, or force, people to act in the wrong ways; the fact that it is still far too hard to reward and replicate good performance, both by trusts and individuals, and punish bad.

This is why Mrs May was right to insist that the new five-year budget settlement — itself a welcome injection of certainty — be accompanied by performance improvements. That NHS leaders will be held to account for how it is spent, that the health service will have to become more efficient. That structural issues such as slow adoption of new technology and the disconnect between health and social care must be addressed.

But there is still a limit to what this government, or any government, can do. That is why the prime minister, as the NHS turns 70, should appoint a cross-party royal commission: taking NHS England’s current plan as its starting point, but going beyond that to deliver a full examination of the health service and how it can improve.

The difference between an NHS that matches its best productivity performance over the coming decade, and one that lives down to its worst, is vastly greater — in terms of patients seen, operations carried out and lives saved — than between the prospective funding settlements.

In other words, to secure the NHS’s future not just over five years, but another 70, it needs a full check-up, rather than just a ten-minute trip to the GP. And we need similar long-term thinking on its funding.

We will not know until the budget how the new cash will be found (though freezes to tax thresholds are rumoured). But economic growth of 1.5 per cent and NHS spending growth of 3.4 per cent is not a circle that can be squared for ever, unless we either want the state to amputate many of its other functions or to end up paying far more tax: approximately £1,000 extra per individual taxpayer by the end of the decade. (Remember: just as voters complain about the NHS, they complain equally bitterly about the pressure on their pockets.)

Yet if you suggest that part of the answer could be to find ways to deliver extra funding to the NHS outside of general taxation — from charging for missed appointments to introducing top-up payments to get more money from richer patients — you are castigated as a heretic. This, again, is an area where a royal commission could make progress, without the usual party-political brickbats.

The humbug that often surrounds the NHS has a real cost because it stops the health service working as well as it could or should. A few days ago, for example, the head of a left-wing think tank grandly tweeted that “the #NHS is as much a social movement as it is a health system”.

But the NHS is a health system, one that all of us rely on. Yes, it’s packed with dedicated staff, many doing impossibly difficult jobs for little money. But sinking into a sepia-tinted, Danny Boyle reverie about #OurNHS and the #TirelessAngels within it is not the way to make it better. Nor is thinking of all of its problems in terms of how much cheapskate politicians put in, rather than what the rest of us get out.

Robert Colvile is director of the Centre for Policy Studies

 

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Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions.

Kat Lay in the Times reports 15th June 2018: NHS (England) must use extra funds to fight cancer

Social Care is means tested, so why not health? More funds for cancer care is appropriate, but in Wales it could go on free prescriptions. If the people have a choice they will choose local, ahead of improved outcomes and travelling. As the population ages, and more people survive cancer, we will need more radiotherapy and oncology services. The shortage of Radiologists and Oncologists is so severe that the potential for improvement is threatened.

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The NHS will be expected to improve cancer survival rates and put a greater focus on maternity safety under a multimillion-pound funding package due to be announced within days.

Theresa May appeared poised to set plans to boost the NHS budget by more than 3 per cent after intensive meetings yesterday between No 10, the Treasury and the health team.

At a conference of health service managers in Manchester, Jeremy Hunt, the health secretary, said: “We need to make sure we unite the NHS and British people with a small set of bold ambitions as to how we want to transform our system. To get our cancer survival rate to the best in Europe; to transform our maternity safety so it is as good as Sweden; to truly integrate health and social care; to make sure we have waiting time standards for mental health that are as strong and powerful as the standard for physical health.”

He was still having “difficult” discussions with Mrs May and the Treasury over the precise details of a long-term funding plan, but an announcement is expected soon. NHS leaders say they need funding increases of 4 per cent a year, in line with assessments by think tanks. The Treasury is thought to be reluctant to provide that much.

Brexiteers want rises in health service spending to be funded by the so-called Brexit dividend — money available after Brexit that would have gone to the EU. They worry, however, that Philip Hammond, the chancellor, will suggest funding it through tax rises.

NHS sources fear that a “big picture” announcement could amount to a fudge because it will not spell out the exact funding increases on offer. That would mean health chiefs including Simon Stevens, chief executive of NHS England, waiting until November for the details.

There is also likely to be disappointment at a decision to keep social care funding, which is delivered through councils and is the subject of a forthcoming green paper, separate.

A report from the Institute for Public Policy Research, a left-wing think tank, has called for social care to be free of charge for people with substantial needs as part of a new long-term health funding settlement. Social care is currently means tested. Making it free would bring the care system into line with the NHS, where healthcare is free at the point of need.

Cancer patients given new drugs that won’t help them. GPs needed in oncology clinics…

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.

Rationed – Start of cheaper technique for breast cancer is delayed in UK despite adoption elsewhere. GP commissioners should be demanding intra-operative radiotherapy.

Cancer drugs fund is illogical. More money should be spent on radiology and radiotherapy.

