It is because this failure is hard to measure that it does not get to the top of our politics-driven National Health Service. I am referring to the treatment of the elderly.
You can put a number on a waiting list. You can measure the number of people who survive different kinds of cancers for five years. You can measure how long people wait in Accident and Emergency. But you can't easily measure the number of elderly people who are not helped to eat and drink or the number who are left to lie for hours in their own urine. Perhaps, though, it would be possible to measure how many are lying on hard beds when they should be on air-filled mattresses to reduce the risk of bed sores?
All this is relevant today because the Daily Mail and Radio 5 Live, among others, have given plenty of attention to a report by the Patients' Association about the treatment of the elderly.
Here is a typical example that has been brought forward:
Last November, the grandmother was admitted to Queen’s Hospital in Romford, Essex, with chronic heart failure after the care home where she had lived for a year became worried about her after a fall.
Mrs Dowsett, a local government consultant, brought her mother home-made food.
But although it was placed in front of her, other patients said staff did not help her to eat or drink.
The call alarm buzzer was also repeatedly left out of her reach.
One day, after using a bedpan, she was left calling for help and ‘in a very uncomfortable position — like a turtle on its back’, said Mrs Dowsett, who had twice to go and tell a nurse before anyone went to help her mother on the ‘understaffed’ ward.
Requests for painkillers were refused.
On another occasion she arrived to find her mother ‘looking like she was dead but still alive, screaming in pain, incoherent, clinging to the bed in a foetal position’.
Her mother also developed bedsores, which went undetected for days.
She was discharged on December 3, readmitted to hospital 16 days later and died on December 21 from a heart attack.
An investigation was launched after a complaint by the care home about the bedsores.
A report by the safeguarding adults team found that on the ‘balance of probability’ there was ‘neglect’. It also found her diet and nutrition should have been properly monitored.
The report added that the police were contacted for their stance and they advised ‘it would be a criminal matter if it was an individual who had the sole care of the patient. As it appeared this was the failing of the institution as a whole, they advised that the institution should investigate their own failings.’
That was the Daily Mail report. It is in full here.
And here is how the article begins:
Tens of thousands of elderly people are suffering appalling care at the hands of the NHS every year – pushing complaints to a record high.
For the first time last year, more than 100,000 patients and relatives were forced to issue complaints after being let down by the Health Service.
Hundreds of thousands more won’t have bothered to complain because they have so little faith that the NHS will listen.
Must do better: Complaints about the treatment of elderly patients within the NHS have soared
The Daily Mail is today backing a campaign by leading charity, the Patients Association, for an overhaul of the complaints system to make it completely independent – and end the scandal which sees people forced to complain to the hospitals against which they have a grievance.
And we are backing their appeal to raise £100,000 to boost their helpline which helps angry NHS patients submit complaints and has become inundated in recent years.
I am glad to see the Patients' Association getting so much coverage for this important story. It is good that the British public is increasingly getting to grips with the unwelcome reality that the NHS has major failings. My only slight regret is that the conclusion reached by the Patients' Association is that we should 'call Matron. I have heard this cry for at least the past two decades, probably more. Newspapers and politicians take up the cry but it never seems to result in a real change. And meanwhile there is a failure to face up to the truth that the problem is systemic. The problem is the nature of the NHS - a top-down monolith with all the same sorts of malfunctions and waste that normally exist in state monopolies.
We need to change the system. The OECD lists six different types of healthcare system (see previous entry). Judging by the results we have experienced in Britain, almost any of the others would be preferable. The government should commission an enquiry using people of all political persuasions to look at systems around the world and find the one that would best suit our needs.
At present, many of us have bitter experience of how badly the NHS has treated elderly people that we love. This must change.
Further data on the relatively low standard of healthcare provided by the NHS compared to the systems in other countries. This is from an OECD report:
They found that Australia, Japan, South Korea, Switzerland and Iceland got the most value for money and that if all countries could follow their example, life expectancy at birth could be raised by more than two years on average across the OECD nations.
The report noted that the UK - the seventh most inefficient country for healthcare among the 29 members - had: infant mortality rates among the highest; life expectancy for women among the worst; and one of the highest rates of avoidable deaths with only Portugal and Denmark worse.
"The UK has fewer acute care beds and high-tech equipment like scanners than other OECD countries. It also has fewer doctors and fewer doctor consultations per capita."
The Daily Telegraph, which is not very full unfortunately, is here.
Here is a link to the full OECD report.
Here a few snippets:
An encouraging note about healthcare systems based on private insurance:
Inequalities in health status tend to be lower in three of the four countries with a private insurance-based system – Germany, the Netherlands and Switzerland – indicating that regulation and equalisation schemes can help mitigating cream-skimming and the effects of other market mechanisms which can raise equity concerns
And here is a rather sad comment about working out which system is best:
Efficiency estimates vary more within country groups sharing similar institutional characteristics than between groups. This suggests that no broad type of health care system performs systematically better than another in improving the population health status in a cost-effective manner.
On page 15 of the report the healthcare systems of the advanced world are divided into six types. The categories are not exactly pithy or easy to remember.
The important thing about this story is not that it is new but that it comes from such a source.
Emergency patients are being let down by the health service because managers are more concerned with meeting targets by treating those with appointments, the heads of Royal Colleges warn.
Patients who come in as emergency cases are stabilised and admitted but then left to wait for surgery
In a letter to The Daily Telegraph, some of the country’s most senior doctors say they are “deeply frustrated” at the low priority given to Accident and Emergency.
Targets concerning waiting times and cancelled operations, introduced under Labour, result in managers pushing doctors to operate on patients whose care has been pre-planned, in order to avoid financial penalties. But they can also mean that those who come in as emergency cases are stabilised and admitted but then left to wait for surgery.
Studies have shown that elderly people with fractured hips who do not undergo surgery within 48 hours are less likely to regain full mobility. Younger patients with shattered pelvises, from motorcycle or horse-riding accidents, are less likely to walk again if their operations are delayed.
Full story in the Telegraph here.
A TV programme is coming up on Thursday evening in which I expect I will appear. It is a 90 minute film by Martin Durkin about the huge national debt that has piled up and his solution. He will be arguing against Big Government and he interviewed me about the NHS and about welfare and social housing. Apparently the film also includes interviews with four former Chancellors. I believe he also filmed in Hong Kong.
I wonder if Channel 4 knew what they were in for when they commissioned this film since these kind of arguments - presented at length - are not usually seen on British TV. If the channel knew what it was doing, then all credit to it. Maybe something really is changing in Britain. There was a time when most of the media elite would not contemplate giving airtime to such ideas.
Here is a link to the programme details.
I can announce that grant funding for social care will be increased by an additional £1 billion by the fourth year of the Spending Review.
And a further £1 billion for social care will be provided through the NHS to support joint working with councils – so that elderly people do not continue to fall through the crack between two systems.
That’s a total of £2 billion additional funding for social care to protect the most vulnerable.
Mr Speaker, we will also reform our social housing system.
For it is currently failing to address the needs of the country.
Over ten years, more than half a million social rented properties were lost.
Waiting lists have shot up.
Families have been unable to move.
And while a generation ago only one in ten families in social housing had no-one working, this had risen to one in three by 2008-09.
We will ensure that, in future, social housing is more flexible.
The terms for existing social tenants and their rent levels will remain unchanged, new tenants will be offered intermediate rents at around 80% of the market rent.
Alongside £4.4 billion of capital resources, this will enable us to build up to 150,000 new affordable homes over the next four years.
We will continue to improve the existing housing stock through the Decent Homes programme.
And we will reform the planning system so we put local people in charge, reduce burdens on builders and encourage more homes to be built, with a New Homes Bonus scheme.
Within an overall resource budget for the Department for Communities and Local Government that is being reduced to £1.1 billion over the period, priority will be given to protecting the Disabled Facilities Grants.
This will go alongside a £6 billion commitment over four years to the Supporting People programme, which provides help with housing costs for thousands of the most vulnerable people in our communities.
The full speech is here.
The NHS has been a much-loved institution all my life. I and members of my family have been treated by it, sometimes wonderfully well.
My elderly mother was treated at Winchester Hospital and I remember a staff nurse there who went extra miles to make sure my mother got the care she needed. I know what it is to feel intensely, emotionally grateful to an NHS nurse.
There are certain phrases that capture powerfully the appeal of the NHS idea: ‘free at the point of delivery’ is probably the most potent. Naturally many people are reluctant to consider anything that goes near to giving up on it.
But I think most people want a health service that provides two things: one, a top class service and, two, one which means we don’t have to worry about the cost when we are ill.
The NHS – in general – is indeed free at the point of delivery. But unfortunately, it is not successful at providing a top class service. The data shows again and again that compared to other advanced countries, Britain is seriously below average.
Eurocare, which is funded by the European Union, records how many people are still alive five years after first being diagnosed with cancer. Let us take one of the most difficult cancers: lung cancer. Survival rates are quite low. In England, only 8.4 people out of hundred survive this cancer for five years after diagnosis. In Germany, 14.7 do – more than half as many again.
In stomach cancer we have a particularly poor record. In England, 17 people survive for five years. In Italy, 33 do. To put this another way, 16 people out of a hundred die in England who would not die if they were using the Italian medical service instead of the British. I am afraid that in every single major cancer, the chances of survival in Britain are lower than in other advanced European countries.
How does this happen?
The NHS often has delays. In France, it would be unacceptable to have a cancer patient wait more than a week between diagnosis and treatment. In Britain, much longer waits are not unusual. On the continent, the latest drugs are used far more quickly. In Europe, the average use of drugs introduced in recent years is three times higher than in Britain. This is according to a survey by the Karolinska Institute in Sweden.
We also have a shortage of up-to-date radiotherapy equipment. In a survey of radiologists, they said that three out of four patients who would have benefited from the use of most advanced radiotherapy technology were being treated, instead, with old machines. This is according to a survey in the leading cancer journal, Clinical Oncology. The use of older technology means more damage to healthy tissue.
The below-standard treatment of cancer patients in Britain is something we have a lot of evidence for. But there is plenty of reason to think it is representative of relatively poor treatment of other diseases, too.
On pretty well every measure you can make of a medical service, Britain is well below the average of other advanced countries. Overall, it is probably right at the bottom.
We have fewer doctors per thousand of population than other advanced countries. We have fewer hospital beds for acute care. Germany has twice as many. We have far fewer CT scanners. We have far fewer MRI scanners, too, – a mere fraction of the numbers in Austria, and Finland and fewer even than Slovakia or Greece.
But there has also been a wasting away of the services that do not hit the headlines - the ‘Cinderella’ services. My late elderly mother needed regular physiotherapy on a continuing basis. The NHS in her local authority paid for six weeks and then it stopped. These things don’t usually get measured. But they matter.
An important thing to note about the NHS is that it is patchy. You could be a woman who suspects you have a lump in your breast, sees a GP and immediately finds yourself referred on to a cancer specialist who has you scanned within a day or two and in the operating theatre within a week. It can happen. But there can also be delays at any stage. These delays give your tumour the chance to grow and to make it more difficult for you to be cured.
But what about the second part of what we really want from a health service: not having to worry about the cost?
The most common system in Europe is called ‘social insurance’. Each country operates in a slightly different way. In Switzerland, for example, you need not worry about the cost because you are compulsorily covered by the social insurance scheme.
Those who are less well-off, have their contributions made up to the full amount by the government. Each person can choose which insurance institution to use. It could be one connected with their particular line of work or run by a trade union. These insurance organisations, in turn, choose which hospitals to make arrangements with to provide you with your care.
France has a government insurance company which covers most of the cost of treatment and the vast majority of people take out further insurance to cover the rest. In the German system, you can choose your insurer. Again, everyone is covered.
Singapore has a highly successful system which is a combination of compulsory health savings and insurance. There are plenty of different models around the world.
Ever since the government took over our hospitals in 1948, politicians have been claiming that they have some changes up their sleeves will make the NHS work better. But after 6o years of ‘improvements’, the results are still inferior to those of other countries. It is now reasonable to suggest that the system is inherently flawed.
The simple point is that it is a government monopoly. We know from experience that such monopolies are prone to waste. To give just one example, one survey asserted that in operating theatres less than half the time scheduled for operations was actually used for surgery. The nursing unions say they have to spend a vast amount of their time doing administrative jobs instead of frontline work.
The number of administrative and support staff employed by an NHS hospital compared to the number of nurses is five times what it is in a private hospital.
In countries such as France, Belgium and Germany, there are hospitals and doctors who have to compete on price and quality. One in five hospital beds in France is in a commercial hospital. Two out of five beds in Germany are in a voluntary hospital. The effect of competition on standards is dramatic. In Britain, there have been attempts to create fake markets and competition within the NHS but they have not worked. It seems it is not easy to create phoney competition.
To get a better system than we have now, we need not give up something we value a great deal: the absence of worry about cost. But we should look around the world at other systems. We should then move to one which would still leave us without financial worry but which bring a higher, international standard of care for ourselves and those we love.
This is an unedited draft of an article which appeared in the Daily Express on Tuesday. The article was based on the opening talk I gave in the BBC Radio 4 programme 'Iconoclasts' on 15th September.
I appeared on the Radio 4 programme Iconoclasts yesterday evening, advocating the abolition of the NHS. I and the producers were surprised that the emails coming in ran 3 to 2 in favour of abolition. It seems possible that the NHS does not retain the almost religious respect and love that it once did.
I found that when I mentioned what I was doing to people before the programme, their first reaction was surprise or shock. But then they connected with some recent bad experience that they or people they loved had undergone. These were usually delays or cancellations. In one case it was poor nursing and the writing off of an elderly relative.
After the programme had finished, Gerry Robinson, who had maintained thoughout that the NHS, for all its faults, could certainly be reformed, suddenly said he thought we should abolish it. Ed Stourton wished he had said this during the programme. Dr Sam Everington also expressed more misgivings about it off air.
For seven days or so, the programme is available on the 'listen again' facility of the BBC. I hope this link may work: http://www.bbc.co.uk/iplayer/episode/b00tq7x2/Iconoclasts_Series_3_Episode_3/
During the programme Sam referred to some Commonwealth statistics which he claimed showed that the NHS was performing well. This was contrary to all the varied statistics which I have seen over some years so I was surprised and interested.
I have now found at least one paper produced by the Commonwealth Fund, which indeed takes a positive view of the NHS. I had imagined that he had been referring to the Commonwealth of countries. However this is the Commonwealth Fund which is a private foundation with no connection, as far as I know, to the Commonwealth. The paper does not appear in a peer-reviewed journal, as was the research which I cited. It is the publication of a kind of think tank or research organisation.
The rankings in this paper appear to be based primarily on answers to questionaires. They are what people think, not whether or not people are cured.
With great respect to Sam, who is evidently an exceptional GP with terrific energy and ideas, figures based on people's answers to questions are problematical for two reasons:
1. Opinions and ways of doing things are not as important as outcomes.
For example, one item which was measured was:
Physicians reporting it is easy to print out a list of patients who are due or overdue for tests or preventive care
People have different opinions on how doctors should conduct themselves. But in the end, the important thing is whether or not they cure people. Instead of measuring this, the Commonwealth statistics are partly based on deciding their opinion of all the things a doctor ought to do and then ranking those who do not do those things as inferior. This is not an objective way of ranking medical services.
2. When patients are asked questions, or doctors too, perhaps, they may answer on the basis of their expectations. One person may have high expectations and find a certain experience unsatisfactory. Another might have low expectations and be pleased with exactly the same kind of experience. Again, this is unreliably subjective.
For reference, a summary by BBC Online:
Cost: $940bn over 10 years; would reduce deficit by $143bn
Coverage: Expanded to 32m currently uninsured Americans
Medicare: Prescription drug coverage gap closed; affected over-65s receive rebate and discount on brand name drugs
Medicaid: Expanded to include families under 65 with gross income of up to 133% of federal poverty level and childless adults
Insurance reforms: Insurers can no longer deny coverage to those with pre-existing conditions
Insurance exchanges: Uninsured and self-employed able to purchase insurance through state-based exchanges
Subsidies: Low-income individuals and families wanting to purchase own health insurance eligible for subsidies
Individual Mandate: Those not covered by Medicaid or Medicare must be insured or face fine
High-cost insurance: Employers offering workers pricier plans subject to tax on excess premium
The information and accompanying article here.
And here is a summary from the White House website:
Overview of Health Reform
Health reform puts American families and small business owners in control of their own health care.
* It makes insurance more affordable by providing the largest middle class tax cut for health care in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today. This helps over 32 million Americans afford health care who do not get it today – and makes coverage more affordable for many more. Under the plan, 95% of Americans will be insured.
* It sets up a new competitive health insurance market giving tens of millions of Americans the same choices of insurance that members of Congress will have.
* It brings greater accountability to health care by laying out commonsense rules of the road to keep premiums down and prevent insurance industry abuses and denial of care.
* It will end discrimination against Americans with pre-existing conditions.
* It puts our budget and economy on a more stable path by reducing the deficit by more than $100 billion over the next ten years – and more than $1 trillion over the second decade – by cutting government overspending and reining in waste, fraud and abuse.
The web page with some more details is here.
And here is a view highly critical of the plan from the Cato think tank in Washington:
For better or worse, President Obama's health care reform bill is now law. The Patient Protection and Affordable Care Act represents the most significant transformation of the American health care system since Medicare and Medicaid. It will fundamentally change nearly every aspect of health care, from insurance to the final delivery of care.
The length and complexity of the legislation, combined with a debate that often generated more heat than light, has led to massive confusion about the law's likely impact. But, it is now possible to analyze what is and is not in it, what it likely will and will not do. In particular, we now know that:
* While the new law will increase the number of Americans with insurance coverage, it falls significantly short of universal coverage. By 2019, roughly 21 million Americans will still be uninsured.
* The legislation will cost far more than advertised, more than $2.7 trillion over 10 years of full implementation, and will add $352 billion to the national debt over that period.
* Most American workers and businesses will see little or no change in their skyrocketing insurance costs, while millions of others, including younger and healthier workers and those who buy insurance on their own through the non-group market will actually see their premiums go up faster as a result of this legislation.
* The new law will increase taxes by more than $669 billion between now and 2019, and the burdens it places on business will significantly reduce economic growth and employment.
* While the law contains few direct provisions for rationing care, it nonetheless sets the stage for government rationing and interference with how doctors practice medicine.
* Millions of Americans who are happy with their current health insurance will not be able to keep it.
In short, the more we learn about what is in this new law, the more it looks like bad news for American taxpayers, businesses, health-care providers, and patients.
The weblink which leads on to a book on this subject is here.
And here is the advert for a book by Sally Pipes available on Amazon, also critical:
On March 23, 2010, President Barack Obama signed into law a bill that will lead to the largest expansion of government in the history of the United States. The Patient Protection and Affordable Care Act was more than 2,400 pages long and will reportedly cost a cool $1 trillion over ten years, give or take a few hundred billion.
But sticker shock is just the beginning. In The Truth about Obamacare, Sally Pipes shows how Obama’s health care “reform” will crash into our economy and culture with a tidal wave of regulations that, taken together, will fundamentally alter the way we live, work, and see our doctors. How will all those changes affect you, your family, and your fellow Americans? Pipes goes over the bill with a fine-tooth comb, laying out the specifics of how and why Obamacare:
* will drive the country’s health care bill ever higher, according to the government’s own economists
* empowers bureaucrats to deny coverage of cutting-edge medicines in order to save the government money
* will exacerbate our nation’s shortage of doctors—and in fact, is already causing many to close up shop
* will make health care less affordable by forbidding insurers from offering inexpensive, bare-bones policies
* ratchets up Medicare payroll taxes—and adds brand new taxes on income—interest, capital gains, and dividends
* achieves every penny of its supposed “savings” through a series of legislative and accounting gimmicks
* creates a huge new enforcement bureaucracy—including 16,000 new IRS agents and an astounding 159 new boards and commissions—to hound taxpayers, businesses, hospitals, doctors, and insurers into compliance
* will still leave 23 million Americans uninsured by 2019, according to the Congressional Budget Office.
Is it too late to stop Obamacare? By no means, argues Pipes—who shows how Americans can, and must, force its repeal. Then, she offers ten principles for real reform that would make health care accessible and affordable for all without destroying individual freedom, quality treatment, medical innovation, and the economy.
Just for reference, here is a newspaper story at the time when the report into the Mid-Staffordshire NHS scandal came out. Reading it again is a sobering account of what happened and the terrible care given to patients:
Up to 1,200 needless deaths, patients abused, staff bullied to meet targets... yet a secret inquiry into failing hospital says no one's to blame
By Fay Schlesinger, Andy Dolan and Tim Shipman
Last updated at 1:45 PM on 25th February 2010
. Up to 1,200 patients died unnecessarily because of appalling care
. Labour's obsession with targets and box ticking blamed for scandal
. Patients were 'routinely neglected' at hospital
. Report calls for FOURTH investigation into scandal
Not a single official has been disciplined over the worst-ever NHS hospital scandal, it emerged last night.
Up to 1,200 people lost their lives needlessly because Mid-Staffordshire NHS Trust put government targets and cost-cutting ahead of patient care.
But none of the doctors, nurses and managers who failed them has suffered any formal sanction.
Indeed, some have either retired on lucrative pensions or have swiftly found new jobs.
Former chief executive Martin Yeates, who has since left with a £1million pension pot, six months' salary and a reported £400,000 payoff, did not even give evidence to the inquiry which detailed the scale of the scandal yesterday.
He was said to be medically unfit to do so, though he sent some information to chairman Robert Francis through his solicitor.
The devastating-report into the Stafford Hospital-shambles' laid waste to Labour's decade-long obsession with box-ticking and league tables.
The independent inquiry headed by Robert Francis QC found the safety of sick and dying patients was 'routinely neglected'. Others were subjected to ' inhumane treatment', 'bullying', 'abuse' and 'rudeness'.
The shocking estimated death toll, three times the previous figure of 400, has prompted calls for a full public inquiry.
Bosses at the Trust - officially an 'elite' NHS institution - were condemned for their fixation with cutting waiting times to hit Labour targets and leaving neglected patients to die.
But after a probe that was controversially held in secret, not a single individual has been publicly blamed.
The inquiry found that:
• Patients were left unwashed in their own filth for up to a month as nurses ignored their requests to use the toilet or change their sheets;
• Four members of one family. including a new-born baby girl. died within 18 months after of blunders at the hospital;
• Medics discharged patients hastily out of fear they risked being sacked for delaying;
• Wards were left filthy with blood, discarded needles and used dressings while bullying managers made whistleblowers too frightened to come forward.
Last night the General Medical Council announced it was investigating several doctors. The Nursing and Midwifery Council is investigating at least one nurse and is considering other cases.
Ministers suggested the report highlighted a dreadful 'local' scandal, but its overall conclusions are a blistering condemnation of Labour's approach to the NHS.
It found that hospital were so preoccupied with saving money and pursuit of elite foundation trust status that they 'lost sight of its fundamental responsibility to provide safe care'.
Health Secretary Andy Burnham accepted 18 recommendations from Mr Francis and immediately announced plans for a new inquiry, to be held in public, into how Department of Health and NHS regulators failed to spot the disaster.
But Julie Bailey, head of the campaign group Cure the NHS, condemned his response as 'outrageous' and backed Tory and Liberal Democrat demands for a full public inquiry into what went wrong.
Tory leader David Cameron said: 'We need openness, clarity and transparency to stop this happening again.' Gordon Brown described the scandal as a 'completely unacceptable management failure' and revealed that the cases of 300 patients are now under investigation.
He told MPs the Government was belatedly working on plans to 'strike off' hospital managers responsible for failures. The hospital could also lose its cherished foundation status.
Shadow Health Secretary Andrew Lansley said 'These awful events show how badly Labour has let down NHS patients. It should never again be possible for managers to put a tick in a box marked "target met" while patients are pushed off to a ward and left to die.'
The Francis probe was launched following a Healthcare Commission report on Stafford Hospital in March last year. It found that deaths at the hospital were 27 to 45 per cent higher than normal, meaning some 400 to 1,200 people died unnecessarily between 2005 and 2008.
Two weeks before the report's publication, the Trust's chief executive Martin Yeates was suspended. He eventually resigned in May after being offered £400,000 and a £1million pension pot.
The Francis report said staff numbers were allowed to fall 'dangerously low', causing nurses to neglect the most basic care. It said: 'Requests for assistance to use a bedpan or to get to and from the toilet were not responded to.
