Category Archives: Uncategorized

Alan Milburn thinks the penny has dropped…. Money alone will solve nothing for the UKs health services.

We cannot expect a former health Secretary to admit we need to ration health care, but this is the nearest we will get. NHSreality does not think the penny has dropped with a majority of the politicians as yet. ….. One of the signs of inefficiency is readmission rates, which are rising fast. There may well not be a bed for YOU when you need one… Rationing is happening but we are all denying it, and as it is covert, Commissioners get away with it where they can.

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Alan Milburn opines in te Times 1st June 2018: The government can gift the NHS time as well as money

The penny has dropped. The Prime Minister has come to realise that the NHS — indeed the wider care system — needs more money. An announcement, perhaps to coincide with the 70th birthday of the NHS in July, is apparently imminent.

It has become obvious to government that demand and supply are out of kilter. Hospital admissions have risen by one third in a decade but resources have failed to keep pace with NHS funding rising at less than half the rate of the 4 per cent historic average.

The arguments are now raging in Whitehall about how much the NHS needs to be sustainable. History seems like a good guide — 4 per cent is surely the minimum needed.

But here I have a health warning for the government. Increasing the volume of cash is only one leg of the three-legged stool on which a stable NHS needs to sit. The second leg is visibility over-resourcing.

The NHS needs long-term line of sight — 5 to 10 years — over resources so that it can plan with certainty to transform local services so they meet future demographic and disease challenges.

It will take time to change services so that they are less fragmented and more integrated, less dependent on hospital care and more more community-based, less focussed purely on treatment and more on prevention. The government can gift it time as well as money.

Thirdly, reforms must accompany resources. People working in the health service know that the current structures are no longer fit for purpose. Structural reforms since 2010 have led to unprecedented confusion and uncertainty.

The reforms were intended to introduce more competition but the thrust of The Five Year Forward View — the NHS’s reform plan — is about encouraging greater collaboration, not least between health and social care.

Today the NHS is in an organisational no-man’s land. In particular there is a misalignment between the ambition of creating integrated, place-based and outcome-led care and the operation of the current financial system. Money talks in the NHS. Not just the volume of money but how it is used, deployed and how it moves around the system. I know that from my experience as Health Secretary in the Blair government.

When we put record resources into the NHS, at first hospital activity levels stalled and waiting times continued to rise. One of the key things that changed that was the introduction of incentives on hospitals to increase activity and reduce waiting.

The more they did, the more resources they got. That change led to unprecedented reductions in the times patients had to wait for an operation. But today, although reducing wait times remains important, the biggest priority for the NHS is to tackle chronic diseases like diabetes and improve population health outcomes. That needs a different set of financial incentives.

The current financial system is caught in a time warp and needs to catch up. Without reform there is a risk that that the government simply won’t get the most bang for the buck out of the new resources it intends to invest in the NHS. That would mean too many of the extra resources would be wasted.

What is more, if left unreformed, the financial system will be a stumbling block to the service transformation that is so desperately needed. According to a new report drawn up by PwC with the help of the Healthcare Finance Management Association, 76 per cent of NHS finance professionals feel the current funding structures in the NHS are not fit for purpose.

I agree. To make sure that the extra resources are put to the best use, reforms are needed. Health and social care budgets need to be brought together at a local level. How providers get paid should be changed to reward improvements in health outcomes rather than increases in the number of people treated — so helping the drive towards prevention rather than activity.

Channeling NHS resources through local systems rather than single institutions would speed care integration. And banning capital to revenue transfers — which have robbed the NHS of billions of desperately needed infrastructure spending in recent years — would provide more investment in out-of-hospital care. These changes would put extra resources to work for the benefit of patients.

Today the NHS has reached an inflection point. Without change, it will not be sustainable as a universal service providing care according to need regardless of the ability to pay. The promise of more government investment is welcome. but it must be accompanied by reforms.

There is a huge opportunity to better optimise resources, better empower patients and better improve health outcomes. Change is always hard in the NHS but there is a big prize on offer — not just to sustain the system, but to transform it.