Cancer chief quits amid radiotherapy shortfall

Artifical Intelligence is no threat to doctors, but it’s potential needs to be managed. A shortage of Radiologists is more bad news for the future.

 

Social care ‘close to collapse’ in most councils. The difference between public and private places, in the same homes, is “covert”, and needs to be routinely exposed.

Whilst Norway has a National Investment fund, which represents joint savings for unforeseen events, the UK has nothing. My pension is not funded from savings, or from my earnings, but from todays younger people in work. The reality of the shortfall for social care, and the difference between the bills paid by private customers as opposed to the state’s, are scandals. Families must ask for the difference between the private and the public funded places when their member first enters a home. Even if they still go ahead and are admitted, the truth is then out in the open. The difference between public and private places, in the same homes, is “covert”, and needs to be routinely exposed.

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Greg Hurst reports in the Times 12th June 2018: Social care ‘close to collapse’ in most councils

Three quarters of local authorities fear that their provision of residential homes and domiciliary care is close to collapse because of rising demand and reduced funding.

A survey found that 78 per cent were concerned that they may be unable to meet their duty to ensure a stable market for social care. Nearly half, 48 per cent, said that providers of home care, which are mainly private companies, had ceased to trade in their area in the past year and 44 councils said that companies had given up contracts because they were losing money.

The survey of 152 councils was by the Association of Directors of Adult Social Services. In addition to arranging adult care they have a duty to stimulate a diverse market for care provision.

The government announced a £2 billion boost for the care system last year. Jeremy Hunt, the health secretary, is to publish plans to reform social care next month.

Comment from the Times:

The welfare state model is going to have to change. People are going to have to save for their retirement (and no, NI is not going to do it for you) like they do other things such as a mortgage and not expect the state (that is other taxpayers) to provide support because you couldn’t be bothered providing for it yourself. Of course there will be means tested exceptions, that it what the state is there for, a social safety net for those in true need who didn’t have the option of preparing for retirement. Being profligate whilst working and expecting others to pick up your bill when retired, doesn’t count!

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NHS using 34‑year‑old equipment

The current crisis of capital  and lack of investment in plant, has left us all subject to old equipment, and inadequate images. Allied with poor purchasing power organisational skills, the health services need to replace their oldest equipment. X ray machines, for example, are much more efficient and use much less radiation and more sensitive plates than 30 years ago.

Chris Smyth reports 11th May 2018 in the Times: NHS using 34‑year‑old equipment

Patients are at risk because they are routinely being treated or diagnosed using equipment that is decades old, including scanners that are past their use-by date, Labour has claimed.

Diagnosis of cancer and other conditions is harder because hospitals have skimped on replacing vital machines, the party says. An x-ray machine from 1984 is being used at a hospital in Leeds, in Oxford staff are using a 1992 ultrasound scanner and an MRI scanner at the Royal Free in London should have been replaced in 2007, according to data from freedom of information requests.

Responses from 93 NHS trusts found that 892 x-ray machines were more than ten years old, including 139 that are beyond their replacement dates. There are 295 ultrasound machines still going after more than a decade, including 134 past replacement age.

Jon Ashworth, shadow health secretary, said: “Tory cuts to capital budgets mean we have among the lowest numbers of CT scanners and MRI scanners per head in the world.”

Theresa May has promised extra money for the health service, but Mr Ashworth said: “It will be a key test of any new funding settlement for the NHS in the coming weeks that it makes up for years of Tory cuts to capital budgets which have left hospitals unable to replace essential equipment and have put patients in danger.”

Phillippa Hentsch, of NHS Providers, said that money to maintain and develop equipment “has been used to prop up day-to-day NHS spending”.

The Department of Health said that the government had “announced £3.9 billion of new capital investment”.

 

Whay are patients like me denied a new cancer drug? You know the answer – rationing…

Sean O’Neill knows the answer to his question. But he thought, before he was ill, that he never would need to ask this question. After all, politicians deny rationing, and only restriction, priorities, and exclusions. We need not ration at the low volume high cost end (as much) if we charge for the low cost high volume end.

Why are patients like me denied a new cancer drug?

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The cancer cure stories have been coming thick and fast over the past month. We’ve had the “biggest breakthrough since chemotherapy”, a woman cured of breast cancer with an injection of her own cells, a hormone pill that will “liberate thousands of women” from chemotherapy and the notion that artificial intelligence will beat the disease.

After Tessa Jowell’s death from brain cancer last month, Theresa May found a magic money tree to give more patients access to experimental treatments. And Simon Stevens, chief executive of NHS England, was moved to declare that an early diagnosis blood test had placed us “on the cusp of a new era of personalised medicine that will dramatically transform care for cancer”.

Mr Stevens’s lofty words are wedged firmly in my craw, impossible to swallow. I have a cancer, chronic lymphocytic leukaemia, that is already striding into a new era in which doctors feel chemotherapy is largely unnecessary and dangerously counterproductive.