'Some families were left to take soiled sheets home to wash or to change beds when this should have been undertaken by the hospital and its staff.' Food and drink were left out of reach, forcing patients to drink water from flower vases.
While many staff did their best, Mr Francis said, others showed a disturbing lack of compassion to patients.
He added: 'I heard so many stories of shocking care. These patients were not simply numbers. They were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated.'
Kelsey Lintern was at the centre of one of the worst tragedies in the hospital’s appalling catalogue of failure.
She lost four members of her family within 18 months, her grandmother, uncle, sister and six-day-old baby.
Mrs Lintern, 36, almost became the fifth victim when a nurse tried to give her pethidine while she was in labour, despite her medical notes and a wristband clearly stating she was allergic to the drug
The full article, with photos of some of the bereaved, is here.
I was researching that old story about the NHS having the third largest number of employees in the world. I came across this from a few years ago:
Jon Hibbs, the NHS head of news, said: "Still peddling that old chestnut about the NHS being the third largest organisation in the world? You may be interested to know that our best intelligence suggests our world ranking is as follows: Chinese People's Liberation Army, 2.3m; US Dept of Defence, 2m; Indian Railways, 1.5m; Walmart, 1.5m.
The article, in the Daily Telegraph went on to cast doubt on it being right to rank the NHS below the US Department of Defence on the basis that perhaps that department actually consists of four organisations - navy, army, marine corps and air force - rather than one.
So anyway, the NHS ranks either fourth or fifth, it seems.
Incidentally, the full article went on to highlight what a high proportion of administrative and support staff the NHS was hiring at the time compared to those who actually look after patients.
How much does an MRI scan cost?
It depends where you are.
In America (see below), it can cost between US$696 and US$1271 in the San Francisco/Sacramento area which is about £455 to £830.
In Britain, one web site says the costs are like this:
What does an MRI scan cost?
These are indicative MRI scan costs in the UK . The price of an MRI scan will depend on the area of the body which is covered.
Body scan (spine, elbow, knee etc) £200 per region
Heart scan £415
Abdominal scan £200
Lung Scan £330
Virtual Colonoscopy £550
These MRI scan costs have been provided by a leading UK provider of private health screening using MRI scanners.
I got the US figures from a Bloomberg story which about the effect of competition and 'market power' which means market dominance - owning a majority or large minority of the facilities.
Two points come out of this:
1. Pricing in the US seems to be higher than that in the private sector in Britain despite the relative lack of competition here. If that is true, why is that? Is there some cost in the US that raises things up?
2. Competition - other things excluded - does make a major difference to pricing.
The full Bloomberg story is here.
Coming up: I am due to be appearing on a Radio 4 programme called Iconoclasts on September 15th. I will be advocating the abolition of the NHS. I will give an introduction of about 900 words. Then there will be discussion, emails, phone calls and so on.
This follows soon after I did some filming for an upcoming Channel 4 programme about excessive and damaging 'big government' which will be shown in about six weeks.
Perhaps, gradually, the post-war belief in big government, including the NHS, is slightly losing its grip. Too many people have observed that big government really does not always work out for the best. But I suspect that 'the government should do something about it' remains the default reaction of most people when confronted with anything imperfect.
In Britain we are now glumly entering the age of austerity and everyone expects unemployment to go on rising. It is normal here for a lengthy lag between growth starting and unemployment falling.
But Switzerland is different. There, unemployment is already falling. It is down from being relatively low in the first place to being even lower. It has fallen from 4.5pc to 3.8pc since January.
If you go to Zurich and ask the reason why, you have a good chance of being told: “employment is picking up fast because it is cheap to sack people”. It is a classic paradox and not the only one to be found in this part of the world.
In recent years, British policy-wonks have looked at how things are done in the USA. Meanwhile the Left has long had a warm glowing feeling about Sweden – usually unsullied by much research into the place. However there may be more to be learned about good social policy in little Switzerland. The country may not, apparently, have invented the cuckoo clock, but it has made a better fist of a welfare state than most countries. That is to say, it gets better results and, just as crucially, it avoids causing as much collateral damage.
The boom in lone and unmarried parenting is one of the ways in which our own welfare state has damaged our society - not only the children involved but also the women and men. Of course I am not blaming all lone parents, only saying that the research shows it is a less than ideal way of bringing up children and the effects on the children are well-documented. In Britain, 46pc of our children are born out of wedlock. In Switzerland the figure is vastly lower at 16pc.
So what happens, I asked, if you are, say, a young mother in Switzerland with a little baby but no husband or similar on the scene and nowhere to live? There is no countrywide answer to this question because it is not dealt with on a national basis at all. It is not even dealt with by one of the 26 cantons. It is dealt with by your local commune. There are 2,900 of these and the population can be anything between 30 and over 10,000.
Officials from this ultra-small local government will come and investigate the circumstances individually. The father will be expected to pay. The mother’s family, if it is in a position to, will be expected to house and pay for her. As a last resort, the young mother will be given assistance by the commune. But the people who pay the local commune taxes will be paying part of the cost. You can imagine that they will not be thrilled at paying for a birth or separation that need never have taken place. Putting yourself in the position of the mother – and perhaps the father – you can imagine that you will be embarrassed as you pass people in the street who are paying for your baby. Instead of feeling you have impersonal legal rights, as in Britain, you are taking money from people you might meet see at your local café. No wonder unmarried parenting is less common.
A similar system applies if you need means-tested benefits. Those made redundant receive, for a while, generous unemployment insurance payments from the cantonal governments. But once these payments run out, people depend again on their local commune. You would be cautious of claiming fraudulently because, if you worked in the black economy, your chances of being spotted would be high. And so it is that Switzerland has the second highest rate of male employment in the OECD. Britain’s rate is about 50pc worse.
Switzerland has arguably the most successful system of healthcare in the Western world. It is an insurance system with a twist. You are obliged to take out health insurance but you can choose which company to use. There is no state monopoly. So you can choose an insurance group which is connected to your line of work. Or you could go with a trade union-run insurance cooperative. Or a private, commercial company. That means there is some competition among these companies to provide the best possible service for the lowest possible price. Then these companies, in turn, have some choice over which doctors and hospitals they commission to work for them. So again, the doctors and hospitals have to compete to offer the best facilities and treatment at the lowest possible cost. The pressure is on and the performance is one of the best in the world. Poorer people get credits which enable them, too, to choose insurance.
The Swiss health service is decidedly superior to that in Britain, too. It has more doctors per capita, more advanced scanners, better cancer outcomes and so on and on.
All right, it is not perfect. Costs have been running ahead because, effectively, people get treated for free and since the service is easily available and good, they tend to overuse it. Thus the costs have been rising worryingly, as with other social insurance systems. However, it is still one of the best systems around. It provides less of a barrier to employment than most social insurance systems. The cost of the premiums is borne by individuals, not shared with companies as in Germany.
Swiss schools are also better, on average, than British ones. That has, again, surely got a lot to do with local control – not the fake kind that we are used to. Primary schools are run by the little communes and secondary schools and universities by the cantons. It means there are villages where the officials in charge of a school will all know the headmaster and many of the students. There is much less wasteful bureaucracy and much more direct accountability. But I should add that I gather home-schooling is virtually illegal. Those of us who care about the freedom of the individual versus the state do not like this part of the system one bit.
But the Swiss system really scores over ours when it comes to preparation for work. We have got used to Labour politicians and some Tory ones, too, spouting that university education is vital for economic success. This theory was comprehensively debunked in Alison Wolf’s book Does Education Matter? The Swiss example is an illustration that it is nonsense. While Tony Blair was claiming that half of young people must go on to university for economic success, Switzerland was and remains content to have a mere 24pc doing so. It has, at the same time, achieved much greater economic prosperity. Education is only compulsory until the age of 15 but actually the vast majority keep going voluntarily because the schools, colleges and universities are pretty good.
Most of the other three-quarters of students progress from school to vocational training. They don’t do airy-fairy theory. The training typically consists of one and a half days a week at college and the other three and a half at a commercial company. This truly prepares people with the skills and attitudes desirable for a successful career. The result? Switzerland has only 4.5pc youth unemployment compared to 18pc in France where they have the supposedly economy-boosting 50pc of students at university. It seems that writing essays on Racine does not make you a shoe-in at a pharmaceutical company. Funny that.
Let’s be honest. No welfare state is perfect. All of them do damage of one sort or another. And there are some claustrophobic, controlling elements in the Swiss system that are unappetising to British taste. There is a continuous pressure there towards centralisation and regulation. But there are plenty of lessons worth learning amid those lakes and mountains. The Swiss way of welfare is a darn sight better than the British.
The above is the unedited version of an article which appears in this week's Spectator magazine. I would simply link to the Spectator website but I can't locate the article there.
The study of 400 NHS operating theatres found that last year, less than 50 per cent of time scheduled for operations was actually spent performing surgery.
In orthopaedics, the biggest specialty, just 45 per cent of "operating time" was spent on surgery, while 33 per cent of time was lost to late starts and decisions to stop work early.
In ophthalmology, only 40 per cent of allocated time was devoted to operations – while 37 per cent of time was wasted at the start and end of the day.
Gaps between treating patients, cancelled operations and gaps on the surgery lists accounted for thousands more hours wasted.
The study by the NHS Foundation Trust Network examined detailed timekeeping records kept by clinical teams at 40 NHS trusts, as they performed 26,000 operations.
This story was from the Telegraph. What would be really useful, of course, is a comparison with other hospitals. How do private hospitals fare here and in other countries?
One of the key reasons that state-run bodies tend to provide less in the way of service at a greater cost is the waste that tends to build up in them over the years.
People are usually aware, though they may not like to admit it, that this is true. So you have politicians declaring at elections: "we will maintain/increase the front line services".
So what are the 'front line services'. They are the services of people like nurses, who actually treat the patients. These nurses are contrasted with the bureaucrats who do lots of paperwork which, it is implicitly accepted, involves a lot of work that is not really as necessary or important as the nursing work.
So the Labour government used to boast that it had increased the number of nurses. That is doubtless true. However, what if it also, at the same time, changed nurses into semi-bureaucrats? You could say, increase the number of nurses by 15% but increase their paperwork time from, say, 25% to 45%. In doing so, their front line time would be reduced from 75% to 55%. That, if you are still with me, would me a 26.7% reduction in their front line work, per person. So, overall, even after the increase in the number of nurses, the amount of 'front line' work would fall.
The numbers I have used are not the real numbers, just an illustration of how this is possible. Here, then, is an indication of the actual proportion of time nurses may now be spending on paperwork, given by the new Health Secretary, Andrew Lansley:
“They often spend just 50 per cent of their time interacting with patients, and in some cases as little as 35 to 40 per cent, because of bureaucracy and the shift system.”
The Royal College of Nursing has repeatedly warned that nurses were being bogged down by the weight of administrative duties.
In 2008 nursing staff across England spent more than a million hours a week on paperwork, the union found, time it said could be better spent tending to patients.
A survey of nurses also showed that most believe that the administrative burdens placed on them had increased over the past five years.
The full article is in today's Daily Telegraph.
This story is a possible lead as to how it was that such a vast amount of extra money was poured into the NHS by the Labour government resulting in a relatively modest improvement in the performance of the NHS.
In the use of new drugs for cancer, we lag several years behind other countries - especially the USA. Now here is evidence that the NHS is even more behind in the use of the latest techniques in radiotherapy. It would appear that the Cyberknife has only started to be used in Britain this year.
...the CyberKnife (pictured above) allows clinicians to target certain cancers much more accurately without affecting the surrounding tissue. The new technology also offers an option for treating tumours that used to be inoperable.
Some of the first British patients to benefit from the CyberKnife, have been treated at the London Clinic since the beginning of the year, following the opening of a new, £80 million cancer centre.
The new machine is at a private hospital but is also available to be used by the NHS.
The UK lags behind many other European countries in the provision of CyberKnife treatment, and similar machines such as Novalis Tx and Gamma Knife. They have been in use in the US for 10 years, initially for brain tumours, and, in the past few years, for lung cancer. They are now also licensed in the US for use in head, neck, lung and pancreatic cancer.
Here is the full article.
The research found that last year, at least 747 women were turned away from maternity units because they were full, or because staff could not guarantee a safe delivery. That equates to an average of two a day.
Full article in Mail
It reminds me of how my own second child was born in the bathroom. We had rung an hour before but were told there was no need to come in yet. Later we were told that the hospital's maternity ward had been at the limit of its capacity. I have since suspected that the midwives knew that they should delay admissions as long as possible. In our case, too long.
Our experience chimes with this comment in the article:
Cathy Warwick, general secretary of the Royal College of Midwives, said: 'There is no doubt that some units are operating at or near their capacity much of the time.'
What was that terrific piece of rhetoric that Neil Kinnock once came out with? He warned that if the Tories won an election he was fighting, "Don't be old, don't be poor..." or something of that sort. Well, with the NHS to rely on, "don't be pregnant".
The NHS has been made a non-issue in this election campaign as if all were fine. All the parties, I think, say that they will maintain or increase funding in real terms. So that's all right then. Except that evidence keeps on piling up that it is not.
Here is the latest about overworked and under-experienced doctors in Accident and Emergency departments at night:
On average, the survey found doctors were responsible for 61 patients, but the range was from one to 400. Almost one in 10 teams reported that the most senior member on duty in charge of a ward was a junior doctor in their first two years of training. Only 6 per cent of teams included a consultant on duty at night.
This information is very much in tune with what I was told by a consultant at a large, well-known hospital in West London. She said that every month the senior people at the hospital meet to discuss the accident and emergency department. And while it takes well over 20 people to discuss it, meanwhile, in the department itself, there was sometimes just one doctor on duty through parts of the night. This is the problem of the NHS in a nutshell. There are lots of staff but only a minority of them are actually doing front line work.
The result, when you go to A&E, is that - despite the targets and the attention the problem gets - there are long delays and people are seen by doctors far more junior than is desirable. The accident and emergency care in Britain is poor and we have no choice. I have several recent anecdotal reports of people waiting hours to be seen. Too many doctors are junior and the ones who are there are rushed off their feet.
Incidentally this story does not appear to have been covered by the BBC. A search of Google News suggests that only three or perhaps four newspapers have covered it. But for all of us who expect that sooner or later we or family members we love may depend on an A&E department, it matters a great deal.
The above quote was taken from the coverage in the Independent.
Of course if it is that bad in a part of the NHS that gets a lot of attention, it is bound to be worse where publicity is not so easily obtained.
This from the Mail:
The survey of GPs, in Pulse magazine, shows that patient services are being directly affected by the Whitehall directive.
Pulse asked 370 GPs whether cutbacks were occurring in their
areas. Fifty-five per cent said they were, and another 33 per cent said they were planned within the next few months.
Dr Krishna Chaturvedi, a GP in Southend-on-Sea, Essex, said he was seeing cuts in his region, including in blood tests and the loss of a health visitor.
Community nursing is also suffering, as is end-of-life care and dietetic and nutrition services. 'The list is endless,' he said.
If you are going to fall from a horse and break your back, try to do it in France, not Britain:
The lower, lumbar region took the full impact and the pain was instant and appalling. When the ambulance came, I was strapped to a body board and taken to a local hospital. An X-ray confirmed I had broken my back and was in grave danger of permanent paralysis, so I was transferred to Pellegrin, a large teaching hospital outside Bordeaux.
The hospital was immaculate and the staff attentive and professional. I was bedbathed daily – virtually unheard of in British hospitals – my sheets were changed every day and the two-bed room was cleaned and dusted on a rolling basis. I later discovered that France is tackling MRSA by making nurses personally responsible for the cleanliness of their wards – it showed.
In the UK, by comparison, contract cleaners are employed. That shows, too.
My medications were always on time and there was an air of pride about the place that instilled confidence in me, despite the language barrier. After the most traumatic week of my life, when I lay terrified and immobilised on a morphine drip, I underwent surgery.
My L2 lumbar vertebra was crushed, so titanium screws were drilled into the L1 above and L3 below, to hold that section of spine in place as it healed. The pins were designed to stay in permanently.
The operation was deemed a success and, post-surgery, the nurses – a kind but forceful bunch – had me sitting up in a chair within three days, which involved a lot of screaming and moaning and was a far greater feat than it sounds.
By day six I was walking with a frame, which they took away after 20 minutes – so I could climb the stairs. It was a steep relearning curve, but I felt supported and looked after. I didn't have any travel insurance, but the bulk of my medical expenses were paid for under the European Health Insurance Card scheme (formerly covered by the E111), although I had to pay about £2,500 for ambulances and drugs.
I returned to Britain, weepy and sore, a week after the operation, to a very different scenario. My husband hired a private ambulance to take me home from the airport, because the NHS doesn't do airport pickups and I made it home breathing gas and air to help numb the pain.
It was all downhill from there. My GP had arranged for a community nurse to visit me that day, but she never came. It was left to my husband to change my dressing, and I had to inject myself in the stomach with the blood thinners prescribed to prevent deep vein thrombosis because I was so inactive.
The next day it was a similar story, so we rang and asked the nurse not to bother coming. But she turned up, with such a sullen, surly manner I decided I'd rather inject myself. She took 20 minutes apply a dressing that fell off before she'd reached the garden gate. Again, we phoned and said we didn't want a nurse – but still someone appeared on our doorstep for the next three days.
At my local hospital, Homerton Teaching Hospital, in east London, I saw a back specialist, who examined my X-rays and gave me a back brace to wear 16 hours a day, telling me that if all went to plan it would come off after eight weeks. When I returned for my next appointment, he was no longer at the hospital.
While orthopaedic doctors are trained to treat broken bones, backs are such complex structures that it is absolutely crucial to see a skilled specialist, as I did in Pellegrin.
But I was told by a general orthopaedic consultant – who, rather worryingly didn't seem to know how read my X-rays – that this wouldn't be happening. Instead, I would be seen in a fortnight by someone who "knows a little bit about backs".
"I mean, it's not as if he's never seen a back before, heh, heh," he laughed. "It's just that – and I'll be honest with you – he's not an expert. Is that all right with you?"
"Um, not really, no," I said, weakly. "That's not all right with me. Do I have a choice?"
He shrugged, smiled and said I didn't.
This is from an article by Judith Woods in today's Telegraph.
Of course it is only an anecdote and does not prove anything. But it is part of a great deal of evidence.
Actually the article leaves a number of questions unanswered including the nature of the ownership and management the French hospital she went to. But the nature of the unreliable NHS service is well described. Sometimes you feel you are at the mercy of an organisation which gives and takes as it sees fit and/or insofar its serious limitations allow. The patient has little power or ability to choose and sometimes has to plead or try to use contacts to get the treatment needed.
NHS total staff 1.43 million - up 30% compared to 1999.
Managers 44,600 up 84%
Administrative and technical support staff up 40%
Nurses 375,500 up by 'a quarter'
Junior doctors up by 'two thirds'
GPs up by 'nearly a third'
Consultants up by 'more than half'
These figures quoted in the Telegraph show that the fastest growing category of people in the NHS has been that of managers. They are ones who are well paid and do no front line work curing or caring for patients.
The Telegraph article does not make it clear where the data comes from.
Here is more information from the coverage in the Guardian,
The number of managers in the NHS in England rose by nearly 12% last year - more than five times the rate at which qualified nurses were recruited, sparking concerns that cash was being diverted from frontline staff.
Despite claims that NHS bureaucracy has been cut the health service has seen an explosive growth in management. The survey shows that the NHS now employs 44,660 managers and senior managers - an annual average increase in their employment of 6.3% over the last decade. This is faster growth than consultants, doctors, nurses and midwives.
A census by The NHS Information Centre reveals staff numbers reached 1,432,000 in 2009 - an increase of 63,300 (4.6%) on the previous year. It represents a steep acceleration in hiring. Staff numbers have grown by 2.7% on average every year over the last decade
The disclosure that just two GPs are available for out-of-hours duty in the county of Suffolk is the inevitable consequence of the contract with family doctors negotiated by the Health Department in 2004. Such sparse coverage is now commonplace throughout rural England
From an editorial in the Telegraph on GP out-of-hours services.
That was a line from the Daily Mail coverage of the latest comparative medical outcome figures from the OECD. What is remarkable is that most other newspapers gave the figures so little coverage. I have searched the Guardian website using the words 'OECD cancer' and got nothing on the story at all. The figures were, however covered in the Daily Telegraph, among other newspapers. But even there the news was less prominent.
Maybe news editors reckon that everybody knows that British healthcare is among the least effective in the developed world. Maybe such figures have come out so often that they are not considered worth reporting any more. Is the failure of the NHS becoming the elephant in the room which no one comments on any more and which some people prefer to think is not there?
Yes, these sorts of figures have been revealed before. But for the past decade, the Labour government has been ploughing enormous amounts of extra money into health care. Is it not of interest that this gigantic boost has left us, still, with one of the least effective health care systems in the advanced world? Should that not tell us something about the NHS system?
In the USA, you have a 90.5pc chance of being alive 5 fears after diagnosis with breast cancer. In Britain you have a 78.5pc chance. The OECD average is 81.2pc. If you are diagnosed with bowel cancer in the USA, you have a 65.5pc chance of surviving five years after diagnosis. In the UK you have a 51.6pc chance.
What about if you have a heart attack? In the UK you have a 6.3pc chance of dying within 30 days of being admitted to hospital. In Denmark you are half as likely to die. If you have a stroke, it is even more important to be outside Britain. You have a 17.4pc chance of being dead 30 days after admission to a British hospital. If you were in Austria, you would be far less likely to die: the figure is 7pc.
It is wholly true that cancer survival rates in Britain are improving. But they are improving around the rest of the world, too. The NHS continues to underperform compared to virtually all other health care systems. Some would like to follow the American system. Some would like the German or the Swiss model. Frankly, in terms of outcomes, any system other than the national government monopoly in Britain would be better than what we have now.
- The OECD press release shows that the USA spends a higher proportion of its GDP on publicly-funded healthcare than Britain.
- Most figures for cancer survival that I have seen before compare only the European countries with each other. This one shows the USA, too, and the figures I have seen so far show it to be doing better than Europe.
- Life expectancy is not a good way of measuring medical care systems. Life expectancy is strongly influenced by lifestyles. Those who are fat will, on average, die younger than those who are not. No medical system can turn that around. The most effectice health care reform that could take place would be if the people of a country adopted the traditional Japanese diet or something of that sort.
For years I have heard it said that, in an emergency, an NHS hospital is the best place to be. Actually it is the only place to be since there are no casualty departments in British private hospitals. But being the the 'best place' does not mean it is a 'good place' or a fit and proper place, functioning to the best international standards.
One thing you would hope for, if you or one of your family were admitted in an emergency, is a senior doctor on hand. Perhaps in a big city you might even hope for a few consultants on duty. You cannot rely on anything like that in British NHS hospitals as this news item revealed:
AN A&E staffing crisis is risking patients lives, it was revealed yesterday.
Nearly a third of casualties had NO senior doctors on duty on sample nights.
And one in eight had only a junior doc in charge.
There was also a shocking lack of permanent staff. Some hospitals admitted HALF the doctors and nurses on duty came from agencies.
The Tories, who uncovered the figures, warned it put A&E users at risk.
Last year there were 32,017 "patient safety" incidents in casualties, the highest number since 2002.
There has also been a surge in clinical negligence cases against units.
Last year, there were 701 claims - totalling £116.5million - up from 46 cases in 1997.
Freedom of Information requests asked how many staff were on duty on two nights in March.
Of 157 hospitals to reply, 47 admitted no senior doctor was on duty.
In 19, a junior doc was the highest ranking worker.
The complete article is here.
The second class nature of the NHS is revealed in many ways but not often is the exposure so clear as it is with the refusal of the NICE to permit the use of sorafenib.
Every other major country in the EU makes the drug available on the state's healtchare or insurance system. That last sentence is not mine, it was written by Professor Karol Sikora, the well-known cancer specialist and former chief of the World Health Organisation Cancer Programme. He went on:
Indeed, in France, the drug has been given to patients ever since it first came on the market in 2006.
That is why the usage in France is 13 times higher than it is here. Meanwhile, in Britain, it was largely confined to private patients while the NHS waited for Nice's verdict.
He also says, "The costs of sorafenib are not exorbitant, but the effectiveness is striking." Sorafenib is for liver cancer. It extends life for an average of three months. The range of life extension is between nothing and three years.