Alan Milburn is chairman of the PwC Health Industries Oversight Board and a former health secretary

Chris Smyth reports 1st June: Millions return to hospital after only a month

Is NHS rationing a possibility? – BBC News

Sarah Page reports for West Susses County Times 1st June: Vital eye surgery rationed across the county despite calls for rationing to stop



Mark Britnell is very perceptive, but avoids the reality of rationing. This means his contribution is not appreciated by the profession. He does ecognise that inaction is paving the way for private health care.

NHSreality was asked to review Mark Britnell’s book: What would the world’s best health system look like? Mark Britnell is very perceptive, but avoids the reality of rationing. This means his contribution is not appreciated by the profession. By default, and denial, the way to private health care becomes clearer daily.

In “Paving the way for private healthcare” 12th Jan 2017 in the Independent:

…..”One is reminded of Mark Britnell’s comments a few years ago at a private equity conference that the NHS would be shown “no mercy” and that it would become a “state insurance provider, not a state deliverer” of care.”

( Mark Britnell “In search of the perfect health system”, (published by Macmillan Education and Palgrave ISBN 978-1-137-49661-4)  2015 by Mark Britnell)

Can “patient centred care” become a reality in the NHS? Mark Britnell 14th May 2013 in the Guardian

Mark Britnell | The Guardian

Books and reading pertinent to the NHS | NHS reality. An NHS …

Five principles behind the world’s most efficient health systems | The Nuffield Trust

[PDF]Something to teach, something to learn by Mark Britnell – NHS England

[PDF]Mark Britnell has been scouring the globe for the perfect health system – Health Service Journal



Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

It is hard to recruit to West Wales. The “little England beyond Wales” is culturally very different from Welsh speaking Carmarthenshire. I used to think Whitland would be near enough, but no longer.

Doctors choose centres of excellence in cities rather than rural areas to work in.

There is an under capacity in diagnostic physicians, and this will remain the case for 10 years.

Reconfiguring West Wales services gives an opportunity to raise standards, reduce infections, accelerate discharge and improve choice.

The medical model is changing, and teams of specialists raise standards fastest.

There has not been the investment in infrastructure that there should have been to speed transport.

Choice for patients needs to be encouraged by the system. A larger Trust ( preferably all of Wales – why not?) will give greater choice.

If a rural area such as Pembrokeshire wishes to recruit consultants and GPs easily, it needs to recognise the drivers for change in the medical profession. New doctors want to have access to new technologies, tests, and treatments. The medical model now involves large teams of specialists raising their standards together. Access to such centres is meant to be “equal” but in effect, especially in Wales, it is dependent on post code. Choice has been restricted to “within your own trust”, and outside referral restricted unless there is no service within your trust. Consultants and their juniors like to have access to specialist investigations, a complete set of treatment options, and research and teaching opportunities.

So why did I move to Pembrokeshire. I enjoy an independent mind-set, and the challenge of working in remote areas. But I saw the possibilities were better where there was a DGH (District General Hospital), a postgraduate centre and teaching opportunities. All these will go if my local hospital closes, or moves outside of the “little England beyond Wales”. I feel cultural affiliation, and when I seek medical care the first language should be one I understand. (English). Consultants arriving in the area were offered subsidised accommodation in a hospital house whilst they looked for a home. New physicians arriving felt they were cared for …

Within GP, the clinical variety and opportunities have reduced, and there is much less room for manoeuvre in todays group practice experience. The shape of the job has changed, and the people in it have changed too. Now it is 80% female reflecting the underperformance of males at age 18 when applying for medical school. It may change even more, because with too few diagnosticians, digital consulting, without an examination may expand, with resultant litigation risk. ( Murray Ellender GPs must embrace digital future – The Times 23rd April 2018 )

The threat to move our hospital outside of our county, and into another tribal area, will not be taken lying down. So we need a solution that allows consultants all the things they want, and our, mainly female, GPs to get what they want. With a 10 year deficit and shortage of diagnostic doctor skills, we have to centralise in some way or other. ( Patients want all services as close as possible, and many would choose local access instead of lower death rates. They will also demand it is all free, for everyone, everywhere, for ever. )

If we take out the hospital we take away part of the culture. House prices will fall further as professionals leave, and choose to live near tertiary care centres. The already dilapidated and sometimes empty heart of the county town will get even more squalid and forgotten. Yes, we can replace one culture with another, more cynical one. People are already disillusioned in the shires, where the vote went against staying in the EU, even though the people there had more to lose. Taking away their hospital without persuading them that it is for the greater good could lead to civil unrest…. and they will also have a Welsh language school they never asked for.

