Category Archives: Stories in the Media

Public Toilets used to be free. Now they are not. The UK Health Services should follow suite

In Pembrokeshire a money saving and frugal county council intends to double the price of a public toilet visit to 40p. This will at first seem wrong to most of us. The progressive nature of free services has always been assumed to outweigh the cost. But with higher standards in businesses, cafes, hotels and shops, and with many more toilets generally available, is this realistic? There is an old fashioned paradigm of public toilets attracting drug addicts and sexual predators, and bored teenagers writing graffiti. Certainly I rarely choose to use a public toilet, but then I am not in the poorest 5%, or disabled, or have a medical problem that sometimes needs a toilet urgently. Access to public toilets for these groups should still be free, and for the rest of us a price of £1 seems reasonable. It is pragmatic.

And just like toilets, the current health services can be abused, and most of us avoid using them if we can…. So lets be pragmatic, and have a dose of reality introduced into health. Simple co-payments for most of us could be the start, and then means related co-payments as ID cards become accepted. We have to move on, Public Toilets used to be free. Now they are not. The UK Health Services should follow suite.

We cannot have “Everything for everyone for ever for free“, and we need to face up to this. Rationing by co-payments is a reasonable solution. We have co-payments in Social Care, but not for Health. Why is this? The £20bn will achieve nothing if we cannot discuss the truth. Prevention is better than cure, but all of us have to die sometime, and delaying only means the treatments come later. The health services are about “fear” of being untreated or treated unequally……  Prevention may not be first on citizens minds when they consider their own health…

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Increased charges for Public toilets in Pembrokeshire. Western Telegraph 16th Jan 2019

Chris Smyth in the Times 18th Jan 2019: Social care ignored in £20bn NHS reforms, says watchdog

Cuts to public health and training coupled with the neglect of social care risk derailing the £20 billion NHS reform plan, the spending watchdog warns today.

A ten-year plan focused on preventing ill health, boosting the NHS workforce and joining up care has not yet been backed by funding for these areas, the National Audit Office says.

Ministers have funnelled cash into the NHS but “key areas of health spending” have so far been ignored and unless money is committed to them the health service might not be able to deliver its promises to patients, the NAO says in a report……

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Humiliation for the Healrth Services: an extra meal may save patients , but it wont save our health services

Not many countries are going “downhill” these days. The book “Factfulness” tells us how well countries as a whole are doing, and with the exception of Central African Republic and Mali most have really progressed in the last decades. Several notable exceptions include Venezuela,  ( A Plutocratic Socialist state without internal competition ) and Pakistan ( A theocracy which had the same opportunities as India, but has failed to redistribute, failed to educate women, and failed to overcome corruption ). When Rhys Blakely reported 14th January in the Times “Extra meal saves frail patients” little did he expect to be broadcast across the world by Xinhua. “Food saves thousands of lives in British hospitals” 

The wealth and health divide in the UK is widening. The WHO will report on the differences in our systems shortly, but outcomes are largely determined by wealth and education, and early presentation is more common in these groups. 

The shaming is self evident, but it appears nobody is willing or able to do anything about it.

“Extra meal saves frail patients”

Hospitals cut the number of deaths among elderly patients with a fractured hip by half simply by appointing a staff member to give them extra food.

A pilot scheme at five NHS trusts in England and one in Scotland involved an extra junior member of staff for each ward who was given the job of keeping patients well fed. They were given a target of boosting intake of food by 500 calories a day, equivalent to about one meal.

Since the trial began two years ago the proportion of elderly patients who died within 30 days of a hip fracture has fallen from 11 per cent to 5.5 per cent.

Dominic Inman, chief orthopaedic surgeon for the National Hip Fracture Database, who helped to design the scheme, said that nurses were too overstretched to make sure patients were eating enough. “Hip fracture patients are among the frailest, most elderly patients that we see,” he said. “Often they’ve fallen and broken their hip because they’re not coping at home, they’re not looking after themselves, they’re getting weaker and weaker. They come into hospital at a disadvantage already, often malnourished.”

The trial also involved reducing opiate pain medication, which can make patients sleepy and less inclined to eat.

On average patients in the trial spent 20 days in hospital, down from the usual 25, saving more than £1,400 per patient.