Karol Sikora's full article is here. Incidentally, do not be surprised if most cancer doctors keep quiet in public. It is part of their contract not to speak out. Only top people like Sikora dare to tell the truth despite government pressure to keep it from the electorate.
One other thing: next time one may be tempted to think that waste and bureaucracy don't really matter, remember that the British get second rate healthcare without drugs like sorafenib because there is not enough money to go round. There is not enough money to go round because in state run monopolies there is enormous waste and bureaucracy (see here and the category 'waste in public services'). Red tape kills.
The newspapers in the past few days have been stuffed like a Christmas turkey with articles illustrating the waste that takes place in publicly-owned services:
- the Ministry of Defence employs about one civil servant to every 2.25 members of the armed forces.
- the government intends to prohibit anybody without a university degree from becoming a nurse, thus increasing the cost of each nurse and reducing the number of years he or she will work.
- the top 100 staff of the BBC are paid £20m a year plus bonuses and entitlements.
- the police have issued a 93 page booklet informing its constables how to ride a bicycle.
These things are even worse than they appear:
- the money that is wasted in this way cannot then be spent on things that are actually important like more soldiers and sailors, better equipment for them and more nurses. There are already shortages now in all these areas. Nurses are already rushed off their feet and unable to give satisfactory attention to patients. This is bound to get even worse as a result of the university rule. The shortages of men and equipment in the army have been prominent in recent news.
- Secondly tax has to be raised to pay for the waste. This tax is levied on poor people, too. The government already demands taxes of those people whom it defines as being in poverty. The extra tax also means extra discouragement to those who might otherwise move from benefits dependency to employment. Without work, they have less hope and self-respect. And the cost of any decision to stay on benefits means extra taxes on those remaining in work.
Waste in public services is normal. It always happens, sooner or later. And it is not a victimless crime.
(Extract from the Daily Mail
The Ministry of Defence by numbers
85,700 civil servants at the ministry
113,000 personnel in the Army
38,400 in the Royal Navy
41,400 in the RAF
So according to these figures, there are 192,800 members of the armed forces and there is one civil servant for every 2.25 members of the armed forces.
Essential reading for understanding how the NHS receives a lot of money from government but is always short of it for spending on healthcare.
There is a very similar story to be told in education, too.
In my previous entry I suggested we should take a closer look at those healthcare systems which came out best in an international survey. How do they work? Should we move in their direction?
Nick Cowen has suggested the Civitas report Quite like heaven? Options for the NHS in a consumer age for information on the Dutch system of healthcare which came out well. There is also information of the Swiss system which also come out well.
I went to the Civitas web site and found this highly relevant part of the summary:
Evidence from abroad, particularly countries such as Switzerland and the Netherlands, indicates that it is possible to deliver universal and comprehensive healthcare, equitably and to higher standards than in the NHS.
The Dutch, in particular have succeeded in setting up a system that has the potential to harness the benefits of real competition and real choice, through insurance arrangements, while maintaining health care for public benefit through tax credits and a Health Insurance Fund.
In both systems the government is neither the provider, nor main funder, of health care, but regulator. Political interference is at a premium compared to the NHS.
The ability of the patient to choose between insurers, insurance packages and hospitals ensures the system is patient-focused. Patients are a lot more cost-conscious and, if they don't like the health care they receive, they can vote with their feet and go elsewhere.
The power of exit for providers is real and acts as a powerful incentive for them to drive up standards. (ch.5)
So two of the top-ranking systems appear to include two layers of choice for the consumer: among insurers and among providers of healthcare.
[I am afraid the 'comment' facility on the website does not appear to working reliably at present. I have asked the website host if this can be fixed.]
<em>The Daily Telegraph reports that Britain has been ranked 14th out of 33 national health systems in Europe. Naturally one may cast doubt on the methodology of the analysis but all the same it might be worthwhile considering exactly how the systems that are ranked highest work. They are:
1. The Netherlands
I have heard quite a detailed description of the Swiss system which sounds interesting and preferable to the German one. But I know little of the systems in the four countries ranked above this pair.
Interesting article about President Obama's healthcare proposals. It emanates from the Cato Institute.
Obama is moving on towards his reforms of American healthcare. The Cato Institute is mounting a carefully argued opposition to his reforms.
The existing US healthcare is, of course, bad in a number of respects. It is just less bad that British healthcare. One of the agreed faults of American healthcare is its ridiculous cost.
Here are a few ways in which the cost could, perhaps, be reduced:
1. All people could be allowed to buy the insurance they want instead of coverage dictated by their state. (See excerpt from Cato paper below.)
2. Break up the cartels that I suspect may exist in US healthcare such as accredition only by a very limited number of associations for doctors and nurses. This kind of cartel leads to many, expensive years of training which are an unnecessary expense if a practitioner is going to work exclusively, say, in in obstetrics. The customer pays for massive over-qualification. Competition in accreditation would bring down costs and allow innovative, lower-cost solutions.
3. Reduce the awards given by courts for medical malpractice. These big awards increase the cost of a doctor's insurance which, I gather, can be amazingly high. If the awards were lower, the doctor's insurance bill would be lower and the customer's bill would be lower. The laws on what constitute malpractice may well be worth revising, too.
I expect there are plenty more, major savings to be had. American healthcare could perhaps be half the price without sacrificing any quality at all.
Here is an excerpt from the Cato paper in which the policy proposals of Obama and also McCain were discussed. Here is the section on McCain's liberalising ideas:
Whereas Senator Obama’s plan relies
heavily on new regulation, Senator McCain
generally calls for deregulation, particularly
in the area of insurance.
Most notably,McCain would allow people
to purchase health insurance across state lines,
a practice that is currently prohibited by state
laws. Since health insurance is largely regulated
at the state level, one of the major reasons
that costs differ so from state to state is
because of the varying regulations and mandates
that states have chosen to impose.
For example, New Jersey has imposed more than
40 mandated benefits, including in vitro fertilization,
contraceptives, chiropodists, and coverage
of children until they reach age 25.
The state has also adopted community rating
and guaranteed issue. In part as a result of this,
the cost of a standard health insurance policy
for a healthy 25-year-old man would average
$5,580 in the state. A similar policy in
Kentucky, which has far fewer mandates and
no community rating or guaranteed issue,
would cost the same man only $960 per
year. Unfortunately, consumers are more or
less held prisoner by their state’s regulatory
regime. It is illegal for that hypothetical New
Jersey resident to buy the cheaper health insurance
In contrast, if consumers were free to purchase
insurance in other states, they could in
effect “purchase” the regulations of that other
state. A consumer in New Jersey could avoid
the state’s regulatory costs and choose, say,
Kentucky, if that state’s regulations aligned
more closely with his or her preferences. Many
consumers would undoubtedly choose less
regulation. For example, young and healthy
individuals with low incomes may choose not
to buy coverage that forces them to subsidize
older, sicker (and generally wealthier) individuals.
For those risk-adverse individuals who
prefer greater regulatory protection, the cost
of those protections would be reflected in
Senator McCain’s proposal would permit
this type of interstate competition. With millions
of American consumers balancing costs
and risks, states would be forced to evaluate
whether their regulations offered true value or
simply reflect the influence of special interests.
As McCain says, “nationwide insurance markets
that ensure broad and vigorous competition
will wring out excessive costs.”
McCain would also allow people to purchase
insurance through nontraditional groups. Today,
three types of organizations can offer group
insurance: employers,unions, and trade associations.
McCain would open this to other groups,
notably churches and professional organizations.
More problematically, he would also allow
small businesses to band together in “association
health plans” (AHPs) to gain benefits
from pooling their risks. That makes sense if
the AHPs can choose among competing state
regulations, but there are reasons to be concerned
over creating federally regulated
AHPs. Doing so would be a step toward
greater federalization of insurance regulation.
As costly and damaging as much insurance
regulation is today, it is at least somewhat
restrained by the fact that special
interests are forced to lobby in 50 state capitals.
Fundamental to McCain’s vision
of health care reform is
changing not just who pays for
health care, but how that health
care is paid for.Moving the locus of insurance regulation
to Washington would simply create a
“one-stop shopping” center for lobbyists.
On the supply side, McCain supports
“innovative delivery systems, such as clinics in
retail outlets and other ways that provide
greater market flexibility in permitting appropriate
roles for nurse practitioners, nurses, and
doctors.” His campaign speaks of healthcare
being offered through a variety of venues such
as “Minute Clinic, COSTCO, banks, investment
such as Wellpoint, Humana or online services
such as Revolution Health, Google Health,
etc.,” with the government’s role limited to
establishing “some standards of transparency,
He has also called for “different licensing
schemes for medical providers.” In particular,
McCain has suggested that some types of
care could be shifted to nurse practitioners
and other allied health personnel. “We need to
have flexibility in the delivery of care so physicians
can spend more time on the tasks they’re
suited for,” a McCain advisor explained.
Although most medical licensing and scope of
practice laws are a state, not a federal,
purview, there are some actions McCain could
take in this area, particularly in terms of federal
Unfortunately, not all of Sen. McCain’s
proposals are free-market oriented.
Treatment of cancer in Britain frequently involves
- late diagnosis
- delayed investigation through scans and other tests
- tests using less than ideal equipment
- non-use of the latest drugs
- delayed treatment
The Daily Mail has pulled together a useful article describing some of the treatments and investigations which a cancer patient in Britain may not get.
Here is one section on PET scanners:
Positron Emission Tomography (PET) scans are immensely sophisticated, showing how body tissues are working. But they're expensive, so many surgeons have to rely on the results of a CT scan (computerised tomography) which is less detailed.
It means in some cases it is only when the surgeon begins operating that they realise a patient is not suitable for surgery, because there are tumours the CT scan hadn't spotted.
Dr Fox adds: 'The last thing a patient needs is an operation that's useless.'
An estimated 20 per cent of operations have to be aborted because of this.
Concerned patients can ask their specialist to refer them to a hospital with a PET scanner, says Dr Fox. However, they might not be granted their request.
I expect there are figures available on the number of PET scanners in Britain per million of population compared with the equivalent fitures for other countries. If anyone is willing to obtain and send me the figures, I will upload them.
A man called Arthur (I didn't catch his surname) was on Radio 5 Live this morning saying that the equipment for treating prostate cancer in Britain is antique. He had had a recurrence of cancer a few years ago and realised that he would need radiotherapy.
He went did some investigation using the internet. He found that the NHS had none of the latest machines available at that time. The only ones in Britain were at the Harley Street Clinic and Cromwell Hospital (both private). Even these were not the very latest models. For these, you had to go to America. There they had a machine which was far more precise in killing the cancer with far less damage to the surrounding area.
I am not sure in what year he did his research. I have not done any research to check his story. So I do not pass this on as evidence of any strength. I only mention it as a lead for inquiry and verification.
A disturbing account of deaths at an NHS hospital in Gosport. It presents concerns not only about the hospital, but about operations of the coroner's office. My own personal experience of a coroner's office in London was not good. These officials seems to be a law unto themselves.
The story does not appear to put the General Medical Council in a good light, either.
Several ways have been revealed recently in which official NHS statistics have been manipulated.
The target: achieving a wait for patients in accident and emergency of no more than four hours.
Why claims of achieving this target are misleading:
1. The ambulance bringing the patient to the hospital is kept waiting outside. The hospital simply declines to accept the patient. This means that the starting time of the four hour wait is delayed and the hospital can claim it is meeting the target.
2. The hospital refuses to accept any emergency patients for a while. The patient has to be transported to a different hospital. This enables the first hospital rightly to claim that patients who get into the hospital are not kept waiting for more than four hours.
Why are the hospitals so keen to meet the target? Because the hospitals receive less money from the government if they fail to meet it.
Who or what suffers? Of course the patient suffers from being kept waiting for emergency treatment for more than four hours. In the second case, the patient may be carried to a hospital that is much further away, delaying treatment. Also people suffer who need an ambulance but cannot get one because ambulances are being kept waiting outside hospitals or taking journeys to hospitals far away. But this suffering is not a direct result of the target. It is a result of inadequate emergency provision in NHS hospitals. What suffers directly as a result of the target and the cheating on the target is the truth and public awareness of the truth. That, of course, suits the government well. The truth that is kept secret from the voters is the extent to which the massive increase in spending on medical services in Britain has been wasted. We simply do not know the extent because NHS statistics are lies.
The evidence: The information for these assertions comes from the article by Laura Donnelly in the Sunday Telegraph in which she quotes from letters sent between NHS senior executives obtained under the Freedom of Information Act. It also comes from comments she obtained from Katherine Murphy of the Patients' Association and Sam Oestricher, ambulance representative of the unison Unison.
Here is a part of the article:
In one of the letters, disclosed under the Freedom of Information Act, Sir Graham Meldrum, chairman of the ambulance trust, said patients were "being put at risk on a daily basis", with 7,600 delays last October - a position which has since deteriorated further.
Sir Graham Meldrum wrote: "The risks of delayed handover cannot be overstated.
"The constant and prolonged delays present risks to two patient groups: 1. the patient waiting in the corridor, with less than ideal clinical care, and forced to endure cramped/busy corridor environments, 2. the patients who dial 999 in an emergency and receive a delayed ambulance response, while ambulances are rendered unavailable whilst queuing at hospital departments."
The letter, sent last November, followed warnings from the ambulance service's head of operations that repeated closures of casualty units to 999 arrivals were putting patients in danger.
Over a six month period, hospitals in the West Midlands closed their A&E units to all ambulances on 472 occasions, forcing 999 crews to take seriously-ill patients on lengthy journeys in the search for hospital care, the documents say.
More than three quarters of the requests for such "diverts", in the six months ending April 2008, came from Heart of England Foundation trust, in Birmingham, the correspondence says.
Last September Rob Ashford, the ambulance trust director of operations, wrote to all hospital chief executives in the area, saying he could no longer "condone" the practice because of the "inherent dangers" it posed to patients.
Ambulance staff believe "diverts" are regularly used by hospital managers to ensure they do not miss Government targets to treat patients within four hours, by shifting pressures to other hospitals.
Mr Ashford proposed a total ban on the practice, in widespread use across the country, which allows hospitals to close their doors to all 999 patients when pressures can no longer be managed.
The local hospitals did not agree to the ban, although some restrictions on its use were agreed.
The full article as it appears online is here. But the printed article had extra sections.
Notably: "Sam Oestricher, ambulance representative for the trade union Unison, said ambulances were being treated "as mobile waiting rooms".
And again, "Katherine Murphy, from the Patients' Association said 'We are hearing increasing numbers of storied of seriously-ill patients lying in pain in ambulances, worried out of their mind. The A&E target is the one that comes with financial penalties attached, and it is the one hospitals care about.'"
And again, "Since family doctors stopped providing routine out-of-hours care five years ago, the number of emergency admissions to hospitals has risen by 30 per cent, while the number of beds has fallen by more than 20,000. More than 100,000 ambulance journeys were delayed at casualty units by more more than 30 minutes in the month of March alone - an increase of 18 per cent in 12 months."
One further quote from the printed article:
Most ambulance trusts measure delays by "turnaround time" - the time between the ambulance's arrival at A&E and its availability for the next call. It includes any time cleaning or restocking the vehicle, which should take no more than a few minutes.
Research by one ambulance trust found three quarters of delays occurred before the patient was handed over to staff, and that 84 per cent of those cases were connected to bed shortages.
It is a pity that the source for this information is not named. That would add further force to the evidence. However, if we trust the source and take it to be representative, then the vast majority of times when an ambulance has an overlong stay when delivering a patient to a hospital, it is because the hospital is overrun with patients and does not want to spoil its apparent (but not real) success in meeting the waiting time target.
Here are further details of the extent of ambulance delays.
The Cato Institute fears the consequences.
When I was in the USA recently, it seemed that Obama was talking mainly about trying to cap the cost of health insurance. But it still appeared to be very vague. There were meetings and consultations. Nothing definite appeared to have been decided.
This account from the front line clearly explains two things:
1. How targets can damage the medical care of patients and
2. How you cannot trust government official statistics claiming to show improved patient care.
Where's my patient?" asked Ruby looking around A&E frantically. "I've lost her. She was here a minute ago." She stood by the cubicle where her patient had been and looked around. "Maybe she's discharged herself," I suggested. "She's just had a stroke and the left side of her body is paralysed, so I doubt it," Ruby replied. "I only turned my back for a few moments."
Now, it's not unheard of to lose things in a hospital: a handbag, even your sanity, but a patient? Surely an A&E cubicle would be a safe place to leave a bedridden patient? Apparently not, as Ruby and I discovered that evening.
"Oh, here she is," I said, looking on the inpatient system on the computer. "She's not in the cubicle, she's upstairs." "How did she get there? She can't even sit up, how could she make it up stairs?" replied Ruby, perplexed. "She's in a bed in the acute assessment unit. Someone's moved her," I replied. "What?" shouted Ruby. "She's not medically stable. She's not ready to go to a ward. There must have been a mistake."
After several frantic phone calls, it transpired that there had been no mistake. The decision to move the patient out of A&E had been taken not by a member of the medical team but by a manager, because the lady was about to breach the A&E waiting target of four hours. The decision as to when a patient is medically fit to be transferred was once purely clinical. Now, it's financial.
With the introduction of targets came financial penalties for hospitals that failed to meet them. Of course, targets were introduced with the best of intentions: to improve patient care. But they have metamorphosed into a stick with which clinicians are threatened by an increasingly powerful non-clinical management.
When I began my training 12 years ago, it would have been unthinkable for a manager to interfere with patient care, let alone act unilaterally. Now, it's commonplace. The shocking story of Mid Staffordshire NHS Trust is an indication of how far things have gone. A litany of failings was uncovered between 2005 and 2008, and managers were accused of putting targets and cost-cutting ahead of patient welfare, leading to as many as 1,200 needless deaths.
The article was by Max Pemberton, a doctor who writes regularly in The Daily Telegraph.
The full article (and the rest of it is worth reading) is here.http://www.telegraph.co.uk/health/healthadvice/maxpemberton/5061576/NHS-Have-targets-become-more-important-than-patients.html
From the Guardian, a remarkably frank account of the continuing failure of the NHS to treat cancer as well as the medical services in other advanced countries:
The government's national cancer plan, backed by a massive injection of cash for cancer services in England, has failed to boost survival rates substantially, a major study shows today.
The findings will dismay government ministers, who have secured a tripling of spending on cancer over the last decade with the ambition of bringing the UK from among the worst countries up to the standard of the best in Europe. But the authoritative study, from a team led by Professor Michel Coleman at the London School of Hygiene and Tropical Medicine, shows that survival rates have barely shifted since the cancer plan was launched in 2000.
"We are at best keeping track with improvements elsewhere rather than closing the gap," says an editorial in the journal which publishes today's study, Lancet Oncology. It adds that the government's aim of matching the survival rates of the best performing countries in Europe by 2010 is looking optimistic.
The study also shows that regional divides linger on, with people in some areas of England likely to survive longer than in others.
Cutting deaths and improving the length of time people survive with cancer, while ending health inequalities, is one of the major health goals of the present government, triggered by an outcry over data which showed Britain lagging at the bottom of the European league.
Full story here.
This account is utterly different from that which I heard on BBC Radio. That entirely accepted the propaganda offered by, I think, the so-called Cancer Tsar (perhaps he should be called the Cancer Commissar). It is a sign of the times that a civil servant should promote misleading propaganda in favour of his political masters. It is also a sign of the times that the BBC should accept this propaganda so readily. It is ironic that a Left-wing newspaper, which you might normally expect to be more sympathetic to the Labour Government, gives a more honest account than a civil servant or the BBC. Well done the Guardian but a sad time for the integrity of the civil service and the BBC.
It is worth adding that the different parts of the BBC perform differently. Radio 4, led by the Today programme, has a Left-wing, politically correct, pro big government mindset, as has been widely observed. However Radio 5 is far less predictable. Its great virtue is that its phone-ins make its producers and presenters more aware that there are other views around beyond the BBC view.
Here is one of the ways in which you would be better treated in an American (and doubtless also a Japanese, German, French or Swiss) hospital for heart disease than you would be in Britain. In America and, I suspect, the other countries mentioned, you might get a scan with a 64 slice CT scanner that will show quickly - and without ill effect on you - just how bad your arteries may be obstructed.
In Britain, you have a much lower chance of having access to this scanner.
The Daily Telegraph today carries a report that the 64-CT scanner has been shown as effective in revealing coronary disease as the traditional, much more invasive method. The chances of anyone surviving heart disease depends crucially on being assessed quickly and effectively and then getting an operation, if needed, quickly. But the process of assessing the disease is bound to be hindered in an medical system which does not have the use of 64-CT scanners.
I saw such a scanner at the Mercy Hospital in Miami about four years ago. It had been installed the day I arrived. That was the only hospital in America that I visited and it had the new scanner. There must have been many such machines even at that time. I looked up to find how many hospitals in Britain had it then. The answer appeared to be only one.
Now, according the Telegraph, still "only a handful" of these scanners are in British hospitals. I wonder how many that means? Is it five, perhaps? Clearly nothing like enough to scan more than a small fraction of those with heart disease.
I am afraid this is another example of the way in which the treatment you are likely to receive in Britain is years behind what you would expect in America and in other countries which have systems of medical care that use up-to-date equipment.
It is worrying that Americans still apparently think that the NHS may be a model worth following. It would be useful to see an estimate of how many people in Britain die prematurely of heart disease each year because of the inferior diagnosis and treatment here. We have such an estimate for cancer from Professor Sikora (10,000).
Incidentally, the 64-CT scanner has other important uses as well.
The Telegraph article is here.
One of the reasons that people are not more worried by the relatively low standard of the NHS is that they are are not aware of the treatments they are not getting.
There are drugs, scans, other diagnostic tests and therapies which are available in other advanced countries which the average British patient does not know he is not receiving. A very clear example of this was reported in the Telegraph last week in a small story. A survey was conducted Myeloma UK, a charity. It revealed that a quarter of specialists in myeloma, a bone marrow cancer, do not tell their patients about treatments that have not been approved by Nice, the government agency which decides whether or not drugs will be available on the NHS.
So the patients of these consultants simply are unaware that they might have been given a more effective treatment in, say, France or Switzerland. The ignorance of the public about how the NHS is treating them less well than other systems is perpetuated.
The Daily Telegraph article is here.
Yet another international study has shown how bad is the record of the NHS in treating cancer. This, in turn, can probably be treated as a proxy for the performance of the NHS in all diseases. Further evidence that by mistakenly opting for the NHS model - the most statist in the advanced world - Britain has suffered tens of thousands of unnecessary, premature deaths.
The point from this latest report which will really gall those for whom the NHS is a religion rather than a means to give the best possible healthcare to the greatest possible number is that the United States, of all countries, comes out either as the best or one of the best. This point was not, of course, highlighted in either the BBC or Guardian reports. How can it be that the USA, which is treated by these two organisations as if it were near criminal in its treatment of the ill, have got a far better overall record than supposedly loving, kind Britain?
I certainly do not hold up the USA as a model healthcare system. It is deeply flawed. But it is still much better at saving the lives of the greatest possible number than our, far more deeply flawed system. It depends what you want: a flawed system that saves more lives or a disastrous system that people feel is virtuous. This is a secular version of creationism. Many people in Britain love the NHS. They don't care about evidence. They don't care how many die. Believing in the NHS makes them feel good about themselves. I find it appalling that people are so self-indulgent and so uncaring about the reality.
Of course the government has claimed that the British performance has improved since the years which the study reflects. This is true. But so has the performance of the rest of the world. There is plenty of reason to think (use the search facility and find entries with the word 'Sikora') that Britain still has performance decidedly below the average in Europe, let alone that of the best in Europe or of the United States.
Here is an excerpt from the BBC report:
The study showed the US had the highest five-year survival rates for breast cancer at 83.9% and prostate cancer at 91.9%..
Japan came out best for male colon and rectal cancers, at 63% and 58.2% respectively, while France fared best for women with those cancers at 60.1% and 63.9%
The full BBC report is here.
The NHS is behaving like a spurned and angry lover. It tells a woman who is dying of cancer that if she has drugs that it refuses to pay for but which she herself will pay for, then she is unwelcome. She can no longer have free NHS care. Never mind that, like the rest of us, she has paid her taxes for a lifetime. It is as if she was unfaithful to the NHS and her lack of love and devotion should be punished by total rejection.
What a perversion this is of the welfare state. How horrified would be Attlee and Beveridge and others who had the dream of excellent healthcare provision for all.