In the end we have to make the new solution attractive to medical applicants, and that means combining Hywel Dda with Swansea so that hospital jobs are rotated, the educational and research opportunities are there for all, and the important services; stents, stroke and radiotherapy are all provided on site. Without Swansea the new hospital needs more money to have the facilities needed to help recruitment and even then it may not be enough.

Dirty surgery such as gut emergencies should be treated in on of the old DGH theatre suites, and the rest of old DGHs become community care recovery centres. The funding must also be changed, so that all the country, patient and professionals, realises that financially, it is founded on a rock rather than sand. This will win hearts and minds.. but it is tough love.

My personal belief is in means related co-payments, scaled and managed centrally. I have some concern about how to deal with citizens who have cash flow poor, but are asset rich, but this can be debated once we agree to ration and use co-payments.

The three options are all reasonable, given the under capacity and recruitment problems described, and NHSreality goes for a new build in Pembrokeshire, along with new roads. If this were done, and/or the trust combined with Swansea, there would be a great improvement in services for West Wales patients. The finances are a different matter, and I expect continued denial all round.

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

Who wants to be a Hywel Dda board member? “Hywel Dda health board looks at hospital closure options”. The obvious solution is to promise a new build at Whitland, and a dualling of roads west.

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

A poisoned chalice. Advertisment for Chairman of Hywel Dda…

Hywel Dda Health Board chief executive Trevor Purt to leave his post

Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

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Rationing cochlear implants. The health divide becomes cyber-lieteracy as well as wealth. It is deaf politicians and not deaf patients, who are the real problem.

This may be appropriate rationing. I have no idea of the longevity or the risks with cochlear implants in young children. But it is rationing if the same consultant fits the aid, as was the one to deny the service. If crowdfunding becomes the norm, the divided society becomes one where ones best chances are when ones family are cyber literate?.. as well as wealth. It is deaf politicians and not deaf patients, who are the real problem.

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Molly Rose-Pike for Mailonline reports on the denial of cochlear implants, and a crowd fundraising exercise. 

This Morning viewers gushed over the antics of an adorable three-year-old guest’s antics on Friday’s show.

Benjamin Wayne was on the show with his mother Joanna, from Carshalton, Surrey, who was there to discuss how his NHS funding bid for cochlear hearing implants was rejected.

He has a condition called Connexin 26, which has left him with only slight hearing in his left ear. Though his hearing is significantly impaired, he does not qualify for the implants under current NHS guidelines – meaning his family are now trying to raise £80,000 for private treatment.

Ben’s mother said her little boy is ‘incredibly behind’ with his speech development because of his severely limited hearing, and she fears that if he does not have the implants his ‘window of opportunity’ to learn to communicate will be missed.

The pair appeared on the ITV chat show to discuss how they are trying to raise funds to pay for the implants privately, but it was Ben’s natural star quality that caught the attention of viewers.

Viewers called Ben ‘adorable’ as he lifted up his arms, clapped and beamed cheekily – all without ever taking his eyes off the camera.

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Looking for more scapegoats: “Banish bosses who cross moral line, NHS is told”

The management of the Health Services is deficient but it is mainly due to the “rules of the game”. Managers are really administrators working within rules decided by their region or trust. The creative part of “change” in a system is decided by politicians and civil servants do their wishes. The system encourages people to keep their heads down. Jobs in administration and accountancy are safe for life, as long as you don’t do anything creative (risky). Politicians are chairmen of committees want scapegoats… It’s the system that needs changing..

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Chris Smyth reports in the Times 4th April 2018: Banish bosses who cross moral line, NHS is told

The NHS must stop “recycling” unfit bosses and get tougher about banishing those who have “crossed a moral line”, the health service’s chief regulator has said.

Baroness Harding of Winscombe, chairwoman of NHS Improvement, demanded tougher action to exclude those who do not deserve to work in the health service again. However, she said that those who had simply done a bad job must be given help to get better rather than just being “beheaded”.

Lady Harding, who used to run the telecoms company TalkTalk, said she was shocked by how bad the NHS was at managing bosses’ performance.