GP pension boost may halt exodus: why when “the NHS ….is the least national health service in the developed world, an insult to the memory of Aneurin Bevan.”?

The idea that successive governments bear responsibility for the manpower crisis has not occurred to the media it seems. Whilst the stressed out GPs, denied access to quick diagnostic tests, have a choice: they can “live with uncertainty” in an increasingly litigious world, or refer. Which choice they make determines the efficiency of the 4 health services. Most inexperienced GPs have higher referral rates, and the more experienced live with more uncertainty, and use time as a diagnostic tool. They play the odds…  When Ed Conway opines, in the same edition of the Times as the report below, he is correct that the “Rules ( of the game ) and red tape make the NHS second best”, and he is right that “..the NHS ….is the least  national health service in the developed world, an insult to the memory of Aneurin Bevan, whose goal was that the miners of Tredegar would have the same quality if service as London stockbrokers.”

He is right that AI could be more useful, right that IT has been badly used, right that some services and follow ups could be done by people other than doctors. He however misses the point that doctors are the only people who make a diagnosis….  He does not comment on the missed waiting targets and other performance indicators, or who is responsible for the manpower crisis. Changing them is an admission of defeat, and a time horizon for the extra 5000 GPs that cannot be met. Indeed, since the announcement of the extras 3 years ago we have 1000 less…

In West Wales we have no tertiary hospital in our area, and we have lower standards and survival for acute coronary events, and we suspect from many other conditions. We pay the same taxes, and although not Tredegar, we suffer from the same inequalities as b=the miners did before the old “N”HS.

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Chris Smyth reports 11th Jan 2019: GP pension boost may halt exodus

GPs could get more generous pensions to prevent so many leaving the NHS.

Matt Hancock, the health secretary, is pressing Philip Hammond, the chancellor, to change pension tax rules that are said to encourage GPs to retire early.

The Treasury believes that the change would be unfair, unnecessary and costly. The pensions of other high-earners in the public sector, such as senior army officers and High Court judges, would be boosted as well.

It is also unconvinced that pensions are a significant cause of a shortage of GPs. A Treasury source said: “The secretary of state for health has just inherited the biggest single cash injection the health service has ever had. He can now put that money to work supporting NHS staff and frontline services.”

Mr Hancock is prepared to push for changes after being told that a worsening shortage of GPs threatens efforts to improve local care and keep patients out of hospital, ideas that are at the heart of the ten-year, £20 billion plan for the NHS announced this week.

GP numbers have fallen by 1,000 since a government pledge to recruit 5,000 four years ago, and doctors complain that they are overworked coping with an older, sicker population.

They argue that the loss is worsened by a cap of £1 million on the tax-free amount that can be accumulated in a pension pot. Many doctors hit this limit in their fifties, making it less attractive to carry on working.

Some complain of being hit with annual tax bills of tens of thousands of pounds because of related rules that limit the amount that can be contributed to a pension each year. GPs earn an average of £92,500 and the average age at which GPs retire has fallen by two years since 2011 to 58.

Mr Hancock told the GPs’ magazine Pulse: “The biggest concern I have raised with me [on GP retention] is around the tax treatment of pensions.”

Richard Vautrey, chairman of the British Medical Association’s GP committee, said that doctors “had been unfairly hit by complex regulations and tax changes. “At a time of plummeting morale, and amid a deepening recruitment and retention crisis, such charges make taking on extra work, or continuing to work full-time, an extremely unattractive prospect,” he said.

Boosting GP and other local care is crucial to the success of the ten-year plan, which promises that budgets for such services will rise faster than hospital spending for the first time.

Simon Stevens, chief executive of NHS England, has also blamed the pensions rules for driving doctors in their fifties out of the NHS.

Ed Conway: Rules and red tape make NHS second best

Don’t drop NHS waiting targets, doctors plead

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First new migraine drug in 20 years too costly for NHS

Kat Lay reports 10th Jan 2014: First new migraine drug in 20 years too costly for NHS

The first new drug designed to treat migraines in 20 years has been rejected by the NHS medicines watchdog on cost grounds.

Charities representing the millions of migraine sufferers in the UK said that they were disappointed by the decision from the National Institute for Health and Care Excellence (Nice). It had been hoped that erenumab, made by the pharmaceutical company Novartis under the brand name Aimovig, would become available on the NHS to half a million people who suffer chronic migraines at least every other day.