The psychology of the NHS decision to abandon those who are so insulting as to pay for some better drugs is a fascinating subject. I guess the reason the NHS feels so bitter towards those who pay for better drugs is the implication that the drugs supplied by the NHS are not good enough. This, of course, is true. But the NHS cannot bear the truth to be pointed out or to accept it. So it wishes to punish those who assert it. This is the psychology, perhaps, not of the jealous lover but the spoilt, vain, self-centred child who cares nothing for the actual well-being of others.
The actions of the NHS are immoral and I hope they will prove to be illegal, too.
Here is the beginning of the story in today's Sunday Times:
A woman dying of cancer was denied free National Health Service treatment in her final months because she had paid privately for a drug to try to prolong her life.
Linda O’Boyle was told that as she had paid for private treatment she was banned from free NHS care.
She is believed to have been the first patient to die after fighting for the right to top up NHS treatment with a privately purchased cancer medicine that the health service refused to provide.
News of her death at the age of 64 has emerged as six other patients launch a legal action to trigger a test case that they hope would force the NHS to allow them to top up their care with private drugs.
The full story is here.
More than 8,400 beds were cut in the year ending March 2007, the largest fall in 14 years. One in six beds has been closed over the decade. There are now 167,019 beds in NHS wards, compared with 198,848 in 1997.
There is an argument for reducing the number of beds. Part of it is that doctors now believe that the long times in hospital that used to take place - after childbirth for example - were unnecessary and even undesirable for the patient. However it is hard to doubt that the massive drop in bed numbers that has taken place since the creation of the NHS goes beyond what would be suggested by improved medical treatment and revised theory on how long one should stay in bed.
Hospitals ought not to be working near to capacity. They ought to have spare capacity so that new arrivals can be admitted quickly and can be treated promptly. For many years, the NHS has been working too close to capacity. What is dismaying is that despite all the extra money spent by the Labour government since 1997 that this is still the case. The system is not working. The NHS does not just lack money. It is a bad system that causes suffering and unnecessary deaths despite the sometimes heroic devotion of those in the front line.
The full article on Labour's bed closures is here.
Further evidence comes that the NHS, despite the vast injection of funds, is failing to deliver medical care that is of the average standard in the rest of Europe.
Professor Mike Richards, the national cancer director, has said that in 2004, Britain spent £76 per head on cancer drugs compared with £143 in Germany and £121 in France. Even after adding in private spending on cancer drugs in Britain, our figure still fell well short of the others at £90 a head.
This spending on cancer drugs - particularly new and therefore expensive cancer drugs - is a forward indication of what the survival rates will be (so I am told by Professor Sikora, the leading cancer specialist). So we may be confident that when the figures finally emerge for cancer survival rates for the past few years, Britain will again be among the worst performers. Or, to put it quite clearly, thousands of people will continue to die of cancer in this country because we have the NHS instead of one of the other systems in the advanced world.
The story from the Daily Mail is here.
The situation with prostate cancer is more complex. But there is reason to suspect, at the very least, that the USA has dramatically lowered its deaths from prostate cancer because of active screening. A friend of mine in the USA is screened as a matter of routine for prostate cancer and colon cancer. Prostate cancer is apparently the second biggest killer of men in Britain. The screening test for it is far from ideal. The British medical profession tends to be sceptical of it to the point of hardly using it at all unless the patient pushes hard for it. I suspect that this is one of many instances where the medical opinion of the British has been influenced by the rationing mentality of the NHS. It is true that the American may over-test and over-prescribe but British medicine certainly has the opposite, more serious defect. In any case, in America, where they screen for prostate cancer, the death rates have come down more dramatically than in Britain. Or, to put it clearly again, many men die of prostate cancer each year in Britain because we have the NHS. The news story is here.
In a single week there was yet one more story about how the NHS has failed to perform as intended. Figures from the NHS Information Centre, apparently, show that nearly half the population has not seen an NHS dentist in the past two years. Story here.
It is possible that regular publicity about the bad record of Britain in treating cancer compared to other advanced countries will, eventually, prompt the government to spend more money on cancer drugs. That could be regarded as a 'good thing'. However, given the huge amount of money wasted in the NHS on excess back-up staff, poor use of staff and under-used equipment, it only means that money will be taken away from other service to patients that are less easily measured - care for the elderly for example. So even if the government moved to spend more on cancer drugs, it could well mean no net improvement in the amount of unnecessary suffering British people accept because we have the NHS rather than the medical care of other advanced countries.
Most of the media has cooperated with the idea that the enormous amount of extra money put into the NHS has made it good enough. This, of course, is not at all true. It is accepted by most people that at least the waiting lists and waiting times in emergency are now fine. Even these things are not true.
Here is a doctor who works in accident and emergency writing about the manipulation of waiting times:
But what about the 98 per cent success rate for meeting the four-hour target?
From the patient's point of view it sounds marvellous - it means you have a 98 per cent chance of being seen and sorted from arrival in A&E.
Right? Wrong. You haven't had a Department of Health maths lesson.
Say you come in to hospital complaining of abdominal pain. You wait three hours to see a doctor -they organise a scan and blood tests and transfer you to a ward next to A&E.
The results come back two hours later and you can be discharged. In the real world, three plus two is five - that's five hours you've been waiting.
But in fact, because you were transferred to the A&E ward before four hours, officially you weren't actually in A&E all that time.
Confused? Me too - and I spend my working life in A&E!
It is even worse if you are a patient referred by your GP for emergency treatment. You bypass A&E and go straight to a ward.
As there are no targets for patients who bypass A&E, you may wait four hours before even being seen by a doctor, but this is not even recorded in the official figures as you went to an emergency ward and not the accident and emergency department.
If you are starting to understand the logic, a job in NHS management awaits you.
As well as the rules being "bent", the fact is the figures are often "fiddled".
This is done in numerous ways, from simply changing the discharge time - it is amazing how many patients are discharged at three hours 59 minutes - to delaying when ambulances are allowed to hand over patients to the hospital.
The most cynical way the figures are massaged is when patients are "moved" on the computer when in reality they are not physically moved at all, but perhaps go from a trolley to a bed, have a curtain drawn round them and the light turned off.
You don't have to be a brain surgeon to know this shouldn't happen, but it does, because A&E staff are concerned that if they have too many breaches, then they will face the Spanish Inquisition from management the next day.
But the saddest thing for me as a doctor, and you as a patient, is that I often have to see people not according to the urgency of their need but simply to satisfy a government target.
I remember having to treat a bloke who had called an ambulance for an ingrowing toenail and wanted to sort it out there and then as he was "off to Ibiza that evening".
Because his four-hour target was nearly up, he was seen before a patient in severe pain with a dislocated shoulder.
So Government claims that everything is lovely-jubbly are inaccurate.
In my experience, the real picture is that between 5 and 10 per cent of patients end up waiting longer than the four-hour target.
At peak times that can rise to 15 per cent - that's a million patients nationwide. And it will probably only get worse.
There has been a year-on-year rise in A&E attendances; many factors have contributed to this - an expanding population (in number and waist size), more alcohol and drug-related attendance, lower-quality GP out-of-hours services, and an increasingly elderly and frail population.
However, there has not been a corresponding increase in resources.
In A&E there are not enough nurses treating patients and there is a lack of senior A&E doctors to make treatment decisions.
When we do decide to admit a patient, there are not enough beds on acute wards, so patients have to wait unnecessarily in A&E.
Why is it that France and Germany have double the number of acute hospital beds that we do in the UK?
The doctor is Dr Nick Edwards. The full article in the Daily Mail is here. He has also written a book, IN STITCHES: The Highs And Lows Of Life As An A&E doctor.
Gordon Brown announced yesterday that the National Health Service would become preventative as well as curative. Actually, this is precisely what Labour promised in 1943 in its pamphlet which originally proposed "A National Service for Health".
Item 2 of the section describing the "The Medical Service that we need" (and which the National Service for Health would provide) began:
(2) Preventive as well as curative. It must be equipped for preventing avoidable damage to the intricate working of body and mind, and for promoting the full flowering of every man's and woman's physical and mental strength; it must be positive as well as negative, helping those who are fit to keep fit, and those who nearly fit to become fully fit.
I expect that some extra testing will indeed take place as a result of Mr Brown's initiative. But this is spinning while Rome burns. The NHS is providing an inadequate curative service, as previous postings in the NHS category have described. There is something grotesque, in the circumstances, about creating new services which will, inevitably, take money away from other areas of the NHS which might have a more important role in the health and well-being of people. Physiotherapy will be even more stringently rationed. Cancer drugs will be more rationed. Care for the elderly will be even worse and so on and on.
A few days ago, I met a consultant who told me patient care has become worse in the past five years. She mentioned a number of things that were worrying and/or were making the business of treating patients more difficult.
1. The NHS management has imposed an expectation that, in her speciality, there should be two follow-up meetings with patients for every one meeting with a new patient. This target varies from one speciality to another. Her target is, as far as she is concerned, wholly arbitrary and damaging to good patient care. She believes that good care requires, on average, a higher proportion of follow-ups. But if the hospital fails to keep to the proportion prescribed, then it will lose some funding. So an attempt must be made to keep to it or to fake it.
If they were to keep to it, then patients who needed to be seen more than twice after the initial visit would suffer. She suggested that therefore, in order to maintain good patient care despite the target, they fake it - at least some of the time. They call an old patient a new patient. Presumably they pretend that the patient has a new ailment whereas, in fact, it is the continuation of the old one.
How depressing it is that senior doctors have to spend their time getting around silly rules rather than devoting themselves to their job of looking after patients.
2. She told me that doctors gain the status of consultants far more quickly than before. Previously they spent four years training generally and then another seven years in their speciality. They also worked all hours, thereby seeing a great deal of illnesses and their treatment. Now, however, they can be called 'consultants' after only five or six years and they have had significantly less experience in those years than they would have done previously because of the new rules limiting their working hours. A consultant today is often not the highly experienced top doctor that he or she would have necessarily been in the past.
3. Another effect of the new working hours is that the new consultants more frequently than before have a shift mentality. When their time is up, they go home regardless of the state of their patients. This is a change from the time when a consultant very frequently felt his or her prime responsibility was to the patient and that this would quite often mean he or she would stay around until a procedure involving the patient was complete.
4. She told me that there is a drive for doctors to account for everything thing they do. She said that in one hospital, I think it might have been Great Ormonde's in London, they were trying out a system whereby doctors would account for each thing they did for patients on a personal digital assistant (PDA. I remarked that I had recently seen another consultant in a different hospital swiftly moving from task to task - ordering an X-ray for one patient, asking for another patient to go to his office, consulting with another doctor about a third patient, examining the second patient, looking at X-rays for a fourth patient, having a word with the relatives of that patient all in quick succession. If he had had to itemise such things, he would not have had time to do them. She heartily agreed. In trying to monitor such things, the administrators were going to damage the productivity of doctors and thus damage patient care.
5. She also remarked what a vast army of people there must be doing all the monitoring of targets. Somebody from her hospital would have to collate all the figures showing whether or not she was meeting the unnecessary and damaging target of two follow-up consultations for every one initial consultation. Then the information would have to be sent to the central administrators who would have to check and analyse the figures. I presume someone would have to decide if the funding should be cut. Letters and warnings would be issued and replied to. Someone must also have been paid who thought up the idea. Someone must have thought up how it should be implemented. Stationery would have been designed, printed and distributed to hospitals. And so on and on. One bad 'bright' idea. Hundreds more people employed by the NHS to produce no improvement in treatment. In fact their employment damages patient treatment since their wages and costs such as office space, heating, lighting, pension rights and so on have to be taken out of the NHS budget and taken away from patient care.
I had spoken to this consultant when researching The Welfare State We're In. She told me that she thought things in the NHS were bad then but they are worse now. She also remarked that having damaged the NHS, the regulators and administrators have also moved in on the private sector, requiring more and causing more damage even to the private sector.
6. There is a requirement now that hospital consultants can only do certain treatments if the hospital concerned has beds that are suitable for that particular speciality. Presumably this is in case there is a mishap and the patient needs a hospital bed. But the result is that hospitals where a consultant used to do minor treatments immediately and on the spot are not allowed to do this any more. In the past, the consultant could decide whether or not it was wise to do such treatments. Now he or she is not allowed to decide. The patient has to make a new appointment at a different hospital, quite possibly seeing a different consultant who has to learn about the case afresh. Patient time and care is damaged. More consultant time is wasted.
She painted a very depressing picture of how the NHS is being administered and how even the private sector is being interfered with and damaged by government.
When I calculated, for The Welfare State We're In, how many people a year die prematurely because Britain has the National Health Service rather than an averagely good system for an advanced country, I did not include deaths from Deep Vein Thrombosis (DVT). There is now plenty of reason to think that if these deaths were added, the toll of unnecessary deaths Britain endures would be even higher.
Today most papers have a report of the high death rate from DVT. However what is lacking, as far as I know, is any comparison with how other countries perform. If anyone knows of an international comparison, I would be grateful to hear of it. It is hard to believe they do worse.
I have personal experience of how much of the British medical establishment has got into the habit of not giving the risk of DVT proper attention (as with hospital acquired infections). A close relative broke her hip and afterwards, I came to learn, being elderly and not very mobile, she was at considerable risk of developing DVT. But she was not monitored. I, as the main person responsible for her, was not told of the risk. And although she was visited by a district nurse and developed symptoms, no effort was made to check whether she had the problem. It was only when I rang the consultant who did the operation to ask about her inflated leg that a check was ordered. She did indeed have DVT and might well have died as a result if I - not the district nurse - had not seen that there was a problem that should be checked out.
I suspect it is true that the failure of the National Health Service in general and, in truth, large parts of the private medical service in Britain, too, to take DVT seriously has caused tens of thousands of unnecessary deaths.
Here is some of the coverage of the story in the Daily Mail:
Nearly 11,000 patients have died during the past seven months because of a failure by NHS hospitals to prevent them developing blood clots, a report claims.
Guidelines introduced in April mean every patient at risk should be assessed for treatment to cut the toll of deep vein thrombosis, or DVT.
But only one in three trusts is taking action, according to the damning report from the All Party Parliamentary Thrombosis Group.
It estimates that the failure to implement the guidance has cost 10,700 lives from DVT in the past seven months - nearly three times the number of deaths from the MRSA superbug and C Difficile infections.
The death toll in a year is greater than that from breast cancer, Aids and traffic accidents combined.
DVT is caused by blood clots forming in the deep veins of the legs. If they travel to the lungs it may trigger a pulmonary embolism that can cause them to collapse, and heart failure.
The blood clots often form as a result of immobility during and after surgery. If part or all of the clot breaks off and lodges in the lung, 30 per cent of those affected will die without treatment.
A substantial number of patients are struck by a surgical DVT - whose medical name is Venous Thromboembolism, or VTE - after they have been discharged from hospital.
The report says it is a "public health emergency" yet preventive drugs given at the time of surgery cost just £1 a day, while compression stockings can help others.
Altogether, 99 per cent of 140 NHS Trusts surveyed in the report are fully aware of the guidelines, but only 32 per cent are taking steps to assess patients at risk.
These include patients in hospital for longer than four days with reduced mobility, severe heart failure, respiratory failure, acute infection, inflammatory illness or cancer.
John Smith, chairman of the parliamentary thrombosis group, said: "The stark realisation is that while nearly all hospitals are now aware of what best practice looks like, and the steps they should be taking on a daily basis to protect their patients, over two-thirds of NHS Trusts admit to not having in place a mandatory risk assessment for every hospital patient on admission.
"DVT causes more than 25,000 deaths each year. It is worrying
that some NHS Trusts are still failing to adhere to these guidelines, which could reduce deaths by over 40 per cent."
Campaigners say DVT causes 10 per cent of all hospital deaths.
Dr Beverley Hunt, medical director of Lifeblood: The Thrombosis Charity, said: "The total costs of managing DVT within the NHS are estimated to be £640million and it's deeply concerning that the simple step of risk-assessing patients is not being taken.
"Any unwell adult entering a hospital bed has a 17 per cent risk of DVT but this risk rises considerably if they are over 40, are having surgery or have a predisposing condition such as cancer."
In March 2005, a report from the Health Select Committee warned the NHS was systematically and dangerously underestimating the threat from bloodclotting.
It found preventive drugs were cheaply and easily available but not widely administered.
The full article is here.http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=495064&in_page_id=1770
I have been unable to upload any entries for a number of weeks and the site has been down for a few days, so I want to catch up on a few items that I have not been able to write about in the past month or more.
The Sunday Telegraph had an article on October 21st about people going abroad for dentistry. I myself have been one of these people, getting dental work done in Malta by British-trained dentists at a fraction of the price in London. But this is still a small business and we should not lose sight of the bigger issue: the decline and fall of NHS dentistry. It is one of the services of the NHS that is simply falling off the back of the lorry, as this passage in the article makes clear:
In April 2006, when new NHS dental contracts were drawn up, they severely limited the number of treatments dentists could claim from the NHS. The supposed aim was to make the service less complicated. Instead, the result was that dentists flocked into the private sector.
While it is true that the number of dentists has increased from 15,000 in 1999 to more than 24,000 now, almost none works exclusively for the state.
Thus, in the past year, 1.4 million people have been left without access to a NHS dentist and, according to a survey by HSA, the medical payment plan provider, about 40 per cent of those questioned believed it was ''only a matter of time" before NHS dentistry disappeared altogether.
Needless to say, the private sector is booming. Virtually non-existent 20 years ago, it is now worth £2.4 billion. In 1990, for example, only five per cent of a dentist's income came from private patients. Today it is nearer 60 per cent.
It is said by some in Britain that although the NHS has its failings, it is still great when it comes to emergencies. I am sceptical about this claim. For one thing, if a hospital lacks up-to-date scanners (as many hospitals in the NHS do)then it may not be able to do the best possible scan for the particular emergency concerned.
I believe, as I have written before, that the only reason that private medicine in Britain includes very little in the way of emergency care is that the scale of private care is not yet big enough in the UK to make the big investment worthwhile for a private company. Companies might also fear political opposition.
There is, incidentally, one emergency care private clinic in London for relatively minor conditions. It is, understandably, in London near the road which leads to Heathrow airport and the West.
Meanwhile, I am interested to get this from a correspondent in Australia,
Hello James, Thought you might be interested in the huge increase in the use of private emergency rooms here in Australia:
"Record numbers of patients are paying up to $300 to beat public
hospital emergency queues by seeking treatment at Perth's only private
emergency department, which charges them according to how sick they
"In the past year, 25,000 people have attended its 24-hour emergency
department, about half the number of patients seen by each of the
emergency departments at (the Public) Royal Perth and Sir Charles
The UK National Screening Committee, which advises ministers, recommended screening for aortic aneurysms in January 2006. In May this year, it agreed detailed plans on how it would work. But the government still has not made a decision.
The Vascular Society of Great Britain and Ireland, which represents surgeons who work in the specialism, said the delays had already cost thousands of lives.
Jonothan Earnshaw, the society's honorary secretary and a leading surgeon, said: "The Government needs to get on with this. There are at least 3,000 men dying an early death every year who could be saved if screening was introduced."
The full article is here.
In the book, I calculated how many people die each year because Britain has the NHS instead of an average system of European healthcare. Perhaps another 3,000 deaths a year should be added to the calculation. But I am not sure because I have not had the opportunity to discover to what extent other countries - and not just European ones - screen for aortic aneurysms. Any comments with information on this would be most welcome.
This is a grim account of one way in which treatment in the NHS is, effectively, being delayed. None of this, I assume, will appear in the calculation of 'waiting lists'. So this is also another way in which the waiting list calculation is being manipulated. To put it more bluntly, it is anothe way in which the waiting list figures are lies.
Family doctors say that new "referral management" systems, set up to allow primary care trusts (PCTs) to overrule decisions taken in the surgery, are being used to delay and cancel hospital care, and to divert patients referred to a hospital consultant to cheaper clinics in the community.
Other schemes run by PCTs have offered GPs payments if they reduce the number of patients sent to hospital.
Of 750 doctors polled across Britain, 75 per cent said they had referred patients to hospital only to have their decision overruled, with 40 per cent saying that it happened regularly. Dr Laurence Buckman, the chairman of the British Medical Association's GP committee, himself a London family doctor, said such schemes were a short-sighted attempt to save money by delaying hospital care.
"If I think my patient needs to see an orthopaedic surgeon, the chances are they do," he said. "These kinds of schemes just set up an extra layer, which delays the patient getting to see the right person."
Dr Buckman said he believed the schemes were "simply about saving money" by delaying hospital bills. "Most PCTs are on the verge of bankruptcy and if they can find a way to defer payment until the next quarter, or next financial year, they will," he added.
Norman Lamb, the Liberal Democrat health spokesman, said that GPs in his North Norfolk constituency had complained to him after referrals for teenagers requiring psychiatric help were delayed, while local PCTs had introduced "minimum waits" for surgery in order to push hospital bills into the next financial year.
He warned: "Patients will be confused. They will trust their GP to make the right judgment and when their referral comes back, they can only assume it was for financial reasons."
Katherine Murphy, from the Patients' Association, said her group was hearing a growing number of complaints from orthopaedic patients who believed their health had worsened after they were diverted for treatment by a physiotherapist when their GP had intended them to see a surgeon. She described the policy as "a prime example of deficits putting lives at risk".
Paul Rybinski, a GP in Croydon, Surrey, said doctors were under increasing pressure to reduce hospital referrals to save NHS funds. His own practice has a referral cuts target of 5 per cent.
Dr Rybinksi said he feared "referral centres" would make decisions based on very partial knowledge of the patient. "When I make a referral it is based on a complex decision relating to the individual in front of me. It is very difficult for a panel at a PCT to second-guess what I was thinking, and the factors I was taking into account, based on a reading of a basic referral letter."
The poll, by Pearl Medical, which provides mobile communications to GPs, also found that doctors strongly opposed Government plans to create networks of "polyclinics", replacing individual GP surgeries with huge group practices, serving populations of 50,000.
The full article in The Sunday Telegraph is here.
After writing The Welfare State We're In, I now notice instances of welfare provision as they appear in novels which previously I would have missed. Recently I listened again to an audio-book of Mapp and Lucia, the comic novel by E.F.Benson. For the first time, I noticed that the focus of the early rivalry between the two women was the competition between their two charitable events for the benefit of the local hospital.
Lucia won this battle hands-down. Everyone went to her fete. No one went to Mapp's event. But underneath the comedy lies the way in which it was simply normal for people of their class to put on events to raise money for local hospitals.
These hospitals might be charitable or run by the local authority. In either case, the people of the town or locality felt that they were connected to it. They, personally, might need it one day. They had a stake. They could also gain status by helping it financially and probably in other ways, too.
The town in which Mapp and Lucia is set is called Tilling. But I think I am right in saying it is based on the very pretty Sussex coastal town of Rye.
I wonder how hospital provision in Rye has changed since Mapp and Lucia was written (circa 1930?)? Did it have a hospital then? Does it have a hospital now?
Whatever may be the case, it is certainly true that hundreds of local hospitals have been closed down since the NHS was created. There are some good reasons for this and some bad. It is noticeable that the Labour Party, when it promoted the idea of the NHS in 1942 argued that local provision of hospitals was important. After the NHS was created, both parties were persuaded that big hospitals offered economies of scale and could develop the capacity to deal with all eventualities. They could also develop particular strengths. But since then, the political parties have re-discovered the idea that local healthcare has it merits in maxi-GP practices or mini-hospitals.
Of course local hospitals have their merits. That is why pre-NHS healthcare created them. In some ways the value of them has actually increased. If there is an emergency in one part of London and a patient needs to be rushed to hospital, it now takes longer to get there because of the density of traffic. The same applies all around the country. I presume that, in some cases, patients lives can be at risk because of the distance between an emergency patient and a hospital.
A local hospital can promote loyalty and commitment on the part of both staff and patients. Patients in hospital are also easier to visit if they are local and this, in turn, means they are more likely to be visited and, I believe, those who are visited are more likely to get well soon.
The closure of quite so many local hospitals has surely been one of the range of bad effects of the creation of the NHS.
A commenter on the posting below has argued that American healthcare is inferior to British healthcare. Here is a link to an article I wrote on this subject a few years ago:
which I followed up with this posting a little later
Here is a new and important report providing evidence that despite the increased spending on the National Health Service, it still provides substandard care.
A report by the spending watchdog concluded that Britain has one of the worst records in Europe for ensuring dementia sufferers receive the best drugs available.