She told the Health Service Journal: “I think the service as a whole doesn’t differentiate properly between people who have done something that has crossed a moral line, which means they should never be allowed to work in the service again, and people who for whatever reason have not performed at an acceptable level in their senior job.

“The reality is that we have pretty much treated both groups in a similar way, which is a public beheading and then they pop up somewhere else and for neither of those groups is that the right treatment.”

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Political collusion to neglect…? If the Regional Health services were companies they would be bust and run by the reciever

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

This mismanagement of the NHS amounts to neglect

We need more co-payments – not less. But “Stealth dentistry charges bring in millions for NHS”

Co-payments are an important principle in Insurance. They reduce claims. There is no incentive to reduce claiming on the 4 medical health services, except waiting lists/times and in England, prescription charges. In ophthalmology, and in dentistry there are big co-payments. Dental care is riddled with worrying incentives, and the contract with dental surgeons needs changing. But before it is changed we need to re-examine the whole ideology of the health services. With the poorest getting more obesity, and more sugar related dental decay, many in the professions are expecting a rise in streptococcal heart disease. Does the recent rise in scarlet fever (The Mirror) and scarletina reflect this risk increase? Rationing (restricting, prioritising, excluding)is usually reasonable, but it should not be covert. or unequal, or subject to a lottery of where one lives.

Chris Smyth reports for the Times 4th April 2018: Stealth dentistry charges bring in millions for NHS (Be sure to read his analysis at the end

Hundreds of thousands of patients are paying a “stealth tax” when they have an NHS dental checkup, making the government millions of pounds a year.

Within five years NHS patients at a third of surgeries will be paying more than their treatment costs as dental fees continue to rise, an analysis has shown. This will raise £20 million for the government, leading to claims of a “rip-off” tax on treatment.

Just over half of NHS patients pay for their dentistry, with children, pregnant women and those receiving low-income benefits exempt from the charges, which are considerably lower than private treatments.

After charges rose at the weekend, a checkup costs £21.60, fillings and teeth extractions cost £59.10 and complex work such as crowns and bridges costs £256.50. These fees go to the government. Dentists are paid through an arcane system for each “unit of dental activity” (UDA) that they perform.

An analysis of NHS payment data by The Times and the British Dental Association found 331 surgeries that are paid less than £21.60 for each UDA. This means that patients are paying subsidies to the NHS of up to £10 at each checkup, making the government £1.3 million over the next year.

Henrik Overgaard-Nielsen, the association’s chairman of dental practice, said: “When patients put in more towards their care than the government pays to provide it, NHS charges cease to be a ‘fair contribution’.”

The government pays most of the cost for fee-payers at 68 practices. Last year The Times revealed that half of dentists with data available were not taking on new NHS patients.

Charges have been rising by 5 per cent a year. If this continues until 2022, and payments to dentists increase at the previous rate of 1.5 per cent a year, then 2,128 of 6,300 high street practices will be charging patients more than their treatment costs, raising £20 million for the NHS.

Neel Kothari, a Cambridgeshire dentist, said: “For many patients, NHS dentistry has become a fixed price service largely funded by themselves. It raises the bigger question: how much should the government be contributing towards NHS dentistry?”

Dentists say that a fifth of patients have delayed treatments because of their cost, while the UDA system has led to concerns that dentists are incentivised to rush appointments to maximise their pay.

A Department of Health spokesman said that access to services was increasing. “Dental charges remain an important contribution to the overall costs of services and this increase will ensure there is no shortfall in the costs paid by users and those met by the NHS.”

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Dentists rarely kill patients. While this is good, the low risk of toothache puts it way down the NHS priority list (Chris Smyth writes).

Ministers have delayed fixing the NHS payment system that rewards dentists for seeing more patients. The system as it is creates worrying incentives: Desmond D’Mello caused the largest recall in NHS history after secret filming showed him not changing gloves and equipment between patients. D’Mello, who earned £500,000 a year from the NHS, was struck off but not before five patients turned out to have hepatitis C.

For almost a decade the government has been saying that it wants to shift to a system that rewards dentists for preventing illness, but little has been done. At a time when the NHS needs money, increasing charges is an easy way of raising it. But the government profiting from this looks wrong. Ministers may claim that this is the least-worst option, but they should own up to what they are doing.