In a trial, a monthly injection of the drug halved the number of days each month marred by migraines in almost a third of participants, who had already unsuccessfully tried between two and four drugs to control their migraines.

Aimovig has a list price of about £5,000 per year, although the company had offered the NHS a confidential discount. However, draft Nice guidance did not recommend the drug.

It agreed the drug was a “clinically effective treatment” for preventing migraines, but said it did not think trial evidence fully reflected real-life NHS patients or included sufficient detail on comparison treatments and long-term patient outcomes. It concluded that its cost-effectiveness estimates were therefore higher than acceptable. Wendy Thomas, of the Migraine Trust, said that the decision was “devastating”.

Meindert Boysen, director of the Centre for Health Technology Evaluation at Nice, said there was not enough evidence the drug was more effective than Botox, already recommended by Nice, for people with chronic migraine.

The draft recommendation will be open for comments until the end of the month.

Indirect consulting: wrigling on the hook of rationing health care

GPs manage more and more chronic conditions by remote control. The telephone is a boon in this respect, and since the patients are known to them, visual contact is not necessary. But when it comes to new patients, who need a new diagnosis “every patient deserves  and examination”, especially if this is reassuringly negative. Hospital consultants can follow up simple post operative patients over the phone, and this can be done by nurses. Just as follow ups in GP practices can be done by nurses. But the total percentage potential for indirect consulting is limited. In an age where many patients are elderly, with multiple pathologies, we have to accept that a face to face consultation is best, and an examination is usually appropriate. NHSreality has been warning that there would be much “wriggling on the hook of rationing health care”, and this is just another wriggle.

Times Letters: The doctor will see you now — by Skype – Times letters 9th Jan 2019:

Sir, Skype consultations will mostly work in general practice because the majority of patients present with self-limiting illnesses (“Millions of patients to see doctor by Skype”, Jan 8). However, I predict some disasters when patients are presenting with an evolving serious condition.

A few years ago, a very ill patient was admitted to my hospital, septic from a large abdominal abscess. This (and more) was treated successfully by an emergency operation. Four days before admission, the patient could only be offered a telephone conversation with her GP, who diagnosed a peptic ulcer. If that patient had been seen in consultation by the same GP it is likely that the rapid pulse rate, the fever and the patient’s reluctance to move freely (a sign of developing peritonitis) would have been recognised.

Telephone and Skype consultations are a compromise solution and are not without risk. This policy is a panic response by technocrats at the Department of Health and NHS England, who may never have worked at the bedside.
J Meirion Thomas, FRCP, FRCS

Consultant surgeon. London SW1

The Times followed this up 10th Jan 2019:

Chris Smyth reports: Seeing Doctor by Skype dismissed as highly unlikely

As little as 2 per cent of hospital appointments could end up being conducted over Skype, according to experts who have cast doubt on plans for a digital revolution of the NHS.

Making online appointments work is “really, really hard”, would take decades and was unlikely to save the NHS any money, according to academics from Oxford University who have studied attempts to digitise care.

On Monday the NHS pledged to move a third of outpatient appointments online, which it said would save billions of pounds and avoid the need for 30 million hospital visits a year. Simon Stevens, head of NHS England, promised that patients would be able to “access advice at the touch of a button”.

One youth diabetes clinic has moved 20 per cent of its consultations online. However, the authors of the most detailed research into Skype consultations in the NHS, published in the Journal of Medical Internet Research, said that it often failed because of problems retro-fitting existing systems and getting staff to change working habits.

In a letter to The Times, Professor Trish Greenhalgh and Dr Sara Shaw wrote: “A national survey from Norway, an early adopter of remote consultations, suggests that overall (incorporating specialties such as elderly care, for example), the fraction of all hospital outpatient consultations that can be conducted remotely is closer to 2 per cent.”

While patients save time on travel, doctors would not gain any time by avoiding face-to-face meetings, they added.

Professor Greenhalgh said: “I don’t want to be the killjoy that says ‘this is impossible’ — I would like more appointments remotely [but] 33 per cent is a high ambition and if it is going to happen, it will be in 20 years.”