It likened the situation to 1950s cancer care when GPs did not tell patients of their diagnosis because they did not want to distress them and because they believed nothing could be done to help them.
In 2004, the UK was in the bottom third of European countries in terms of the proportion of patients receiving antidementia drugs.
Only 18 per cent of British dementia patients received drugs to alleviate their condition - compared with 50 per cent in France and 46 per cent in Ireland. Only Poland, Bulgaria, the Netherlands, the Czech Republic and Slovakia fared worse.
Care for the elderly has been one of the services that has been allowed to fall behind international standards while the NHS has concentrated its attention on the more politically sensitive issue of waiting lists. There is not enough money for everything in the NHS because the huge amount of waste and inefficiency (please see the book for more on this) uses up a large part of the budget.
The story is from the Daily Mail, citing a report from the National Audit Office. It has a league table which is particularly telling. I assume it comes from the National Audit Office report.
From the Guardian:
One in eight NHS hospital patients still has to wait more than a year for treatment, the government acknowledged yesterday in its first attempt to tell the full truth about health service queues in England.
A Department of Health analysis of 208,000 people admitted to hospital in March showed 48% were wheeled into the operating theatre within 18 weeks of a GP sending them for hospital diagnosis. But 30% waited more than 30 weeks and 12.4% more than a year.
In a key manifesto pledge at the 2005 general election, the government promised that by December next year all patients would be treated within 18 weeks.
One of the ways in which the government has sought to hide the dreadully low effectiveness of the extra money it has put into the NHS has been by cutting back on services which are not in the public eye.
Great effort has been put into cutting waiting lists. Plenty of money has been put into hiring staff, especially managers but also doctors and nurses. But the money has not reached many other service which are less in the public eye but extremely important. One of the major ones is care for the elderly.
This is from yesterday's Sunday Telegraph:
Hundreds of thousands of elderly people have had their "social care" cut in the past decade.
Seven in 10 councils in England have been forced to "ration" services since Labour came to power, according to the Local Government -Association.
Most town halls now provide services - including meals-on-wheels, trips to day centres and home visits from social workers - only to pensioners with "substantial" or "critical" needs.
Although council spending on care for the aged has risen 65 per cent since 1997, central government grants have increased only 14 per cent. In a foreword to the document, Lord Bruce-Lockhart, chairman of the LGA, says: "[To receive care] people have to wait until their life is threatened, they have serious physical or mental illness, or they are unable to carry out the majority of domestic routines."
Full article here.
One of the allegations in The Welfare State We're In is that the published figures for deaths resulting from MRSA in Britain are seriously understated.
This suggestion was supported this weekend by Dr Mark Enright, a microbiologist at Imperial College, London. He was quoted in the Sunday Telegraph saying,
"I would expect that the death figures substantially under-report the true situation. In a lot of cases, MRSA doesn't make it on to the death certificate when it should. Instead you see organ failure, pneumonia, or sepsis.
"Often it is hard to say exactly how much of a contribution MRSA caused to the death, but there is a tendency not to include it."
And further on,
He said that neither the number of deaths officially linked to MRSA nor the rate of bloodstream infections provided a full picture.
"I would say bloodstream infections account for 10 per cent of the infections in total," he said. "If people tested every infection, the rate would be far, far higher."
The Sunday Telegraph also offered a particular example of someone who was not classified as dying from MRSA yet who was evidently suffering from it very seriously:
John Howard Crews, 50, died in hospital in December 2003, three months after suffering a heart attack. His death certificate recorded the cause of death as pneumonia and cardiac failure. However, his stepson Derek Butler, who witnessed the last six hours of his stepfather's life in which he was "coiled up in a foetal position with his legs turned blue", was convinced an infection was to blame. When he and his mother asked questions of Blackpool Victoria Hospital, it emerged that Mr Howard Crews's lungs were "profusely infected with MRSA" and that the infection had been identified a week before his death.
Katherine Murphy, of the Patients Association, was also quoted as saying,
"We hear time and time again of cases where there is MRSA but the death certificate says pneumonia, or a chest infection, and it is only when relatives start asking questions that they find out that MRSA was present."
The full article is here.
After all the extra money that has been pumped into the NHS, we still underprescribe the latest drugs. People have died as a result and will continue to die. It is shocking and dismaying.
The report - in lots of newspapers this morning - is very important. It is based on an updated version of the report I cited in the revised and updated paperback edition of The Welfare State We're In. It is the clearest evidence that the extra money put into the NHS has not and will not result in an improvement in Britain's inferior treatment of those with cancer. It is simply the case that if a person gets cancer in Britain, he or she is more likely to die than would be the case in France, America or other advanced countries. Since the NHS is continuing to underprescribe the latest drugs, this will continue to be the case.
Here is the story as it appears in the Independent:
British patients are being denied access to life-saving cancer drugs that are widely available in the rest of Europe and the developed world, according to a report.
The NHS's "penny-pinching" attitude to new treatments and "excessive bureaucracy" surrounding their assessment is condemning cancer sufferers in Britain to an early death, it says.
A review of the availability of 67 new cancer drugs in 25 countries has found that Britain languishes close to the bottom of the league. along with Poland, the Czech Republic, South Africa and New Zealand.
The authors, from the Karolinska Institute in Sweden, say research in the US, which has the highest use of new cancer drugs, has shown that new treatments have significantly increased the chances of surviving cancer.
A separate study of 20 countries showed that nearly a third of the improvement in cancer survival between 1995 and 2003 could be attributed to new drugs.
In Europe, the UK has the lowest survival rates and the lowest use of new drugs compared with the major Western countries of France, Spain, Germany and Italy. In all four countries, more than half of cancer patients were being treated with drugs launched since 1985, but in the UK only 40 per cent were.
The full story is here.
The simple point about the NHS computer fiasco is this: that governments repeatedly botch up major projects. The result is that huge amounts of money that could have been spent on patient care has been wasted.
Why do governments keep on wasting money on this spectacular scale? Because no one is truly both a) in charge and b) accountable. When Marks and Spencer was adrift and losing market share, the chief executive and many others got the sack and their reputations were damaged. No one has publicly got the sack for this vast waste of public money.
Here are some of the details as described by Richard Bacon M.P. in the Daily Telegraph today:
By now, almost every hospital in England is supposed to have key administrative software deployed as the essential first step in introducing the shiny new electronic patient record. They are miles behind schedule, yet the limited deployment has already caused havoc, with significant delays in providing inoculations to children, waiting list breaches, missing patient records and the inability to report activity statistics. Not to mention the trifling matter of the largest computer crash in NHS history, when 80 hospitals had no access to patient administration systems for four days.
This is a truly grim tale. More than £2 billion has been spent, and although there is no detailed record of overall expenditure on the programme, estimates of its total cost have ranged from £6.2 billion up to £20 billion. There have been six bosses in five years. Timetables are fictitious and the programme is now years behind.
Doctors, nurses and hospital managers have been left spitting with rage. Most GPs think the appointment booking system is a joke. And three fifths of the programme is dependent on a software supplier called iSoft, which is currently under investigation by the Financial Services Authority and whose flagship software product, "Lorenzo", does not exist yet (even though the company said it was available three years ago). In the meantime, iSoft has been merrily selling old software that pre-dates the national programme.
Today, Parliament's spending watchdog publishes a report on this multi-billion-pound fiasco, which concludes: "At the present rate of progress, it is unlikely that significant clinical benefits will be delivered by the end of the contract period." The whole project has been an object lesson in how not do it.
The full article is here.
The news story is here.
The poor treatment of cancer sufferers in Britain is reflected in this article in The Sunday Times (March 25, 2007:
Delays give patients new cancers
Sarah-Kate Templeton, Health Correspondent
CANCER patients who have had tumours removed are dying because they are waiting so long for for follow-up radiotherapy that their tumours return, a government report has found.
After surgery, patients should receive radiotherapy within 28 days, according to the Royal College of Radiologists. However, in some areas, patients are waiting three times as long. In Kent, for example, the waiting time for breast cancer patients who have had tumours removed by surgery is three months.
Dr Michael Williams, vice-president of the Royal College of Radiologists and co-author of the report, said that, in addition, some patients were not receiving enough radiotherapy.
Williams said: “One problem is delays in some areas of the country and the other is that, when patients are treated, they receive fewer fractions [doses] of radiation than they would receive elsewhere in Europe and America.”
It is understood that the report, co-authored by Mike Richards, the government’s “cancer czar”, also says that the NHS is administering only about half the amount of radiotherapy needed to treat British patients properly.
Williams has research showing that, in Britain, only 28,000 doses of radiation are given per million people compared with the recommended 54,000.
Williams accepts that the government has invested heavily in radiotherapy since 2000, but he says: “Restricted access to radiotherapy services means that some British cancer patients are dying.”
The full article is here.
The debate which I took part in today went pretty well. My argument was helped by those who spoke from the floor. While many present, no doubt, had been brought up to believe that the welfare state was a good thing, they were old enough to have had experience of how the dream has gone badly wrong.
The speaker on the other side of the debate naturally argued the case that public spending was a jolly good thing and improved people's lives. But the first person speaking from the floor told how she had had a terrible time looking after her mother. The hospital had refused to give her mother a drug which the GP had been giving her. Why? It wasn't in the hospital budget, she said she had been told.
She said that she had had to fight to get her mother looked after. She had no doubt that if she had not been around, that her mother would now be dead - due to the poor care of the NHS.
Other speakers spoke of immense waste in government departments that they had known.
I find increasingly that people relate to the criticisms I make of the welfare state. They can see how my analysis fits in with their own experiences.
Here is an email I have just received. I copy it here because sometimes I sense that people think that mine are 'ivory-tower' views. I have left off the name of the sender in case he/she wishes to remain anonymous.
I commute 3 hours a day to my job in London, as a NHS dentist in a
deprived area. In this most boring time I usually crave a good reading. Your book "The Welfare State We're In" accompanied me on my daily commute for the past week.
I am extremely disappointed with it because I paid £12.99 for it and I believed that it would keep me company for 2-3 weeks. However, its
content was so rich and irresistible that sadly it only lasted me for a week! I practically devoured it.
Your book was not exactly an eye-opener for me, as I had reached pretty much the same conclusions through the almost daily contact I have with the welfare state. I was amazed however by the strength and clarity of your argument and by all the evidence you've mustered to support it.
It saddens me to think that I considered myself a socialist before I
started working and it only took 3 years working in the coalface with
the welfare zombies to bring about a complete reversal of my beliefs. I have spoken with colleagues that shared the same beliefs and everyone has undergone a similar transition. You are very right to say that most middle- and upper-class people do not understand the real extent of the problem because they don't come in close contact with the welfare state.
Keep up the excellent work.
Belatedly, I want to mention the extraordinary mess the government has made of the hiring of junior doctors. It has been well covered in the Telegraph.
It should not come as a surprise that the NHS has completely mucked up this business. The government is a bad administrator. It is also in a monopoly position. This kind of disaster is the sort of thing that governments operating monopolies go in for - although this does rank among the most cack-handed foul-ups that even a government monopoly has managed.
The dislocation the NHS has brought upon itself and the misery endured by doctors are appalling. The only possible silver lining is that perhaps more in the medical profession will come to view the NHS as a failed idea. Already there are far more who take that view than there were a decade ago.
Here is part of a letter printed there which was written by a doctor:
These last few weeks have been the final straw for many of us. We have been subjected to the most unfair and least meritocratic selection process ever seen, MTAS [medical training application service] via MMC [modernising medical careers].
Here is a link to several letters.
We have had to sum up our years of work and experience in several politically correct short answer questions, on which we are then judged. Examinations, experience and references are all but ignored in the pursuit of vague waffle. Shame on those who are behind this scheme. Many a tear will be shed this week by many brilliant young doctors who have had their hopes and dreams crushed in a quite barbaric fashion. Many of us will emigrate and many of us will leave the profession; I hope those behind the scheme are proud of these achievements.
Here is the beginning of an excellent article on it by Dr Max Pemberton:
The sight of people breaking down in tears is not uncommon on wards.
But on wards this week there have been scenes never witnessed before — scores of people bursting into tears, inconsolable and scared.
As I walked on to a ward there were huddles of people attempting to console others; nurses with outstretched arms, consultants with kind words, people shaking their heads in disbelief and hugging each other. They aren't patients though. They are doctors.
This week saw the results of the new Government initiative Modernising Medical Careers (MMC), which has been branded by those caught up in this chaotic reshuffle as "Massive Medical Cull".
All junior doctors in the country have had their contracts of employment terminated from August and been forced to reapply for their jobs through MTAS (Medical Training Application Service), an online, Kafkaesque application service.
From the beginning the process has been fraught with technical glitches, delays and conflicting information.
In my hospital, over half of the doctors I work with have not been selected. Most have been training in excess of 10 years, many of them have already obtained further degrees in their field of work and yet are now deemed surplus to requirements. They face an uncertain future.
Others face the prospect of relocating to another part of the country, selling their homes and uprooting their families, or attempting to retrain in another speciality. Many are considering taking their skills abroad, more still are considering jobs in the City or industry.
The full article is here.
Here is the beginning of the main story:
Thousands of young doctors have been left without jobs because a new NHS training system has gone "disastrously wrong", it was disclosed yesterday.
Patricia Hewitt is preparing for further NHS closures
As much as £2 billion has been spent on the training of up to 8,000 doctors who find themselves without a new job under a Government initiative.
Such is the fury at the scheme, called Modernising Medical Careers (MMC), that doctors have renamed it "Massive Medical Cull".
It costs £250,000 to train a doctor and the "shambles" is said to be blighting the careers of dedicated young men and women who may now leave the NHS. Many are also saddled with debts of more than £40,000 after funding their training.
The Daily Telegraph has been inundated with letters and emails from despairing doctors and their parents who "feel like crying".
This comes a day after this newspaper reported that three out of four trusts were restricting patients' treatment because of the NHS financial crisis.
There was also an article by Bill Deedes, who writes from the perspective of someone who remembers Aneurin Bevan and the introduction of the NHS. When Deedes, who is actually somewhat on the left of the Tory party, starts suggesting the NHS is an idea whose time has gone, then there surely is a change in the air:
A district nurse who occasionally attends to my needs brought sad tidings. Six nurses she had trained to carry out her invaluable duties were leaving the nursing service: there is not enough money to pay them.
At my time of life, you get a view of what is going wrong with the National Health Service, and why we shall not be able to continue on the present lines for much longer.
A vast, unwieldy organisation is outstripping our taxable resources and fraying the golden thread of selfless service that runs through the NHS. We need, for a start, to think back to 1945, when Aneurin Bevan, Labour's minister for health, began to shape the service.
I had returned from the war to work on this newspaper for £18 a week - and lived comfortably. The Daily Telegraph itself was less comfortable. Imported newsprint, which cost foreign exchange, was severely rationed. We ran a four-page newspaper most days, six pages a couple of times a week.
My circumstances and this newspaper's have improved since then; indeed, they have been transformed. Bevan's National Health Service stays much as he left it. That is the fatal flaw.
Those in the Labour Party who worship the memory of Bevan - and he was a wonderfully talented politician - also worship what they see as his memorial, a free health service for all.
In fact it was never this. Bevan flounced out of the Attlee government because Hugh Gaitskell insisted on some payment for spectacles and dentistry.
"A desiccated calculating machine," Bevan called him. But it is an article of Labour faith: nothing in Bevan's legacy must be touched. This is nonsense.
The NHS is crying out for a new source of money and it is best raised by encouraging personal health insurance.
When I last looked at Australia's health service, half the population had taken out health insurance, encouraged by tax concessions on insurance premiums. It is probably more now.
Ah yes, it means a two-tier system which is anathema to Labour stalwarts.
But if, as you find in Australia, the tier for those without insurance enjoys more reliable care than our NHS because there are fewer queuing up for a free service, what is wrong with that?
Yes, people will resent any charge on what has once been free for all.
But unless we can swallow our political prejudices and move on, we shall assuredly destroy a wonderful medical service. Nurses are leaving this country to find work overseas.
The interesting thing about the call for charges to made for certain treatments is where it comes from.
The argument has not been put by some right-wing think tank. It has come from the Association of Directors of Public Health. So it has come from within the NHS. This represents another milestone in the change of attitude to the NHS. It seems like a long, gradual shift both of attitude and actuality.
Dentisty on the NHS has gone to a large degree. It is difficult for most people to get sustained physiotherapy. I suspect that the same goes for osteopathy. Care for the elderly has been cut back. Now part of the NHS itself suggests dropping various treatments.
The background is quite simple. The NHS is incompetent as an organisation. Its costs are high, its bureaucratic overhead is enormous, it fails to make full use of its assets and it has powerful unions which contribute to the above. Meanwhile the politicians know there is a limit to have much people are prepared to pay in tax. So as the costs grow, the only way to keep the taxpayer half-way happy is gradually to lop off some of the branches of what the NHS does. This process has been going on for a long time. It has continued through the big increase in NHS spending and it will go on into the future.
Here is the the recent news about cutting back treatments:
The NHS should consider billing patients for ineffective treatments and drop all prescription charges, senior public health doctors said yesterday.
Spiralling health costs had to be controlled, said Dr Tim Crayford, the president of the Association of Directors of Public Health, and one way would be to charge patients for treatments for which there was not good evidence that they worked or when cheaper options were available.
Their list includes insertion of grommets, surgery for benign moles, varicose veins procedures, hysterectomy for heavy bleeding, carpel tunnel surgery for sore wrists, tonsils removal and homeopathy.
Dr Crayford also said not offering cataract or hip replacement surgery too early in the progression of the disease, could be added to the list.
He called for national standards to be set as to when NHS surgery should be offered for these complaints.
There is a danger that, as time passes, people will begin to think that the communist states were not so bad after all.
Gradually the generation that lived through the last few decades of European communism will become a minority. New generations will grow up who never heard the many anecdotes of deprivation, misery and political oppression that were widespread in those years. I have already heard one BBC radio programme in which Russian communists lamented the passing the 'good old days'.
It is, of course, a reflection of the political bias at the BBC that this programme idea was selected from the thousands that which are constantly being submitted. The way in which the programme was done - giving credence to the idea of 'good old days' - also reflected this bias. But this kind of thing is likely to become more common, not less.
Last night I heard another story of just how bad things were in the Soviet Union. Professor Christopher Andrew, the historian of secret services, gave a talk in which he mentioned in passing that mothers to be 'fled' from hospitals in Moscow and Leningrad. They went to the country to have their babies because they were terrified of having them in City state hospitals where the cross-infection rates were so dreadful.
Later, Mary Kenny, who was in the audience, told me that when she stayed with the Irish ambassador in Moscow in the 1980s, she learned that an American anti-abortion film sent to the Soviet Union had not had the effect intended. An American lobby group had wanted to shock Soviet women with pictures of how dreadful is the reality of abortion. Instead, Soviet women seeing the film were ecstatic by how wonderful - particularly how clean - were American hospitals.
I asked Professor Andrew if he knew of any book which documented the terrible state of the Soviet Union prior to its collapse. He did not. Surely someone has written about this. If not, someone should gather together and verify the stories and the data. The disaster that was communism should not be forgotten. Otherwise it could well be repeated.
It is good to hear of someone suing an NHS hospital over MRSA. One of the great scandals of the NHS, as detailed in The Welfare State We're In, has been it dreadful record in combating infection and MRSA in particular. The NHS's record is very dramatically worse than that of the private sector - a fact which I have never seen anyone else report.
The story reported below is reminiscent of the famous case in medical history in which women giving birth were mysteriously dying in alarming numbers at a particular hospital (in Vienna, perhaps?). No one could work out why the women were dying. Some women no longer wanted to have their babies in this hospital but preferred to take their chances at home. Going to the hospital came to be seen as dangerous. Finally a doctor worked out that the mothers were being examined by medical students who had previously been working in the hospital's mortuary. The students were infecting the mothers and, effectively, killing them. So washbowls were installed outside the ward and all the students were required to wash before entering. The death rate fell. That was a very long time ago. Yet we now have a woman who goes into hospital perfectly healthy. She, too, comes out dead because she became infected in the place that was meant to help her. I wish Mr Espaba well in his suit. The hospital might claim that it followed procedures. That is not good enough. The NHS has 'form' when it comes to MRSA.
The husband of a nurse who died from a virulent strain of MRSA six days after giving birth said yesterday he was suing the hospital at the centre of the outbreak.
Maribel Espaba, 33, died at the University Hospital of North Staffordshire after contracting Panton-Valentine Leukocidin-producing MRSA after an emergency caesarean in September.
Mrs Espaba is one of 11 people connected to the UHNS who have caught the infection, which destroys white blood cells and can kill within 24 hours.
Nine members of the medical staff and two patients, one of whom died in March, have also been infected.
Yesterday Mrs Espaba's husband, Wen 30, said: "I am absolutely heartbroken. It was the worst and best time of my life. My wife had just given birth to our beautiful baby boy and then just days later she had died.
"It was all very sudden. We had just moved into our new house and were looking forward to our new life with our son. Only a couple of days after she came out of hospital she suddenly fell very ill.
"She was rushed into the hospital but her condition just kept deteriorating. I was helpless and I could see she was dying.
"When the doctors told me she had died I was numb. I had no idea why she had died. They never mentioned MRSA and they had not mentioned to my wife that there had been an outbreak of MRSA even though she worked at the hospital."
He added: "Maribel was a strong and happy person who was dedicated to her work and was always helpful. I was very dependent upon her support and have found it extremely difficult to cope. "This was our first child and the only comfort I have is that Maribel got to see him and spent six days with him before her death."
Visiting Siena I came to learn that opposite the wonderful cathedral is a charitable hospital called Santa Maria della Scala that was founded, if I remember rightly, some 800 years ago. It was a charitable venture like St Bart's in London. And like St Bart's, it has some wonderful art in it. It was, also like the British charitable hospitals, taken over by the government. The last ward was apparently only closed quite recently. The ill found themselves surrounded with early renaissance frescoes.
Wherever one goes, if one's eyes are open, one comes across welfare provision before welfare states took over.
This does not prove this kind of provision (alongside the family, mutual organisations, friendly societies and self-support) was better. But many people are not aware at all that, prior to government welfare, that there was any welfare provision at all.
Below is a little more about it:
It is called della Scala because of its location, opposite the steps at the front of the Duomo. Inside, the most notable room is the pilgrims' great hall which, until the 1970s, was used as an infirmary. The frescoes covering this spacious room are mainly by Sienese artists from the 15th century. The best known of these are Lorenzo di Pietro, il Vecchietta, and more interestingly Domenico di Bartolo whose paintings show how the hospital functioned and the importance it had for the people of Sienna of the time.From here.
Santa Maria della ScalaFrom a site called Nozio.
The building Santa Maria della Scala takes up an area of about 350,000 square meters and was originally built as a city hospital, one of the first to be built in Italy. Today, many parts of the building have been recovered thanks to a massive restoration program, and exhibition spaces for Siena and international artists are now available. Inside the building it is possible to see three chapels, the Cappella del Manto, the Cappella della Madonna, the Cappella del Sacro Chiodo and the Church of the Santissima Annunziata.
Below is a disturbing article from yesterday's Sunday Telegraph. Can it really be true? It seems like a grotesque parody of how the NHS is now working. I would like to see more sources identified to be fully confident that the situation is as described. But if the story is, indeed, true, then the Government has set up - or has allowed the creation of - a new layer of bureaucracy which in theory exists to speed up access to consultants but, in fact, delays access to them. In short, it is a new way of hiding the waiting list and a new way of denying access to patients whose doctors think they would benefit from such access. It puts together a waste of resources (the new offices and personnel) and a denial of healthcare to those who need it. It appears to add to the evidence that the reduction in the waiting lists - which is assumed by most observers to be an uncontested fact - is, in reality, exaggerated or a lie in which this dishonest government and frightened officials in the NHS collude.
The paperback edition of The Welfare State We're In has a extra small chapter called The NHS: so did it get better? In that, as well as looking at the under-prescription of new cancer drugs (which suggests that thousands of people are continuing to die each year because we rely on the NHS rather than having a European system of average quality) I look at the boasts about waiting lists and conclude they are highly misleading. Having said that, I should add that I believe the King's Fund has recently issued a report which supports, at least in part, the government's claim that waiting lists have been greatly improved. I have not yet seen this report and so cannot comment on it.
Here is the Sunday Telegraph report:
New centres that "screen" patient referrals from GPs to hospital consultants are being used by the NHS to ration health care by stealth, say medical professionals.