There is a groundbreaking drug available, a once-a-day pill, which stops the growth of cancerous cells without blasting the bone marrow. It’s a drug that allows most patients to get back to a full life — enjoying time with their families, going to work, paying their taxes.

This is no pie-in-the-sky experiment: it’s here now. The National Institute for Health and Care Excellence (Nice) says this drug, ibrutinib, is “innovative and effective” and should be “routinely available” for patients (like me) who have relapsed after a previous course of chemotherapy.

But Mr Stevens is denying us ibrutinib. His bureaucrats overruled Nice and issued doctors with a checklist restricting the prescription of the drug. Instead, Mr Stevens thinks I should endure another six months of debilitating chemotherapy, this time including a drug called bendamustine, derived from mustard gas by East German scientists in the 1960s. So much for a new era.

True to form for Whitehall, Mr Stevens’s communications officers refuse to answer questions about who overruled Nice, why or what other drugs are being restricted like this. Jeremy Hunt, the health secretary, should surely intervene. The health department says the NHS “is legally required to fund” Nice-approved treatments.

If Mr Hunt, who has received dozens of letters from MPs about this issue, has not already called in Mr Stevens to ask him why NHS England appears to be breaking the law by secretly curtailing access to approved drugs, now is the moment.

Sean O’Neill is chief reporter

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The cost of technology is exceeding our ability to pay.

Commissioners and Trust Board directors find themselves in an impossible position. Their political masters will not allow use of the word “rationing”, and yet they are expected to keep up with new treatments, and make them available to all. We rarely hear any “exit interviews” but the resignation of Bob Kerslake following the demoting of KGT to “special measures” should tell the politicians what the professionals already know: the health services are founded on financial sand. The edifice is falling.

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Chris Smyth reports 6th June in the Times: Discount deal opens up new cancer treatment but 

Of course there are numerous other treatments, and much money has been invested to get a return!

Hundreds of lung cancer patients will receive a cutting-edge immunotherapy drug on the NHS after health chiefs boasted of beating down prices.

The deal was the first test of a controversial policy that allows NHS England to restrict or delay medicines that will cost taxpayers more than £20 million a year, even if deemed cost-effective.

Officials said the threat of such measures had been enough to persuade the drugmaker, MSD, to agree a confidential discount. Pembrolizumab costs £84,000 per patient at full price and to get below the threshold would have to be reduced to a fraction of that. About 1,800 patients a year will now be eligible.

Pembrolizumab is one of new class of medicines that boost the body’s own natural defences against cancer. It is used in cancers of the lung, stomach, head and neck, skin and bladder and is being tested in other types such as prostate cancer.….

On the same day Kat Lay reported: Targeting cancer’s genes prolongs life

Treating cancers based on their genes, rather than where they occur in the body, increases a patient’s chance of surviving for a decade six-fold, a study has found.

Data presented at the American Society for Clinical Oncology (Asco) meeting in Chicago showed that 15 per cent of patients given drugs that targeted specific genetic mutations in their tumours survived for three years, compared with 7 per cent of patients who had standard unmatched therapy.

Six per cent of the matched group survived for ten years compared with 1 per cent of the unmatched group.

“All patients should have access to next-generation sequencing and I believe in the next few years we are going to see this approach dramatically improving outcomes,” Apostolia Tsimberidou, who led the research, said. “We need to know what is really causing these diseases so we can treat them properly.”

Researchers from the University of Texas looked at more than 3,000 patients with cancers including breast, lung, gynaecological and stomach tumours. After using a technique called next-generation sequencing, which tested between 20 and 50 genes simultaneously to determine exactly which molecular abnormalities were present in the tumours, they found that 1,307 had at least one genetic change. Some 711 of those patients received drugs matched to the biology of the tumour, for example blocking the function of the mutated or altered gene, sometimes alongside chemotherapy. A further 596 received a drug that was not matched to their tumour’s biology, usually because a matched treatment was not available to that patient at the time.

Those studied had advanced cancer that standard care had failed to halt, with some having tried 16 therapies. While overall survival in the study was small because the patients involved were very ill to start with, Professor Tsimberidou said that the results would probably be even more striking had the technique been used earlier.

In the NHS, many cancer patients receive genetic testing of some type, but next-generation sequencing has yet to be adopted widely. The cost can vary but has declined rapidly in recent years, with some versions costing about £300.

Professor Tsimberidou said that one patient in her clinic had had glioblastoma — the aggressive brain cancer that killed Tessa Jowell, the former cabinet minister, last month — diagnosed in 2011 but was still alive thanks to personalised treatments.

Catherine Diefenbach, an Asco expert, said: “We’ve just scratched the surface. Now with faster and more robust genetic tests we can help even more patients by treating the cancer based on its genetic makeup rather than solely on its location in the body.”