She said that the most optimistic scenario was that the NHS “can probably get to 10 per cent but I don’t think it’s going to save any money”. She added: “The argument is it will make the NHS more efficient and I don’t think it will. If you build another lane on the M25, more people will start travelling. If you make doctors and nurses more available by Skype, patients will want more appointments.”

Although many GP surgeries offer video consultations on smartphone, Professor Greenhalgh said that hospitals are way behind: “One of the reasons is sheer scale; buying a laptop is easy, getting 100 people on to a network is hard.”

Existing Skype clinics had failed from lack of administrative support, but Professor Greenhalgh said that too vigorous a national push risked repeating the mistakes of the chaotic £10 billion NHS IT scheme set up under Tony Blair that failed to link up hospital records. “A target of 33 per cent over Skype in ten years sounds like a top-down policy that hasn’t learnt the lessons of history,” she said.

She advised the NHS to reform rules that meant hospitals did not get paid for online appointments, suggesting: “Don’t start with the technology. Start with transforming the service.”

Professor Stephen Powis, NHS England medical director, said: “There are often better alternatives to the traditional outpatient visit. Many areas are already doing this, with practical benefits for patients and staff . . . [the] plan is clear that while digital services will not be everyone’s choice, they will be provided for those who want them, helping to avoid an extra £1 billion in newoutpatient costs over the next five years.”

Doctors to see groups of patients – is probably madness. The fox is waiting..

Any GP you want: so long as you’re healthy



Rather than looking abroad for doctors, we should be looking overseas for system design solutions.

The idealists in the government have their eyes on a longer term plan. It is an altruistic and worthy ideal, and the objectives have little against them. It is the practicality and feasibility of the plan which meet with most disbelief in the professions. A lot of what doctors do could be done over the phone, especially if the patient and their family are already known to the doctor, and repeat and follow up consultations, which every practice is trying to reduce, could often be managed this way. BUT the main purpose of a doctor, and what differentiates them from nurses, is the ability to make a diagnosis, and to be efficient in their use of technology and investigations. This is why GPs are gatekeepers. Many of the GPs currently working believe that not examining the patient, especially at first consultation or meeting,  is a risk, and they are unwilling to take this risk. Since continuity of care has died, particularly in the cities, the uncertainty inherent in not examining could cause more litigation and stress. Only some doctors are able and willing to live with this….. And they are unlikely to be those recruited overseas. Rather than looking abroad for doctors, we should be looking for system design solutions. 

Of course, those of us who actually realise the value of a consultation, continuity, and examination in order to make a diagnosis, will just have to go privately. 

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Nick Triggle for the BBC on 7th Jan 2019: NHS plan: What it means for you and Labours response from a day before (I wonder if they had read it?): Labour attacks Theresa May over proposals

Alex Matthews-King in the Independent opines: NHS 10-year plan relies on raiding other countries for thousands of nurses and doctors – ‘It is neither sustainable nor ethical long term to rely on other countries to provide our nurses’

An ambitious 10-year plan for the NHS unveiled by Theresa May relies upon recruiting thousands of nurses and doctors a year from overseas – a practice widely criticised for draining developing countries’ health services of vital qualified staff.

The prime minister revealed parts of the blueprint detailing how the extra £20bn a year she announced last summer will deliver improvements in patient care across the beleaguered service, which has had to cope with years of real-terms cuts under austerity.

It includes targets to diagnose three-quarters of cancer cases early enough for successful treatment, treat more emergency patients and send them home on the same day, and a right for every patient to have online GP appointments via apps by 2024, among other initiatives.

However, to fulfil these commitments, it makes clear a “significant uplift” in international recruitment is needed right away to fill the more than 100,000 vacancies that currently exist. ……..

The FT reports:  Financial Times Theresa May claims Brexit bonus will help fund new NHS plan and is very jaundiced.

The reality is mistakes, cross infections, delays and all sorts of post code differential outcomes. Birmingham is reeling from repeated mistakes… (Birmingham Live)

In the Times Chris Smyth singles out one area for his headline: Millions of patients to see hospital doctors by Skype under NHS plan – Theresa May wants digital consultations to become NHS norm in order to give patients greater control

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

Too fast, too furious, too many…… The 10 minute consultation needs to be challenged.. Interview rape is commonplace.. There are not enough people with enough time to care.