More than a third of primary care trusts (PCTs) have established "referral management centres" that, critics say, are preventing patients from seeing the doctor of their choice and in some cases are prolonging waiting times in order to save cash.
In one case, GPs found thousands of referral letters stashed in a cupboard for weeks.
Patients' groups and doctors' leaders say the referral schemes, which are sanctioned by the Department of Health, are creating another tier of NHS bureaucracy and could actually harm people's health.
GPs say some centres are refusing to let patients see consultants sooner than the Government's outpatient target of 13 weeks. This limits the number of appointments in any one year - saving the PCT money.
In some trusts, people are being sent back to their GPs by doctors employed by referral centres, who decide they are not sick enough to warrant a hospital consultation.
In a survey carried out by the medical magazine Pulse, 10 per cent of all PCTs admitted they had a specific target to cut GP referrals.
When patients in Milton Keynes started complaining of long delays, their GPs investigated. Milton Keynes PCT had set up a referral management centre, which was meant to scrutinise all referrals in order to speed access and ensure patients got the right treatment. But Dr Peter Berkin and colleagues discovered a backlog of more than 2,000 letters locked in a cupboard by the centre's secretaries until just short of the 13-week waiting-time target.
"It got really scary," said Dr Berkin. "There were cases that could have been very serious and needed to see a consultant quickly. We were horrified. The decisions were taken by secretarial staff, not doctors."
A spokesman for Milton Keynes PCT admitted there was a backlog, but said it had mostly been dealt with.
Katherine Murphy, of the Patients' Association, said: "These centres are springing up all over the place, but who's monitoring what they're up to? It seems to be another way of rationing patient care by stealth." Dr Hamish Meldrum, chairman of the British Medical Association's GPs' committee, said: "There is considerable concern among doctors. Where clinicians have been involved, things may be working well, but in other places there has been no effective consultation and it seems the main intention is to cut costs. This is potentially harmful to patients' health."
A Department of Health official said referral centres were a "local initiative" by PCTs, but national guidance had been issued on running them. "They must only be set up where they will have clinical benefits and should add value to patient services. They should not conflict with giving patients more choice [and] must not lengthen the patient journey or create 'hidden' waiting times."
I was fascinated today to come across a sidelight on the psychology of welfare before the welfare state.
I was doing a check on the history of Moorfields, the eye hospital. The hospital's own website reveals how it was set up explicitly for the poor. It also shows how it was consider utterly wrong for those who could afford to pay for medical care to take advantage of its free services:
The London Dispensary for curing diseases of the Eye and Ear was opened in 1805 by John Cunningham Saunders (1773-1810). The impetus for the formation of the world's first specialist eye hospital seems to have been an epidemic of trachoma. This is a form of potentially blinding tropical conjunctivitis which was brought back to England by British troops returning from the Napoleonic wars in Egypt. However, the number of patients seeking treatment steadily increased, forcing a move to a larger site in 1822 and finally to its present main site on City Road, central London, in 1899. At this time, the first specialist departments were set up (X ray and Ultra Violet treatment rooms). The hospital was still operating as a charity and each patient received an admission card that read:
'This letter is granted to the applicant in being poor. Its acceptance therefore by anyone not really poor constitutes an abuse of charity.'
I notice that the Moorfields website includes guidance on waiting times. They are pretty daunting if you add, as it seems you should, the waiting time for the first appointment to the waiting time for sugery. For glaucoma, for instance, the total waiting time is over six months.
I wonder what the waiting times were like before the NHS took over the management of the hospital? I wonder what the waiting times are like now in other comparable countries in Europe and in America and Japan?
It is sometimes said, by those who continue to regard the NHS as the best possible healthcare system, that as soon as there is an emergency or the need for intensive care, that private sector hospitals ship their patients back to the NHS. (See a comment along these lines in response to a posting this weekend.
The implication is that the private sector by its nature is, for some unspecified reason, wholly incapable of providing emergency care or intensive care. This, it is implicitly suggested, means that we cannot and should not ever rely on private healthcare. After all, what good is healthcare without these things?
The argument is, of course, simply ludicrous. Did St Bart's not provide emergency care before it was taken over by the NHS? Was St Thomas's incapable of looking after any but those who came for elective surgery prior to 1948?
Emergency and intensive care was provided by hundreds of private - or, to be more specific - 'voluntary' hospitals prior to the NHS. And in America, right now, private hospitals provide emergency care and intensive care. I visited the Mercy Hospital in Miami which actually had two kinds of accident and emergency cover. One was for minor accidents and the other for more major ones. Quite a good idea, perhaps. The Mercy Hospital, like the voluntary hospitals that used to exist in great number in Britain, is part commercial and part charitable.
Why, then, do British private hospitals provide little in the way of emergency cover?
I cannot give an authoritative answer but I will suggest answers that seem likely to me and would appreciate responses from those involved in medical care.
First, the private sector, while no longer small, is spread around the country. More important, its customers are spread around the country. So the hospitals lack the size - the critical mass - to be big enough to offer emergency care.
Full-scale emergency care requires a lot of equipment, facilities and staff to be on hand. Ideally such a hospital should have an MRI scanner, a CT scanner, x-ray scanners, several operating theatres, plenty of full-time staff, plenty of doctors on-call. There is currently no private hospital in Britain, as far as I know, that is big enough to provide all this (and doubtless other necessaries).
In London, meanwhile, there is a planning permission issue. The state will give itself permission to build great big hospitals. It can pay for them by closing down other hospitals and selling the land. For a private hospital to get permission to build something the size of the Chelsea and Westminster NHS hospital would be like a miracle.
Then there is the funding problem. At present, perhaps, many health policies do not cover emergency treatment at a private hospital. What about if someone arrives as an emergency but has neither funds nor a health policy to pay for the very expensive treatment? That would pose all sorts of problems. Why should a private company pay a fortune to create emergency facilities and then find itself under intense media and moral pressure to offer the expensive treatment for free, at a loss?
That is what the voluntary hospitals used to do. That is what they could and should do again. But the old voluntary hospitals, like St Bart's, were expropriated by the state. The biggest expropriation of property since the Reformation, as a GP said at the time. Do we have to create new voluntary hospitals? Yes, I suspect.
But how much better and more just it would be if the state gave back the hospitals it took away. How wonderful it would be if the Chelsea and Westminster became a voluntary hospital. Think of the donations and the goodwill it would receive. Think how the attitude of consultants would change to their work there. They would not demand large sums because it would then be work done largely or entirely done out of goodwill, as used to be the case. They would make their money out of private work.
Let no one get away with the nonsense that the private - or to put it more generally - the independent sector is institutionally incapable of providing emergency or intensive care. It is rubbish. It is shown to be rubbish by examples both from our own history and from what is happening abroad.
At the time of Tsunami, incidentally, some of the patients were treated in the Bumrungrad Hospital in Bangkok. It is a private hospital.
It is all too easy for me - through personal experience of the care given to a relative - to blieve that the following is true:
Thousands of elderly National Health Service patients are dying because they are denied intensive care treatment after surgery, a study has found.
A six-year survey of four million operations found that 85 per cent of the most vulnerable patients do not get the intensive care that could save their lives or prevent serious complications.
As a result, it is estimated that up to 5,000 frail and elderly patients die each year because they are not put in intensive care beds for monitoring after their operations.
I remember how my own relative's blood pressure was falling to a dangerously low level after a major operationa few years ago. I believe the problem was only noticed and acted upon in the nick of time. I saw, in the NHS surgery ward where she was lying,just how busy the nurses were. It was not their fault at all. I thought they were all the more heroic because of the difficult conditions in which they worked. It was the fault of the lack of staff. In short, it was the fault of the NHS.
In The Welfare State We're In I made a cautious assessment of how many people die unnecessary, premature deaths because we have the NHS. I also wrote about the discrimination against the elderly. Of course it readily follows that the biggest number of unnecessary deaths take place among the elderly. This article, in the Sunday Telegraph, adds to my feeling that my cautious minimum estimate of 15,000 a year dying prematurely because our healthcare system is absurdly low.
Further evidence that you are more likely to catch MRSA in an NHS hospital:
The Office for National Statistics said that between 2003 and 2004, the number of deaths in which MRSA was mentioned on the death certificate rose by 22 per cent.
The MRSA infection was also six times more likely to be mentioned on the death certificates of patients in NHS hospitals and care homes than those who died elsewhere.
Cited in the Daily Mail.
David Penman, a consultant gynaecologist, has resigned from the NHS. He has written about it in an article in the Mail which unfortunately does not seem to be online.
Here are some extracts:
"I resigned from my post at the Medway Maritime Hospital in Kent days before I was due to attend an internal disciplinary hearing, held to discuss ann alleged breach of my employment code of conduct.
"My supposed crime did did not relate to any clinical matter or professional ineptitude.
"In the eyes of my accusers, I had committed the more serious offence of daring to speak publicly about the way I was being prevented from doing my job properly by the ridiculous decisions of hospital managers.
"Essentially, I had been told than many operations for patients on my waiting list were being postponed until the next financial year in order, it was claimed, to save money and meet government targets.
"I found this utterly absurd.
"I had the capacity to carry out the opreations but, thanks to some bureaucratic diktat, I had to sit around completing Sudoku puzzles rather than dealing with my patients.
"This is no way to run a health service in an advanced, wealthy country.
"The British public, which pays for the the NHS through an increasingly heavy burden of taxation, is not receiving the health care it deserves. Instead, it is subsidising a creaking edifice of statistical fraud, political dogma and over-mighty officialdom."
"Anyone who has worked in the frontline knows that the system is failing badly."
"This statistic-driven culture...meant that any service which did not have its targets set by central government would not be treated as a priority.
"As a result, it would be deprived of resources and staff. I saw this in my own department, the only specialist foetal unit in the area. But because we did not have targets, we were starved of funding and the service was run down."
"My disenchantment came to a head at the end of last year when I found out that, as a result of Government guidelines on annual financial targets, the hospital had decided that all new routine outpatient cases had to wait a minimumn of nine weeks before being seen, while all routine surgical cases had to wait a minimum of 20 weeks.
"So even if we had the capacity, we were still not allowed to treat patients.
"The situation became even worse when I discovered in Feburary that managers were shifting my case into the next financial year so that the costs of their treatment would not be in the accounts for 2005-06.
"The idea that this would save any real money was ludicrous. All that this statistical maneoevring achived was to creat a backlog for April and May."
I am sorry to quote the Daily Mail for a third time in one day. Why on earth does not every newspaper carry this story?
Scores of newly-qualified consultants are stuck without jobs because of mounting NHS debts, Britain's most senior surgeon has warned.
Bernard Ribeiro, president of the Royal College of Surgeons, said the predicted £1 billion deficit in the NHS has led to a 'vacancy freeze' for doctors who have passed their consultant exams.
This means dozens of trainee consultants are now facing unemployment or are considering retraining.
It amounts to a huge waste of taxpayers' money given that it costs £237,000 to get just one student through medical school.
Each of these new consultants has also had up to 12 years training within the NHS to reach consultant level.
Figures from specialist associations within the college suggest there are 37 cardiac surgeons, 12 neurosurgeons and 35 ear, nose and throat specialists, who are all qualified to be consultants but have not got a job.
Mr Ribeiro said: 'Trusts are not employing new surgeons because simply the money is not there.
'All have their certificate, all are available for a job and there are no jobs for them.'
The full story is here.
One of the arguments that is always put in favour of the NHS is that it provides medical treatment for the poor. This is a travesty of the true position. The NHS patchily provides medical treatment for the poor. The treatment is often delayed so much that it results in the death of the person who, only theoretically, is in the care of the NHS. The drugs that would be beneficial are not given or else the inferior drugs are given or they are only given after the person has reached a terrible condition and has little quality of life.
A prime example of how the NHS does not reliably look after the poor has been in the papers. This is about a man who would have died if he had relied on the NHS. His life was saved by charity or mutual help, call it what you like. It is a living example of the sort of mutual help that existed in a very big way indeed before the creation of the NHS. It is a kind of mutual help which is, due to the increasingly understood failure of the NHS model, coming back.
A delivery driver has thanked his workmates for saving his life after they paid for a scan which revealed he had a life threatening brain tumour.
Gary Harris' colleagues stumped up £700 for the private scan which revealed the deadly tumour, after he was told he would have to wait months to receive the scan on the NHS.
Doctors removed the tumour immediately after it was diagnosed and told Gary, 38, from Bristol, that it was so severe that he would have died while waiting to have the scan on the NHS.
Mr Harris said he is furious that a string of medical staff repeatedly failed to spot his condition.
Father-of-two Mr Harris first started to develop excruciating headaches and vomiting in November last year. The keen cyclist, who rarely took time off from work as a delivery driver for Park Furnishers in Bristol, became increasingly concerned as his symptoms became more and more severe. But numerous doctors told him that there was nothing seriously wrong.
He was told his illness could be down to eye problems, a winter vomiting bug or vertigo. In April this year he saw a neurologist who said that the pain was caused by an injury sustained during cycling.
He was put on an 11-week waiting list for a precautionary scan which would have taken place in July. But on hearing how long the wait for the scan would be workmates stumped up the £700 cash for him to have a private scan a week later. The scan revealed a tumour which had started attaching to his brain stem.
'Only two weeks to spare'
Doctors told Gary that he would be die in the next fortnight if he didn't have an emergency operation to remove the tumour immediately. Mr Harris is now recuperating at home following the operation. He said: "If my work mates hadn't paid for that scan I would be dead now.
"After the scan, surgeons told me that if I didn't have the operation there and then I would be dead in two weeks. I can't put it into words what I feel for what my colleagues did for me, I can't thank them enough.
"They more than saved my life, they saved my daughters from growing up without a dad and saved my wife from having to bury a young husband."
Deryn Cotter director of Park Furnishers said that all of his 60 staff had donated money for Mr Harris' scan.
The full article and picture of Gary Harris with his wife and child are here.
It is a truth, insufficiently acknowledged, that whenever the central government organises something, it wastes money and people. The cost is borne by taxpayers who, these days, include many who are relatively poor. It therefore follows that the process of having the government organise things is automatically to cause the relatively poor to be taxed more heavily.
The most extreme, single demonstration of the waste perpetrated by government is the computerisation of the NHS. The whole appallingly wasteful exercise, costing billions of pounds to taxpayers, appears to have started with the wholly ignorant, amateur idea of one politician: Mr Tony Blair.
Here, from the Sunday Telegraph yesterday, is an account of how he made this very important decision and how effective the actions he started have been:
Elated by the prospect of prescriptions pinging into patients' e-mail accounts, of ridding surgeries of yellowing records and A&E departments of carbon paper, Mr Blair, according to one observer, had "a Tony moment". With a wave of his hand, he gave the go-ahead for the biggest public sector IT project the world has seen - a scheme which has now become one of the biggest IT turkeys the world has seen.
The plan would link more than 30,000 GPs with 300 hospitals. "Up to 600 million pieces of paper a year" would be saved, Mr Blair promised. Patients' notes would be available in any hospital at the click of a mouse, and GPs would be able to book hospital appointments over the internet ("choose and book"). The Prime Minister even joked about making GPs' handwriting "legible for the first time in history".
Four years later, the joke is on Mr Blair, and the taxpayer. The "Connecting for Health" project is two years behind schedule and more than three times over its initial £6.2 billion budget. Lord Warner, the health minister, revealed this week that the real cost of the programme would approach £20 billion by 2010, its revised delivery date.
A report by the National Audit Office (NAO) is expected to be damning, suggesting that corners were cut so that political deadlines could be met. More than £11.75 million of taxpayers' money has been lavished on consultants, including Ernst & Young, Price Waterhouse Coopers, PA Consulting, Cap Gemini and IBM.
Yet the glitzy, "joined-up" NHS remains a low-tech hotch-potch. Doctors are largely unimpressed. Dr Richard Vautrey, a GP in Leeds and spokesman for the British Medical Association on IT, has struggled for months, for example, to get "choose and book" working.
It should enable GPs to offer patients a choice of four hospitals but has been beset by technical difficulties. "It does work in some places, but we haven't been able to get it to," says Dr Vautrey.
Certain hospitals, mindful of waiting-time targets, are also refusing to make appointments available.
With its 950-strong staff and an annual wage bill of about £50million, Connecting for Health does not lack resources. Still, it has become the latest in a series of public sector IT fiascos which include the Passport Office, Air Traffic Control, the Child Support Agency and the Inland Revenue.
See also the accompanying article which begins:
It is very unclear how the NHS is going to find the money to pay for the National Programme for IT. A project that was supposed to cost £5billion and last less than three years is now due to cost £20billion and last at least a decade.
It is interesting to observe that most people think their care in an NHS hospital has been 'excellent'. But when they are asked about specific aspects of their care, it becomes clear that it was not excellent at all for many of them.
This reflects, I suspect, the way people want to believe in the NHS. Or to put it another way, it reflects the way people are in denial about the failure of the NHS to provide world class medical care.
The remarkable figures are in this Daily Telegraph article.
...Andrew Foster, the Department of Health's outgoing director of workforce, compared the crisis-ridden NHS to a ship with a 'burning deck'.
Mr Foster also revealed that a report by the management consultants McKinsey, which was ordered by Health Secretary Patricia Hewitt and presented to ministers earlier this year, concluded that the department was 'dysfunctional'.
In an interview with the British Journal of Health Care Management, Mr Foster said: 'The word is it was deeply critical of a Department of Health which had lost control of its relationship with the NHS, of finances, and of the system reform agenda. The report found that the Department of Health board had basically shot itself in the foot. It was very critical a dysfunctional department and board.'
Mr Foster, who is rumoured to have been pushed out of the department after six years in the job, warned that there was a 'corrosive' culture of blame with the NHS. He highlighted massive failings in the system, saying managers were 'concentrating madly on activity planning to hit waiting list targets'.
The above extracts are from a Daily Mail article on Wednesday 3rd May. It would, of course, be fascinating to see the actual report by McKinsey. It is, of course, of critical importance that the 'payment by results' system should have been well designed and should be well administered. What is the situation there?
If any reader can obtain more of the article by Mr Foster in the British Journal of Healthcare Management, please do post it as a comment. If anyone can get hold of the actual McKinsey report, please let me know.
The reason why so much new money has done relatively little for the quality of the NHS is that so much has been wasted. This is part and parcel of how state monopoly services tend to operate.
One of the ways in which money has been wasted in the NHS appears to be in paying GPs more than is necessary to retain their services. Of course it is also true that the NHS has increased the amoung of money that is necessary to retain their services by making the job less satisfying and more bureaucratic. So there has been a double-whammy of extra cost.
This is from a good article in the Sunday Telegraph detailing quite a few examples of waste in the NHS:
There is no doubt that GPs have been the biggest winners of the boom in NHS spending, which has increased by £22 billion over the past four years. In 2003/04, the last year before GPs were put on to new performance-related contracts, they worked according to a contract that gave them an intended annual income of £61,000.
This year, admits the BMA, GPs are taking home an average of £94,000 a year, making them the best-paid in the world outside the United States. Moreover, many have simultaneously managed to cut their workload dramatically. Until 2004, GPs were responsible for 24-hour care of their patients. They didn't have to be on call at night, but if they opted out they were obliged to provide cover out of their own pockets.
Under the new contracts, by contrast, GPs can opt out of being on call at weekends and during evenings by giving up just £6,000 a year of their pay. But they can quite easily more than make up for this in other ways. GPs are now paid on a points system called the Quality and Outcomes Framework. Points, each worth £125 a year, can be earned, for example, by monitoring diseases and providing advice.
For example, GPs can earn an annual bonus of £8,472 if they record whether patients with heart disease or asthma are smokers and offer them advice on giving up smoking. Compiling a register of diabetics, taking their blood pressure and treating their symptoms can earn a GP a further bonus of up to £11,587.
"The system was predicated on the basis that GPs would get 700 or 800 points," says Dr James Le Fanu, a GP for 20 years. "But it quickly became clear that it was not very difficult to start getting 1,000 points a year, which is where salaries of £125,000 a year come from. What's more, GPs are earning this extra money for doing things that they should have been, and most were, doing anyway. Paying GPs to meet targets is a very bureaucratic view of what the health service should be about. Being a GP is not just about measuring blood pressure. It is about sitting down with people and talking to them."
For a truly grim account of the state of the NHS from a frontline doctor, click here.
(My thanks to a reader for drawing this to my attention.)
Many people remain committed to the NHS, I believe, because they think "if I get seriously ill at any time in my life, I will be looked after and it will be free". In their hearts, they may think the care may not be great, but at least they will get some care and it will be free.
But this is simply not true. Last night on Panorama there were graphic portraits of people who had believed this. But then they had got severe Alzheimer's Disease or had endured disabling strokes or had been knocked down by a car and become totally paralysed. They were treated, for a while, as patients in NHS beds - for free. But then they were shunted out into private nursing homes and told that they would have to sell their homes and pay for their care.
In theory, the government pays for medical care by not for 'social care'. In the Coughlan case, the Appeal Court upheld this distinction and insisted that the government should pay for someone with medical problems. But the programme eloquently argued that, in practice, the NHS ignores the Coughlan judgement and in many cases goes to great lengths to categorise people as being in need of social care, rather than primarily medical care.
In other words, the NHS shuffles off responsibility for paying for people who have become totally dependant on the help of others. It says, "you pay for it, we won't".
The NHS - and the government as a whole - offer the myth that you will be looked after, for free, if you become disabled for the long term. For many people, it is simply not true.
The welfare state has created an insurance policy that does not provide what it claims. It is another welfare state mis-selling scandal. It would be better if the welfare state were honest about it from the start - if it said, "We will not provide. Take out proper insurance because this is not it. Rely on us and you could lose your home."
"We are an accident and emergency service. We don't do long-term care." But such honesty is not a part of the welfare state. Perhaps it is just not a part of democracy as it has developed in Britain in recent years.
One of the more telling clips in the film was a fresh-faced Tony Blair boldly declaring in 1997 that he did not want a Britain in which old people needing care had to sell their homes. Well, that is precisely what, after nine years of his rule, we have got. It was all blather and lies. It was aspirational and wholly misleading. The programme could have made a lot more of that if it had wanted to. It could have repeated that clip after every case of a disabled person whose home had been sold. It would, quite justifiably, have highlighted the chasm between what Mr Blair has said and what has actually happened. It would emphasise the failure of his administration in connection with the elderly.
I feel that the distinction between medical and social care is anyway absurd. If someone cannot look after himself or herself and needs a lot of help, that is the overriding fact. If you were buying an insurance policy against that eventuality of needing care, you would not choose a policy that only paid out if someone arbitrarily decided that your problems were primarily 'medical' not 'social'.
It was refreshing, incidentally, to have a serious BBC programme pointing out a gross deficiency in the welfare state and in the NHS as run by this government. It made a very welcome change from the regular failure of the BBC flagship Today programme to do anything of the sort.
Here are some of the cases highlighted by Panorama. The reporter was Vivian White who did an excellent job.
The slow take-up of new cancer drugs in Britain is one of the clearest ways in which the 'new, improved, richer NHS' is continuing to provide a health service which is inferior to that of other advanced countries.
Another example of this is in the news today:
Leading doctors have called on the Health Secretary Patricia Hewitt to ensure patients can get access to two new brain tumour treatments. In a letter to the government, 36 clinicians say the National Institute For Health and Clinical Excellence (NICE) is ignoring patients' needs.
They say the treatments, temozolomide and carmustine implants, are a major advance, and value for money.
NICE initially rejected them - but said no final decision had been made.
This is from BBC online.
The propaganda surrounding Patricia Hewitt's white paper on health is quite breathtaking in its cheek. She has appeared on radio interviews saying that she is going to make the NHS 'even better'. There is the trumpeted proposal that people will get health M.O.T.'s and certain ages which she considers important (the oldest of which appear to be 50). There is even talk of people being given 'personal trainers' if they need one.
The reality is that the NHS does not successfully do what is currently supposed to do. The idea that it is about to do some extras is ludicrous.
Last week I rang to get an appointment with my NHS general practitioner for my daughter. I was told I could not have one that day. They had all been taken. But I could try again at 1.30pm when more times would be released. I rang at 1.50pm and was told all those appointment had gone. I cut up rough and said what sort of GP service was it that refused to see an ill eight-year-old child?