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

Man’s £54,000 NHS cancer bill raises ethical questions that can’t be ignored. Hepatitic C rationing..

When the inevitable rationing arrives it has to be seen to be just, and have a buy in from patients and politicians. The hard truths around the unaffordability of expensive new drugs, or investigations, will be much less painful if we ration the high volume cheaper items. And we need to ration for all. Meanwhile, by neglect and denial, the health divide will inevitably get larger. Those with means will pay for those treatments that the state cannot afford. And of course the Health Services of the UK face a miserable decade, not just a year, as there are not enough trained people...Desperate times demand desperate measures and paramedics will be licensed (and insured?) to treat emergencies. Lets hope they make the right diagnosis… NHS reality has consistently pointed out the threat of falling standards. When you cannot meet a target you change it. .

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Dolin Bhagawati on Thursday 29th March 2018 reports in the Guardian: The Royal Marsden said Albert Thompson’s treatment requires payment. It’s the first step in applying the same logic to us all The case of Albert Thompson has raised a worrying precedent that should worry NHS workers and patients alike.

….I am a brain surgeon and putting me in a position where I distribute care according to an immigration status puts unnecessary strain on a patient relationship where trust must be established quickly and effectively. It also flies in the face of the underlying principle of the NHS.

Thompson has prostate cancer and needs radiotherapy. He currently lives in a hostel while his cancer goes untreated after being evicted from council housing when the Home Office questioned his immigration status. His situation was looked at by Theresa May who decided not to intervene, stating it was a matter for his hospital – the Royal Marsden in London. Thompson has paid taxes for 30 years.

His situation raises the spectre of another problem as yet not considered in the current discourse – one I have not encountered during my practice as a doctor in the UK for 10 years. Such a problem is illustrated by a case I was involved with, however, in India, where I regularly go back to talk to patients with poor access to healthcare.

Four years ago, I saw a patient in my home state of Assam in the north-east of that country called Horen. He was a thin wiry man in his mid-50s who worked as a manual labourer. His salary was equivalent to £80 per month. He had been diagnosed with a very aggressive brain tumour, had undergone surgery and made a very good recovery – and he showed me his scans (on film – no computer or electronic records in remote rural Assam).

As I held up his pre-operative film to the sliver of sunlight creaking into the dark room we were sat in, my heart sank. This was a large tumour that Horen had no hope of surviving. His surgeon had fought a valiant battle and taken as much could be safely taken while ensuring Horen remained with as little disability as possible.

While I was peering at the film, with the dust dancing and forming a halo around the blue-black plastic, Horen’s husky-voiced Assamese asked me the question that jerked me back to the reality of his situation. “My doctor says I can have radiotherapy, but I don’t know whether I should pay for it or not. How much time will it give me if I pay for it? It’s a lot of money that I can give to my son or daughter.”

Seven years of working in the NHS at that point had made me forget about such dilemmas. Payment was not an issue for those I treated. Horen sat opposite to me, back at work just a few weeks after major brain surgery; he faced this decision in a context of very limited funds, even by Indian standards……..

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Billy Kenber in the Times 30th March 2018 reports on the rationing of Hepatitis C treatments: Drug firms must give £33m of profits to NHS

Drug companies, including the US manufacturer of an expensive treatment for hepatitis C, will have to pay the NHS millions of pounds a year under rules designed to reduce the cost of medicines.

The government is to claw back up to £33 million a year by requiring manufacturers of all branded medicines to return almost 8 per cent of the net income from sales to the NHS.

At present, only companies that have opted in to a voluntary scheme that seeks to control the costs of branded medicines have to make the payment but from tomorrow this will be extended to those in a concurrent statutory scheme.

This includes Gilead, which makes breakthrough hepatitis C treatments that have shown a high success rate in curing the disease without causing the damaging side- effects of other drugs.

Despite the effectiveness of the new drugs, because of their high cost NHS England has limited the number of hepatitis C patients that can be treated to 10,000 a year. A 12-week course of one Gilead drug, Sovaldi, has a list price of almost £35,000, although the NHS is likely to have negotiated a discount.

Hugh Pym for BBC News 29th March: Does the NHS face another year’s misery?

Kat Lay reports: Paramedics given the power to prescribe drugs

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