Desperate situations require desperate measures. Virtual consultations are without evidence, risk GP burnout, errors for patients, and increased litigation costs..

The NHS can no longer provide everything to everyone, and we should “Look abroad for serious solutions to the NHS crisis”.

Primary care telephone triage does not save money or reduce practice workload

Why not introduce more NHS charges?

At saturation point – the system seizes up

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More money is no use. An honour is debased. Poor systems lead to poor decisions… just like the 4 UK Health Services

The one good thing about a businessman philanthropist getting a “gong” is that he has exposed a loophole in the system for funding and provision of drugs. The idea that he should be rewarded for exposing this perverse incentive is anathema to all health service staff, and their lack of respect for our government and politicians will only be reinforced.  NHSreality has already commented on awards: The New Year’s Honours (RHS) List 2014 and there are suggestions for the “gong” system to be rearranged so that honest exit interviews are rewarded..

The next announcement should be the funding of health and social care. There is no chance that this review will change anything. There is so much money overspent already; even with the new funding they are £1bn short! At least the voters seem to have a longer term perspective... Expectations are reducing. Watch out for all the private options in the next decade. We have a poor system: money alone is not the answer. 

BBC News 6th Jan: NHS 10-year plan: Labour attacks Theresa May over proposals

Spend extra money on more nurses and doctors, urge voters – Chris SMyth reports in the Times

and NHS faces £1bn budget hole despite cash boost

The Times Leader sums it up well: The Times view on NHS funding shortages: Poor Service – Money alone is not the answer to the the health service’s long-term challenges

rexit will not be the only topic on the agenda of MPs returning to parliament this week. The country faces multiple other challenges, many of which have been neglected for too long while the government has been arguing with itself over the terms of our EU departure. Among the most pressing is the future of National Health Service. It is more than six months since Theresa May announced an extra £20 billion above inflation for the NHS by 2023 and asked its chief executive, Simon Stevens, to devise a plan to spend it. That plan was delivered to ministers last month, but its announcement was delayed amid Brexit chaos. It will be revealed this week instead.

The prime minister gave a preview over the weekend of what it will contain. It includes better mental health and maternity care, better protection from and detection of diseases such as cancer, increases in the NHS workforce and a drive to introduce better use of technology throughout the NHS in areas such as GP booking, prescriptions and health records. These are all important goals, though as we report today, health bosses rightly fear that Mrs May risks raising unrealistic expectations as to what can be achieved. The Nuffield Trust estimates that even with an extra £6 billion investment planned for next year, the NHS will still face a £1 billion shortfall.

Besides, money alone is not the answer to the NHS’s challenges. One of the biggest of those challenges is to free up hospital beds from people who have no clinical need to be in hospital. That requires far greater levels of integration between hospitals and other parts of the health system, including GPs and social care providers. Yet with the passage of time it has become clear that the reforms pushed through by the Cameron government at the start of the decade were misguided: new rules designed to bring greater commercial discipline between hospitals and GPs have not increased efficiency but proved a barrier to effective integration. The government’s first priority should, therefore, be to keep its promise to deliver any legislative changes requested by Mr Stevens that stand in the way of integrated health services.

The second priority must be to deliver an overhaul of social care provision. In an ageing society, finding a solution to the long-term care needs of elderly people is crucial to freeing up resources in the NHS. A tenth of hospital beds are occupied at present by people who cannot return home, solely because they have nowhere else to go, and that number is certain to rise, given that the numbers of those aged above 75 is likely to double over the next 30 years. It is now more than seven years since a government-ordered review recommended capping what individuals should pay for their care and nearly 18 months since the government promised a green paper on social care, yet ministers are still unable to give a date for its publication.

The broader question is whether, even with the extra cash and the right legal frameworks, the NHS has the requisite leadership skills to manage a vast, complex bureaucratic system that employs about 1.5 million people and consumes about 11 per cent of the national budget. Ministers insist that Britain’s model of a free health service at the point of use is sustainable, providing that resources are used more efficiently. But sustainability also depends on the stability of the public finances. In that respect, the fate of the NHS may hinge less on Mrs May’s long-term plan than her Brexit deal.

The Times view on V J Patel’s OBE: an unworthy honour.