I was put through to one of the GPs on the practice who started asking me about my daughter's condition. She said this was 'triage' - the process whereby people are sorted into those who need help urgently and those who don't and, when they get help, what sort it should be. But you cannot feel a child's tummy over the 'phone. Eventually she said in an irritated way, 'Oh just come over now'.
So that is how you get a child in to see a GP these days. You have a couple of conversations in which a receptionist tries to put you off, then you have another conversation with a GP and finally you get an appointment if you are persistent enough.
And Patricia Hewitt talks about making the NHS 'even better'. The pretence that all is well is absurd.
I know very well, incidentally, that one anecdote proves nothing. But who really thinks this is rare any more? Ten years ago, the same GP practice might try to postpone seeing an adult. But you could always get a child in on the same day. Not any more.
As for MOT's, an elderly relative of mine has never been called in even for something less grand like a 'check-up'. That is would be routine in some countries. The elderly are the ones who are most likely to need health care. There are many elderly people in this country quietly starving themselves and getting into other problems. No M.O.T. for them, though. They are not on Patricia Hewitt's list.
Yes, the NHS Confederation is certainly getting fed up. This is from the press release:
"A fixation with buildings with buildings is preventing the development of new and imaginative services and we will have to work hard to convince the public that, with technological advances, the loss of beds does not necessarily equate to a decline in services.
“Our members are taking a long term view that has patient care at the heart. The government needs to give them the space and the control to get on with it.”
Dr Gill Morgan further commented: “The causes of the current problems are deep-rooted and long term. Many of them relate to changes in accounting rules. It is wrong of the government to simply blame NHS managers. If this was easy it would already have been done.
“We are running a serious risk of undermining public confidence in the NHS when we are actually treating record numbers of patients and making them better quicker”.
Long term solutions to NHS finances
88 per cent of the chief executives surveyed believe that they cannot take the tough local decisions about their health services without strong political support
74 per cent of chief executives polled said that long term reform, including redesigning and closing services, will be key to balancing the books
51 per cent citied long term financial management as a major solution to solving the problems
49 per cent said that the service must control activity and demand
46 per cent said the service must improve productivity
34 per cent thought that in the long term, workforce costs must be reduced
Causes of the deficits
I in 4 chief executives say that the biggest problem is no longer being able to borrow money from other parts of the NHS
1 in 3 primary care trusts, who pay acute trusts to deliver services, cite payment by results – the government’s new policy of paying trusts by the volume of activity they deliver – as the biggest cause of the deficits
9 per cent believe that the biggest problem is deficits incurred elsewhere being ‘parked’ with their trusts
9 per cent cited workforce reform as the biggest problem
Short-term action being taken to balance the books
90 per cent are reducing agency staff costs
85 per cent have put a freeze on new expenditure
82 per cent have imposed a vacancy freeze
78 per cent have seen staff reductions
52 per cent have temporarily closed wards
48 per cent are rescheduling work
38 per cent have cancelled services or restricted eligibility for services
28 per cent have frozen partnership or other contractual arrangements
Notes for Editors
1. The NHS Confederation has completed an in-depth survey of 35 of the 63 chief executives who have been sent KPMG ‘turnaround teams’ by the Department of Health. They are all in deficit, most by at least £5 million. The full findings of the survey will be published in the Health Service Journal on 2 February.
The full press release is here.
The NHS Confederation leadership has, for a long time, been very supportive of the government regarding the NHS. But there seem to be signs that it is getting fed up.
At the same time the NHS Confederation, which represents most NHS organisations, reported big cuts in services, including ward closures, staff reductions, non-replacement of staff and restricting patients' eligibility for treatments.
Sixty-two trusts in trouble have been identified by the Department of Health, 18 of them needing urgent help. Together, they have predicted deficits of nearly £250 million. Four private sector financial organisations are bidding for the trouble-shooting work.
Mrs Hewitt said the fees of the turnaround directors would be more than met by the savings achieved.
She said that some problems had been outside the trusts' control but added: "In some cases managers were letting patients down and that will not be tolerated."
The NHS budget will be more than £70 billion this year, twice the amount spent when Labour came to power. But the department has predicted a £620 million deficit in England at the end of March.
A report, Financial Turnaround in the NHS, said 28 primary care trusts were forecasting a deficit of £264 million and 34 hospital trusts a deficit of £467 million - a total of £731 million.
The trusts with the biggest problems are: Barnet and Chase Farm £8m; Brighton and Sussex University £14m; Cheshire West £15m; George Eliot Hospital £5m; Hammersmith £37m; Hillingdon £26m; Kennet and N Wilts £6m; Mid Yorks £15m; North Sheffield £4m; Selby and York £10m; Sheffield South West £4m; Sheffield West £4m; Shrewsbury and Telford £10m; South East Sheffield £4m; Surrey and Sussex £41m; Royal West Sussex £17m; University Hospital of North Staffordshire £18m; West Wiltshire £8m.
This is from the Daily Telegraph coverage.
Cancer patients are still being denied the best chances of survival because of 'postcode lottery' care, MPs have alleged. The Commons Public Accounts Committee has found 'stark inequalities' in death rates across England - six years after the Government launched its Cancer Plan to tackle the disease.
Those who live in London and the South have the highest survival rates, while the largest mortality rates are in the most deprived areas of the country.
The Government launched 34 cancer networks to oversee services in England. However the latest report found that nearly a third of cancer networks have no comprehensive plans for providing services to their localities.
Committee chairman Edward Leigh said there were also "stark inequalities" in cancer treatment across England.
"Many cancer networks, particularly in more deprived areas, are failing to address these problems," he said.
The committee review found regional variations in the availability of vital drugs, including breast cancer wonder drug Herceptin.
In some areas 90 per cent of eligible women are receiving the treatment compared to 10 per cent in others.
Joanne Rule, chief executive of charity Cancer BACUP said: "Cancer patients are in a lottery in terms of late diagnosis, access to treatments and survival rates.
This is from the Daily Mail. Full article here.
I have just returned from a brief appearance on the Today programme where I was up against Polly Toynbee, discussing the welfare reform green paper which is coming out today. During today, you should be able to hear it on the Today website. The time of the discussion was 8.55am.
I argued that one could have little confidence that much would happen. In America, the welfare reform programme had resulted in a 60 per cent reduction in the benefits caseload. In Britain, nothing approaching that result has been achieved or even attempted.
Now, after eight and a half years in power, the Government is producing a mere Green Paper - a discussion document. The performance has been lamentably slow and inadequate.
Polly Toynbee said she understood that the Government intended to take 100,000 people a year off incapacity benefit (from a current figure of 2.5 million). She was utterly confident this would be achieved. She thought that the figures were already going that way.
Her faith in the effectiveness of government action on this is illogical given the government's dithering and lack of effectiveness thus far.
As to the actual proposals in the Green Paper,they are not fully out as I write, but I notice one in particular that seems worrying.
It is the idea that the contracts of General Practitioners should somehow be adjusted so that they have some kind of incentive not to sign patients off as sick.
One can see why the government would have this idea. It is concerned tht GPs sign people off as sick too readily. That is surely right. But this is the wrong way to deal with it. It will corrupt the relationship between doctor and patient, which should be supportive. This will make the doctor into a kind of policeman of benefits, suspicious of symptoms which a patient claims. The patient will sense this suspicion. What should be a friendly relationship will become something different.
A better way to deal with this is what they did in New York. Those people who seek to be on incapacity benefit should be seen by doctors who are not their usual General Practitioners. These doctors should be looking for what work these claimants can do. Their role should clearly be that of acting for the government helping the individuals get benefit, if entitled, and/or identifying what kind of work they could do.
More generally, the Green Paper plan seems to be that people will be required to come in to talk about getting a job in the 'Pathways to work' programme. If they do not come in to talk about it, they might have their benefits reduced. This is nothing like as radical as in New York, for example, where claimants were:
1. Assessed for what they could do.
2. Required absolutely to seek work of the sort they could do. Aided by private companies which got paid more if they succeeded in getting claimants into work.
3. If no work could be obtained, they would be required to work for the state for three days a week (sweeping the park, helping in a hospital, clerical work and so on) and required to seek work the other two days.
The difference between the New York and that of the British government is that between chalk and cheese.
Not long ago, someone commented on this site that whenever all or part of the NHS runs out of money, wards are closed or operations are delayed or some other cost-saving measure is taken. But never are salaries cut back.
The fact illustrates the way in which government-provided services, as opposed to commercial or charitable ones, have a particularly strong tendency to look after their staff first, rather than the customers (or patients or students) who receive the service. Of course it does not feel like that to the doctors, nurses, administrators, teachers and so on. It feels to them like they are badly paid and enduring difficult and frustrating conditions. This is often true, too. But the fact remains that their pay and pensions are kept sacrosanct that would not apply if they were in the commercial or charitable world.
Further evidence of this came at the weekend in this story:
Studies of the proportion of council tax used to fund pensions are usually restricted to contributions that go solely to the pension funds of local authority staff.
But Mr Anderson discovered the hidden cost to council tax payers was much greater - when the money used to fund centrally administered "pay as you go" schemes benefiting the police, firefighters and teachers was added.
"We calculate some 26 per cent of council tax receipts go towards public sector pensions. There's every possibility this figure will rise over the next five years as age-related costs continue to feed in."
Such is Mr Anderson's expertise that he is regularly called in to advise Government departments on pensions. His calculations were based on a trawl through the books of 16 county councils.
The full story from the Sunday Telegraph is here.
British consultants, general practitioners and nurses are all paid more than their equivalents in Germany, France and Italy. That is surely one of the reasons why we have a health service that costs a similar amount but is inferior to that provided in all those three countries. (The fundamental reason, of course, is that healthcare in Britain is far more state-provided than in those other countries.)
Why are British frontline health professionals paid more?
A couple of possibilities occur:
It could be that the government (perhaps aided and encouraged by the profession) has consistently failed to train enough people for these jobs. There has therefore been a shortage. As a simply matter of supply and demand, these professionals have been able to command higher salaries than people in comparable jobs on the Continent.
A second possibility is that working in the NHS has proved to be so demoralising, compared to working in the medical profession in less state-dominated health systems, that the frontline professionals need to be paid more money to persuade them not to leave.
Figures for the pay levels are shown in a bar chart superimposed on a graphic in The Times today.
Reading the figures as best I can, the pay levels are approximately as follows@
I have to say that some of these figures look decidedly odd. I don't believe, for example, that British hospital specialists only earn £60,000. The figures for Italy look so low that they seem hard to believe, too. No source is mentioned for the figures as far as I can see.
Still, I suspect it remains true that British doctors and nurses are paid more than elsewhere. Any further data or views on the causes would be welcome.
I have to admit confusion about average waiting times for the NHS. The Independent's package on the NHS today includes a box (not on website as far as I can see) in which the following average waiting times are given:
1999: 7.7 weeks
2005: 6.6 weeks.
1998: 14.2 weeks
2005 7.5 weeks.
The figures for outpatient waits are very similar to those given by the Financial Times on January 6th and mentioned in this posting.
I reported that the FT said , "The average time for stage 1 has fallen since March 2000, falling from 7.7 weeks to 6.8 weeks (as at October 2005)."
But the change in average waits for inpatient treatment was shown as very different in the FT. In related the FT's view like this:
"The time for stage three, from the decision to admit up to the operation has gone up, from 6.1 weeks to 7.4 weeks (as at March 2005). (The well-publicised waiting list figures are based on this stage 3)."
Looking at a report by the King's Fund published in August 2005, The War on Waiting for Hospital Treatment I find this comment in the summary:
"By the time of the 2005 election, substantial progress had been made in reducing the number of long waits. While average waiting times had not changed by much..."
So has the Independent inadvertently put in a wrong figure, or is there more to this?
1999: 7.7 weeks
2005: 6.6 weeks.
1998: 14.2 weeks
2005 7.5 weeks.
The figures for outpatient waits are very similar to those given by the Financial Times on January 6th and mentioned in this posting.
I reported that the FT said , "The average time for stage 1 has fallen since March 2000, falling from 7.7 weeks to 6.8 weeks (as at October 2005)."
But the change in average waits for inpatient treatment was shown as very different in the FT. In related the FT's view like this:
"The time for stage three, from the decision to admit up to the operation has gone up, from 6.1 weeks to 7.4 weeks (as at March 2005). (The well-publicised waiting list figures are based on this stage 3)."
Looking at a report by the King's Fund published in August 2005, The War on Waiting for Hospital Treatment I find this comment in the summary:
"By the time of the 2005 election, substantial progress had been made in reducing the number of long waitis. While average waiting times had not changed by much..."
So has The Independent inadvertently put in a wrong figure, or is there more to this?
A new consensus is emerging about the cash put into the NHS. The old media view that the money was making things much better has faded rather suddenly.
Here is the new consensus, very concisely put in a front page special feature in The Independent:
Since 1997, NHS spending in the UK has doubled to £94bn this year. Consultants and GPs have had salary increases worth up to 50 per cent over three years, taking the average GP through the £100,000 barrier for the first time, making them the highest-paid doctors in the world outside the US. Nurses have had smaller but still substantial rises.
More than 190,000 extra frontline staff have joined the NHS since 1997. Health is a labour-intensive activity and well over half the extra billions invested - 56 per cent - has been spent on pay and pensions for staff. When the NHS Plan was launched six years ago there was plenty of money but a shortage of staff and capacity. Today, the capacity is there but there is a shortage of cash. Too much has been spent to deliver too little - NHS productivity has not risen in line with the resources. In the end, the NHS has ended up costing more but delivering less value for money.
Here is a link to the full article and others in the Independent's package.
I have written before about how people are dying as a result of delayed radiotherapy. Now there is an article in the British Medical Journal about it. I cannot give a direct link to it all since it is by subscription. But here is a part of it, expressed in the usual dry way of that journal. Beneath the long, logical argument backed up with studies that are duly footnoted on the website and in the journal, the writers are saying three simple things:
1. There are long waits for radiotherapy in Britain.
2. The service is inferior to that in most developed countries and, indeed, many poorer ones.
3. People die or suffer as a result.
Over the last five or so years, substantial funding has been made available for the purchase of replacement and new linear accelerators (linacs) and for supporting simulation and radiotherapy planning equipment—but many radiotherapy departments cannot meet demand because of shortages of radiographers, physicists, and dosimetrists. Increased numbers of training places have been created to improve the complement of these critical staff groups, but current shortages mean that in many centres the disparity between demand and capacity is great. Radiotherapy services in the United Kingdom are inferior to those in most developed countries and indeed in many poorer countries.
In services that deliver vital treatments, an excess of demand over supply causes a delay between referral and the start of treatment. Approaches used to lessen the consequences of inadequate treatment capacity include reducing the number of treatment sessions, transferring patients to other centres, or some form of rationing.
And further on...
Changes in work pattern and skills mix have increased treatment capacity slightly, but centres experiencing major difficulties have already made such changes. Even if other radiotherapy centres have space, transferring patients is difficult on a practical basis, hindered by cumbersome commissioning arrangements, and removes patients from the care of their local multidisciplinary team.
The demand for radiotherapy could be reduced by limiting the indications for treatment. For instance, within a patient population where postoperative radiotherapy is routine, the benefit of radiotherapy is correspondingly less than "average" in subgroups with a lower than average risk of local recurrence — but the selection of such subgroups is not necessarily supported by a statistically secure evidence base. Also, withholding radiotherapy in these circumstances may breach national (NICE) or local (Cancer Network) guidance. If the cancer recurs, this process could expose clinicians to complaints or litigation.
Many radiotherapy centres have substantial waiting lists despite efforts to prevent these from occurring. In patients with incurable cancer, a delay in receiving palliative radiotherapy prolongs symptoms and causes distress but is unlikely to adversely affect survival. In radical radiotherapy, where longer term disease control or cure are realistic treatment objectives, delays affect control of the cancer, organ preservation, and mortality.
It is a central tenet of modern radiobiology that the probability of controlling tumours decreases as tumours grow. Because prospective trials of delayed versus immediate radiotherapy are confounded by the use of systemic therapy, the evidence that delaying the start of radiotherapy may be harmful is derived from retrospective, cohort, and epidemiological studies. Despite this weakness, a growing body of data gives rise to concern.
Longer radiotherapy waiting times were associated with diminished survival outcomes for patients treated radically for cervical cancer and soft tissue sarcoma. In 29 patients initially suitable for radical radiotherapy for lung cancer who waited on average 94 days between first hospital visit and starting treatment, six (21%) became unfit for radical radiotherapy. In head and neck cancer, two large studies report a significantly increased local relapse rate if radical radiotherapy was delayed beyond 40 days, but another did not confirm these findings. A systematic review of 12 studies of the impact of delay in instituting adjuvant radiotherapy after surgery for head and neck cancer found a threefold increase in local recurrence if radiotherapy was delayed more than six weeks.
The management of early breast cancer makes a colossal demand on radiotherapy services, and many studies have addressed the impact of delayed adjuvant radiotherapy in early breast cancer. A systematic review of 21 of these studies showed that local recurrence was increased by 60% if the interval between surgery and radiotherapy exceeded eight weeks. In a large epidemiological study involving 7800 patients treated with breast conserving surgery and postoperative radiotherapy, a surgery-radiotherapy delay of 20 weeks or more was associated with significantly increased mortality. These studies strongly suggest that delayed radiotherapy is harmful, and it would be specious to rely on the methodological shortcomings of these types of analyses to assert that delayed radiotherapy is safe.
The article is by D. Dodwell, consultant in clinical oncology and A. Crellin, consultant in clinical oncology. Both are at Cookridge Hospital, Leeds LS16 6QB.
The BMJ website is here.
I discovered it because of the ever-vigilant and absurdly over-criticised Daily Mail. The Daily Telegraph, for instance, did not, as far as I can see, have the story. Nor, I suspect, did most newspapers.
The above is the headline of a Guardian story here.
The average waiting time for operations on the NHS has gone up since 2000. This is not a fact that the Government advertises, but it is true.
It was referred to in The Financial Times on Wednesday, in which there were a couple of very good stories on NHS waiting lists .
They basically argued that the government's goal of getting the maximum wait to 18 weeks for a non-emergency operation on the NHS by 2008 would be missed without additional capacity and more reform. To put it more bluntly, the target will almost certainly be missed.
The target apparently includes three stages between a patient going to a GP and having an operation:
1. From the initial visit to the GP to the first outpatient appointment.
2. From that outpatient appointment to any diagnostic procedure like a CT or MRI scan.
3. and "finally onto the operation itself once a decision to admit has been taken" (I am not clear whether or not this includes the time between the diagnostic test and the subsequent outpatient appointment)
The average time for stage 1 has fallen since March 2000, falling from 7.7 weeks to 6.8 weeks (as at October 2005).
The time for stage two is, at present, unknown.
The time for stage three, from the decision to admit up to the operation has gone up, from 6.1 weeks to 7.4 weeks (as at March 2005). (The well-publicised waiting list figures are based on this stage 3).
So the overall time, excluding the unknown time of stage 2, has actually risen since 2000, from 13.8 weeks to 14.2 weeks. So much for the government propaganda about the great improvement in waiting for treatment.
The government always boasts about the waiting lists. But the above figures are the time people actually wait, on average.
As the FT says,
"...in order to eliminate the relatively small tail of very long waits (more than six, 12 and 24 months) has meant that paradoxically, the average wait patients have faced at the time they get an operation has been going up in recent years, not down.
"Since March 2000, the median wait for an operation has risen from 6.1 weeks to 7.4, a 20 per cent increase, when it needs to fall to an average of about four weeks if the overall 18 week target is to be met."
This is a kind way of referring to the fact that hospital priorities have been shifted away from treating the most urgent cases most urgently to giving priority to patients who are getting near the figure of six months waiting. So, as a previous posting has mentioned, it has now happened that people with broken bones have been kept lying in hospital beds while those with far less urgent conditions have been treated ahead of them.
The boasts of the government on long waiting should be thought of as an admission that people with less urgent needs are being treated ahead of those with greater needs. It is truly disgusting. No wonder so many doctors are angry about it.
Unfortunately I cannot link to the full articles since they are by subscription only. But here is a link to the letter in response by Sir Nigel Crisp, chief government civil servant propandist for the government on healthcare (his formal title is different).
David Green has an excellent, measured but actually highly critical reaction to Cameron's policy announcements in today's Telegraph.
Here is an excerpt:
Mr Cameron was elected without anyone being quite sure what he stood for. Now quite a few of the blanks have been filled in. Yesterday, he ruled out social health insurance. Oliver Letwin, his head of policy, has said he would be "utterly astonished" if education vouchers were accepted, and has called for welfare policy to be based on egalitarian redistribution. It is beginning to look as if the policy commissions will not be open investigations of policy options at all. The "right answers" have already been decided for health, education and social security, which account for about 55 per cent of public spending.
On Sunday, Mr Cameron declared the police to be the "last great unreformed public service". They are no such thing. Health and education remain public-sector monopolies, frayed at the edges by talk of consumer choice but firmly under state direction. Allowing for Gordon Brown's renaming of welfare benefits as tax credits, 500,000 more people are dependent on welfare than in 1997, whereas welfare reform in the US cut dependency by half between 1995 and 2000.
The full article is here.
BBC Online has a report today which throws in private hospitals with NHS hospitals as being part of a report which indicates standards of cleanliness are not good enough.
This is the opening of the BBC report:
Two-thirds of NHS and private hospitals are failing to meet the highest standards of cleanliness, snapshot inspections have revealed.
This makes it sound as though two thirds of private hospitals and two thirds of NHS hospitals are failing in this respect.
However going to Healthcare Commission website, the official press release summarises the findings as follows:
Dividing the hospitals into four bands, the Commission found:
- High standards of cleanliness were being achieved in a significant proportion of organisations with 33 hospitals in band one.
- But too many hospitals failed to perform as well as they could with 44 being in band two, indicating they have room for improvement.
- There was evidence of systemic problems in the 23 hospitals that were in bands three and four, indicating that cleanliness was unsatisfactory for an environment in which clinical care is being provided.
- Standards were markedly poorer in NHS mental health hospitals visited. These made up all six hospitals in band four, indicating serious and widespread problems, plus 18 of the 22 hospitals in bands three and four
So all of the hospitals in the worst category, without exception, were run by the NHS.
And what about the hospitals with the best results?
Simon Gillespie, Head of Operations at the Healthcare Commission, said
Among the highest scores were hospitals of all types.
In other words, despite being a small minority of the hospitals inspected, private hospitals were among those with the best results. And none of them had the worst results.
I have not seen the full report and perhaps there is some justification for the BBC's opening line there. But I very much doubt it. It looks very much as though some journalist at the BBC has twisted the report to say something that it does not say and which, moreover, is totally misleading and wrong.
It should be emphasised, in any case, that the hospitals inspected were not a random sample and were chosen with a view to finding both bad and good examples. This was not - and not inteneded to be - a scientific study.
Further to the previous entry, here is a letter printed in the Daily Telegraph today from a consultant surgeon:
Sir - Patricia Hewitt claims that NHS staff have not been instructed to cut back on services. I have. My colleagues have. Colleagues in other hospitals have. I have been told not to operate on non-urgent cases until May because our PCT will not pay for the treatment.
Not only is this grossly unfair on those people with uncomfortable conditions that cannot be classified as urgent, but also there is the complete nonsense that at the end of this period, there will be demands for us to deal with all the backlog within a few weeks or risk financial punishment to our hospital trust. At that stage this will be impossible.
Like all health ministers, Miss Hewitt will move on to something else, leaving the professionals to pick up the pieces.
Robert Kirby, Consultant surgeon, Stoke-on-Trent
It seems hard to believe but the NHS is back in crisis. It has been the top spending priority of this government for the past five years. The funding has been boosted from £65 bn in 2002-03 to £87 bn in the last three years alone.
Yet it now emerges that the chief of staff of the chief medical officer has instructed officials to put an "embargo on all new commitments" for this year and "all future years". No new spending plans must go through even if ministers public say that more money is going to be devoted to a particular area.
Many trusts are in deficit and stories abound of cutbacks. Alastair Paterson, a surgeon in Cornwall, has been told not to treat so many people because it is costing the NHS too much money. In London, the famous of St George's Hospital has closed a ward and imposed a freeze on recruiting all but desperately needed staff. New drugs, like Herceptin, are not made available. Some people who have treatable tumours are having to wait three months to get radiotherapy, even though their tumours may grow in that time to the point where they cannot be controlled - with the result that the patient dies.
Tony Blair knows there is a big problem and is reported to want to appoint a new minister or a new senior adviser to the Department of Health.
In Whitehall, the common assumption is that the Government has got only one of two years left to make the NHS work or else the public will just stop believing the government is capable of doing the job.
Amidst this, the complacent self-congratulation of Patricia Hewitt, the Health Secretary, in her speech yesterday and Sir Nigel Crisp, the NHS chief excutive, is simply irritating to those who know the situation on the ground.
Yes, the waiting list has been reduced to 800,000 - a long way below its 1,300,000 peak. But the median or average waiting time has been reduced very little. And the figures cannot be trusted these days. Hospital trusts have been leaned on to reduce their lists by fair means or foul. The numbers treated on the waiting list have not risen either. And then there is the waiting list to get on the waiting list, not to mention the distortion of priorities.
A surgeon in Hampshire recently was boiling with fury as he told me that the previous weekend he had twelve people in his hospital with broken bones. They were waiting to be operated upon - anxious, dosed heavily with pain killers and unable to get up to go to the loo. But the management of the hospital still brought him people on the waiting list for hip replacements and the like ahead of those with broken bones. All common sense and humanity towards those in most urgent need were jettisoned so that people like Patricia Hewitt could boast about waiting lists.
Another grotesque little trick deployed by government propagandists is to say that more people are being cured of cancer or heart disease. They know - or should know - that such improvements have been going on for years in Britain and other countries. Still Britain has probably the worst overall record in treating cancer and heart disease of any advanced country.
After all the extra money that has been thrown at the NHS, there have indeed been some, modest improvements. But we have not got a decent bang for our bucks. We have only got a squeak. And now, with Gordon Brown's luck running out, the extra money will soon be arriving in smaller dollops. A new report from Reform, the think tank, argues that the squeeze will get even worse because the NHS is training a new regiment of doctors without having the budget to employ them all. It will also need to fund new drugs and hospital buildings. Reform suggests there will be a £7 billion deficit.
How on earth can it be that so much money has been thrown at the NHS for such a limited progress? Where has all the cash gone?
Approaching a third has gone on increased pay for existing staff. Of course, we could say that they deserved the money. Perhaps they even needed it if they were not to leave the NHS altogether. But pay increases evidently do not, of themselves, cause the service to improve. That is achieved by making the staff''s work more productive, through better working practices and use of technology.
Much money has been spent on recruiting new staff. Some have indeed been doctors and nurses but the numbers of support and administrative staff have increased at a much faster rate. Even before, the NHS used four times as many administrative and support staff per nurse than private sector hospitals. Now the administrative superstructure is even bigger.
Again and again, only a small minority of the extra money actually gets through to the front line. The waste is terrible - with wards closed, expensive scanners used only part of the time and consultant surgeons standing around waiting for patients to be ready for their operations. Even Patricia Hewitt herself admits that productivity in the NHS is improving at no more than one per cent a year.
We have had a great experiment in these past few years. It was a test of whether the NHS could become a first class health system if enough money was put into it. The people of this country were prepared to give it a go. They paid up the money - and will be expected to pay more. But it looks as though, at the end of all this, they will have an NHS that is still not top class and has a funding crisis to boot. The NHS is the most state-run health system in the advanced world and it still has probably the worst treatment records. Surely it is an idea whose time has gone.
(The above is the unedited version of an article that appears in today's Daily Express.)
Researching an article for the Daily Express, which should appear tomorrow, I read the speech today by the Health Secretary Patricia Hewitt. It is a remarkable document.
Naturally she claims great improvements have been made and that yet more will be made. But what most striking is a series of admissions about how bad the NHS has been up until this pivotal moment.
Here admissions are wholly inconsistent with her assertion, early on, that the the NHS is "the institution that makes people proud to be British".
She says waiting times have come down so that no one will wait more than six months. Then she adds,
But six months? Six months to wait for in-patient treatment - on top of the three months maximum, for the first out-patient appointment, not to mention the weeks or even months in between that it can take to get the necessary scans and other diagnostic tests and additional out-patients appointments.
It doesn't happen in France or Germany.
Quite right. For decades we have suffered from this because we have had the NHS, not the French or German systems of healthcare.
Then she goes on to the prevention of illnesses:
We are still spending less of our health budget on prevention than almost any other developed country
Yes. And this despite the fact that preventing disease was a central plank of the whole NHS idea. Another failure.
The NHS has not done well by the poor either,
The pioneering work of two of the LSE's most distinguished thinkers - Richard Titmuss and Brian Abel-Smith - showed that the NHS all too often supplied 'poor services to poor people'.
She updates their observation by saying,
The truth is that, despite the commitment of the NHS to equal access, the poorest people are still at greatest risk of falling ill....and they still tend to get the poorest services.
How about improvements in productivity? Much better than some have said, she suggests:
...the old measures...understated NHS productivity. But even if the real productivity growth is around 1% - as we believe - rather than negative, it needs to be far higher
That's right. She boldly claims that NHS productivity growth is not negative, as others have said, but is rising by a miserable one per cent a year - far less than is the assumed improvement in productivity whenever an industry has been privatised and prices that the privatised entity may set are being fixed.
And how good has Labour management of the NHS been up until she herself assumed control?
For the last five years, we have relied heavily upon national targets and a system of command and control. But heavy performance management demoralises staff and risks distorting priorities. An NHS that is performance managed by Whitehall is inclined to face inwards towards the Department of Health, not outwards towards its patients and users.
She goes on to suggest such management was essential "in the short term" (an idea that reminiscent of the assertion that the terror in Soviet Union was necessary "in the short term") but her condemnation of command and control as a way of managing the NHS is explicit and, of course, wholly correct.
I can't help having a little sympathy for Patricia Hewitt. Personally she is smug and pompous. But her analysis of what has been wrong with the NHS is clear and right. She is also right that things could be better with the money following the patient - provided such a system is done well. But there's the rub. What confidence can we have, with the disastrous Department of Health in control, that it will be run well?
I have been updating the British record in heart disease. At the talk on Wednesday, Niall Dickson, chief executive of the King's Fund (who defended the NHS with remarkable enthusiasm) was very keen on the idea that the British record on diseases (I think it was heart disease in particular) had improved markedly. It is certainly true that the deaths from heart disease have reduced in that way. However so have the figures for many other countries, including Australia, Canada and Germany. The exceptions are those with remarkably good figures in the first place. At the end of the day, Britain still has one of the worst heart death rates.
World Health Organisation statistics show how many men per 100,000 die before the age of 75 of coronary heart disease in different countries. The figures are “age adjusted” so they take account of the fact that older people are more likely to die than younger ones.
Former Communist countries such as Latvia have easily the worst figures. Leaving them aside and sticking only to advanced countries, Japan and France have easily the best results. Only 53 per 100,000 died in Japan and 82 in France in 2003. But deaths from heart disease reflect more than just the quality of the medical service. Diet and smoking make a big difference. To be fair to the NHS, we should look, perhaps, only to those countries where diets are not so very dissimilar to be sure. In Australia, for example, 138 died per 100,000 men. In Germany the figure was 170 and in the Netherlands 113. What was the figure in Britain? The death rate was 201 per 100,000. To put it another way, a man living in, say, Australia, is 31 per cent less likely to die prematurely of coronary heart disease than someone in Britain.
How likely are men to die prematurely from coronary heart disease?
(previous figures for 1998 in brackets)
Japan (56) 53
France (85) 82
Canada (184) 115
Australia (171) 138
Germany (200) 170
United Kingdom (265) 201
Source: World Health Organisation figures published 2004 relating to 2003 and earlier.
But if Britons do have a particularly high propensity to suffer heart disease because of their lifestyles, one would expect Britain also to have a particularly high rate number of heart operations by-pass operations. It does not.
In around 2000, British surgeons performed open heart surgery, for example, 645 times for every million people in the population compared with 907 times in Switzerland, 904 in the Netherlands, 1061 in Sweden and 1,191 in Germany*. If Britain does indeed have a higher propensity to heart disease, this lack of treatment is all the more dramatic and disturbing.
*Source: European Society of Cardiology (2004) as cited by www.heartstats.org.
'standardised' deaths from cerebro-vascular disease here
World Health Organisation standardised deaths from coronary heart disease as shown on British Heart Foundation website here.
I have just returned after giving a talk at the London School of Economics which will be broadcasting on BBC Radio 4 on 21st December at 8pm. I think it went all right. There were even a few laught. My voice held out, thank goodness - or rather thanks to a strong dose of a cough-suppressing drug. I started cautiously, in case my voice started to break, but then I became more confident as I realised it was not going to.
In each section of the three sections of my argument I was barely able to get past the first quarter or third of what I intended to say because the objections of the four 'hecklers' were so long and extended. So it was really half-way between a talk and a debate.
Whether or not my attempts briefly to fill in the argument will make it through the editing, I don't know. As ever, one is in the hands of the editor. The playing time will be about 45 minutes, I think, but at least an hour and 10 minutes was recorded, so there will be plenty of opportunity to shape the programme through the editing.
But I have no reason to think that I will be 'edited against'. I look forward to hearing it. I had a drink with the producer afterwards who told me the audience should be about half a million.
Also having a drink with us afterwards was a neuro-surgeon who told me that as young British doctors are to be limited to 48 hours on duty each week whereas young American doctors will be on duty for - if I heard him right - 80 hours, the difference in experience between the two will become very marked.
I asked where in the world he would want to be treated if he had a serious illness. He wanted to know which disease was involved. I said, 'let's pretend you don't know the disease'. He opted by the Massuchusetts General in Boston.
If it had to be in Britain, he said he would go for the London Clinic.
The foundation stone of St Mary's Hospital was laid on 28th June 1845 by Prince Albert. It was to be a voluntary hospital for the benefit of the sick poor. It relied upon charitable support for its maintenance.
St Mary's opened with 150 beds on 13th June 1851 the year of the Great Exhibition in Crystal Palace. From the beginning St Mary's was planned as a teaching hospital. A medical school was opened in 1854
This is from a brief local history here.
Further updates of figures that appear in The Welfare State We're In:
Despite all the NHS propaganda, Britain continues to lag far behind on many measures of medical performance and facilities. This certain applied to access to CT scanners. We have less than half the scanners of Germany, per million of population, and a third of the number in Switzerland.
Here is the latest league table of major countries:
United States 13.1
United Kingdom 5.8
With MRI scanners, Britain is, for once, ahead of France in a measurement of medical care and facilities. But the NHS is still far below the international average. Taking 13 advanced countries, the average is 9.6, or 7.6 if you exclude Japan as anomalous. Britain has 5.2. Even excluding Japan, other comparable countries generally have 46 per cent more MRI scanners than we do.
Here are some links to the statistics I have used which are from the OECD Health Data 2005:
MRI scanners per million of population view here.
CT scanners per million of population is here.
I visited a cancer consultant this morning. He or she must remain anonymous because of the NHS requirement that such people must seek the permission of the NHS press office before talking to a journalist such as myself. Such permision had not been obtained.
He or she tells me that if the press office had been consulted, he or she would have been required to obtain a good idea of what questions would be asked and the interview would have had to be recorded, if it was permitted at all. He or she tells me that a number of his or her colleagues have received official warnings for what they have said to the press and one was threatened - though not in writing - that if he went on talking to the press as he was, his pension rights would be taken away.
You could argue that all this was a matter of an employer requiring employees not to speak out of turn or bad-mouth the employer. But this is a government-run organisation. If it effectively censors the most knowledgeable people within it, then the public remains in ignorance of what is going on. We rely, instead, on the propaganda of the government about the NHS. This means we rely on highly misleading information since the NHS press office is itself now a propaganda machine pushing forward any favourable information it can obtain and putting a veil over anything unfavourable.
According to my informant
one of the things that is no longer mentioned is the waiting time for radiotherapy. Radiotherapy is vitally important. It saves people's lives. It is also time-critical. A tumour that can be destroyed on day one, may well have grown too big after three months to be treatable. So the patient dies.
The waiting time for radiotherapy in many centres in Britain is three months. People die because of this waiting.
The government had a target for reducing the waiting time but found it was failing to get there. So mention of the target has been dropped. I am told that the Department of Health website had the waiting times but, in 2003, on realising that they were not going to meet their target, the waiting time was removed from the website.
I should say that I have not checked this out for myself. This is what I was told by a cancer consultant this morning.
If anyone finds any of this reminds them of Stalinism, he or she is not alone. If anyone is concerned that they might not get timely treatment for cancer on the NHS, he or she is right to be.
Updating the statistics in The Welfare State We're In, I have come across official figures for how many people opt to "pay twice" and have private medical insurance or some other kind of health insurance which might enable them to have private medical care.
The proportion of households with insurance of this sort or of a related sort are:
Private medical insurance 17 per cent
Permanent health insurance 3 per cent
Critical illness cover 8 per cent
Friendly society sickness insurance 2 per cent
Any other sickness insurance 2 per cent.
These figures should not be added together since a single household may have two or more of these sorts of insurance. Also, some of these policies are intended primarily to provide cash in case someone loses income because of ill-health. They are not intended for paying medical bills.
Nevertheless, the simple figure of 17 per cent for private medical insurance is quite a high one in a country where, in theory, everybody is covered by the NHS. It reveals a significant degree of belief - backed by cash - that the NHS will not provide an adequate service.
The figures are from the Family Resources Survey which can be reached here.
How likely are you to get the drugs you need if you are in a British hospital with 'established' coronary heart disease? It is impossible to give an accurate answer. But we can say that you are less likely to get the most commonly used drugs than you would elsewhere in Europe.
In Europe, 85.9 per cent of such patients are on 'Anti-platelets' but in Britain the figure is lower at 80.9 per cent.
Beta-blockers? The European average is 62.9 per cent. In Britain the figure is much lower at 43.8 per cent.
ACE inhibitors? Europe 38 per cent. Britain much lower at 27.4%.
Anti-coagulants? Europe 6.6 per cent. Britain 4.2 per cent.
The only class of drug which we use more of is that of lipid-lowering drugs. Britain uses it in 69 per cent of cases compared with 60.8 per cent in Europe on average. Germany uses these drugs to a similar as britain (67.6 per cent of cases) and has significantly or drastically higher usage of the other drugs.
I suspect this study points at one example of many in which drugs are under-prescribed in Britain. The study is available on www.heartstats.org and comes from the EURASPIRE II Study Group (2001)
More updating of statistics in The Welfare State We're In:
The average number of NHS beds available in England continues to shrink.
There were fifty-five per cent more beds in 1988/89 than there are now (282,895 versus 181,772).
Since Labour came to power, the number of NHS beds has fallen from 193,625 to 181,772. Of course, there has been no announcement of this fact so it has gone largely unreported.
The biggest falls have been in geriatric beds, beds for the mentally ill and those for people with learning disabilities. There has been a small rally, since Labour came to power, in the number of acute beds. But the total of general and acute beds taken together has continued to fall.
When people say "Well of course, medical care has to be more expensive these days because people live longer and the drugs are more expensive" they do not mention this major way in which medical care should have got much cheaper. The most expensive thing in medicine is caring for people in hospital. The wages bill is far bigger than the drugs bill. Yet the amount of caring for people in hospital has declined very dramatically over the past 50 years. A huge amount of money should have been saved because of this.
Mothers who had just given birth used to spend two weeks in hospital. Now they are often sent home the same day. There were long-term diseases for which their used to be no effective cure. Those suffering stayed in hospital for months on end.
I was invited to appear on Radio 5 Live last night in a discussion about the decision of the NHS in East Suffolk that GPs and consultants will not refer anyone classed as obese for hip and knee replacements.
I argued that this level of rationing of healthcare was the inevitable result of having the NHS which, like most state monopolies, wastes its money and staff on an enormous scale. I referred to the study by Maurice Slevin which indicated that the managerial, administrative and support staff in the NHS per nurse runs at four times the level of a private hospital. In the NHS there are eight management, admin and support staff per ten nurses compared to only 1.8 in a private hospital.
Unfortunately I did not have the opportunity to counter an argument put forward by Roy Lilley (please excuse me if I have mispelled his name) a former NHS Trust chairman. He asserted that only 2.8 per cent of the staff in the NHS were senior management.
That is the sort of statistic that the NHS loves to trot out on such occasions. It gives the impression that there is no overmanning. But that impression is utterly misleading.
One needs to note the precise phrase being used. He did not say 'Management, administrative and support staff' he defined it very narrowly by saying 'senior management'. That really does not address the argument at all. The assertion is that the NHS is inefficient and wasteful in its employment of all these managerial and back-up staff as a whole - not that it is merely wasteful with the numbers of 'senior management'.
Incidentally, I don't know how the word 'senior' is defined. But it is obviously very easy to define that word as one likes. If one defines it very narrowly, then even this figure could indicate wasteful use of resources. Think of this parallel: if one said, 'only 2.8 per cent of the employees of the army are generals' it would indicate massive over-employment of generals.
Scores of community hospitals face closure or cuts as the NHS heads for a deficit of nearly £1bn this year, the Conservatives have claimed.
The party surveyed its MPs, and found evidence that 93 local community units were at risk - including 30 whose future was under serious threat.
It also found strategic health authorities in England are forecasting a debt of £997m in this financial year.
But the government denied community hospitals were under threat.
It said it was confident that the NHS would balance the books.
(From BBC Online today)
One of the great untold stories of the NHS is the number of hospitals it has closed down. The history of the NHS tends to be written by people who are sympathetic to it, so they simply have not counted up the closed hospitals and the beds removed. There are figures for short runs but I know of no figures for the whole run since 1948. It is nevertheless certain that the number of hospitals closed runs into hundreds and the number of beds removed runs into hundreds of thousands.
It is hard to doubt that the Conservatives are right and that some dozens more smaller hospitals and other units will be closed, as has happened over previous decades. The 'crown jewels' established by local councils and charity in the pre-1948 continue to be sold off.
It is slightly disturbing, in this story, to see how eagerly the press office of the NHS wages a propaganda war on behalf of the Labour Party. All sense of a civil servant's proper role seems to have been bullied out of them. It is sad to see this, among other elements, of the corruption of the independence of the civil service by the present Labour government. Previous Labour governments were perfectly proper about such things. The statistics with which the NHS press office appears to have countered the Conservative assertions are highly selective and do not answer the case at all. They are the sort of thing a politician might well say but it is quite inappropriate for a tax-payer funded civil servant to say them.
The remainder of the BBC story:
The Conservatives say their research has shown that NHS spending on administrators has risen by £1.3bn a year in real terms since 2000.
Shadow Health Secretary Andrew Lansley said even though the government had pumped extra money into the NHS, costs were still spiralling out of control.
He said: "There is a huge demand for community hospitals and the services they provide.
"While choice and vital services are taken away from those in need, the government wallows in denial.
"They have supplied more money to the NHS but lost control of costs.
"The increase in resources has not been matched with reform, and frontline services are suffering the consequences of this mismanagement."
A cross-party pressure group CHANT - Community Hospitals Acting Nationally Together - is being officially launched at the House of Commons on Tuesday.
A Department of Health spokesman denied community hospitals were under threat and dismissed the research on debt as "misleading".
He said: "Far from being under threat, NHS community hospital services have a bright future.
It's nonsensical to use the category 'non-medical workers' to calculate the number of managers, as this group includes staff like cleaners, porters and medical receptionists
Department of Health spokesman
"We are committed to building, rebuilding and refurbishing at least 50 community hospitals as part of a £100m investment."
He said similar grim warnings about large NHS deficits had been made last year - but the actual deficit had turned out to be just 0.4% of the total budget.
"We have no reason to believe that the NHS will not disprove this scaremongering again this year," he said.
He added that managers and senior managers accounted for less than three of every 100 NHS staff and only 2.8% of the total NHS workforce.
"The number of senior managers is falling, while clinical staff such as doctors and nurses are increasing," he said.
"It's nonsensical to use the category 'non-medical workers' to calculate the number of managers, as this group includes staff like cleaners, porters and medical receptionists."
The Tory survey comes after the Audit Commission warned last month that NHS wards, departments and even entire hospitals may be forced to close under the latest health reforms designed to extend patient choice.
The commission said the funding method, where money follows the patient, was destabilising the NHS and fuelling the current financial crisis.
A British Medical Association report released in September found three-quarters of NHS trusts were facing budget shortfalls.
The BMA said this could lead to cuts in services, and recruitment freezes.
HOSPITALS UNDER SERIOUS THREAT
New Forest: Milford-on-Sea; Hythe; Fenwick Lyndhurst; Fordingbridge; Romsey
Suffolk: Walnuttree; Aldeburgh; Newmarket; Felixstowe; Hartismere Eye
Wiltshire: Westbury; Melksham; Malmesbury; Trowbridge; Warminster
Source: Conservative Party
A doctor concisely describes what many others, less qualified, suspect about Patricia Hewitt's latest intiative:
Sir - I am a general practitioner of 18 years' standing and am amazed at Health Secretary Patricia Hewitt's naive, populist and partisan suggestions, such as GPs extending their hours to see patients late into the evening (News, November 11).
I get to work soon after 7am, and usually leave for home after 7pm - a 12-hour day. How many more hours would she want me to work?
Why has she singled out GPs for this extended service? Why hasn't she suggested that all hospitals run their outpatient clinics into the late hours and weekends, so that busy office workers, after finishing work, can be seen by the hospital, and not just in the accident and emergency unit? And why stop there? Surely she must insist that all patients wanting NHS appointments with a dentist, or even an NHS eye test at the local optician, should be seen late at night, at times convenient to office workers?
She cites the example of supermarkets opening late at night and at weekends to provide a service for these busy office workers.
May I remind her that a supermarket which extends its opening hours needs to fund the additional lighting, heating and staff costs, but this is paid for by the extra revenue on sales. I have not heard her mention how she will pay for these extended services.
Perhaps the Health Secretary should carefully think through any bright ideas she gets, considering manpower and funding, before sharing this wisdom with her electorate.
Dr Ian Morgan, Solihull, W Midlands
This was in the Daily Telegraph today.
A toddler struck down with a deadly strain of meningitis had to be flown 120 miles for treatment after five hopsitals had no spare intensive care beds.....
She was taken into a paediatric ward and given an intravenuous drip, but could not stay at the Royal [the Royal Worcestershire Hospital] because it had no intensive care children's ward. Staff began ringing around the hospitals nearest the couple's Worcester home but found units in Bristol, Oxford, Stoke-on-Trent, Birmingham and Nottingham were all full.
Four hours after...an intensive care paediatric bed was found at Guy's Hospital in London and an air amublance flew her south. The couple followed by road but when they arrived staff told them Georgia had been transferred to St Thomas' Hospital, half an hour away....
Mr Byan said the couple had no complaints with their daughter's medical care, but said it was 'disgusting' that she had to travel so far.
A spokesman for the Worcestershire Royal Hospital said: 'There is a specialist children's hospital in nearby Birmingham - it is just unfortunate it was full at the time.'
From the Daily Mail, today.
Note the use of the word 'unfortunate'. It would, one supposes, also have been 'unfortunate' if Georgia had died as a result of the absence of an intensive care bed. But of course this was not an act of God, it was a direct result of a system running too close to capacity. And that is what we still have in British hospitals run by the NHS.
Birth centres across Britain are under threat because of a shortage of cash and midwives, campaigners have warned.
The National Childbirth Trust is urging the government to take action after six of the NHS-run units recently closed permanently or temporarily.
The centres, of which Britain has about 100, offer more "homely" care than maternity units, campaigners say.
The government said it was up to NHS trusts to decide how best to provide a choice of maternity services.
The NCT said the closures in Hampshire, West Yorkshire and Lancashire were threatening to undermine the government's pledge that by 2009 women will have a choice of where and how they can give birth.
Birth centres are run by the NHS either in the community or linked to hospitals. They are staffed by midwives.
But the NCT said the units were being affected by cash shortages - one in four trusts finished last year in deficit - and a shortage of midwives that has led some trusts to recall staff to hospitals.
This report was from BBC Online.
The audience of parents of children at Tonbridge School last night was one of the most positive and supportive I have come across.
I talked mainly about how the welfare state has damaged the culture and morality of Britain and how it has led to higher levels of crime. One member of the audience responded by saying he had been a fireman who had worked in council estates. There had been youths there who he described as 'untouchables' - that is they were not touched or cowed by anything. They did not care if they were arrested, or got hurt or went to prison. These youths would throw bricks at himself and other firemen as they tried to put out fires.
What an extraordinary level of alienation for society must have taken place for people to throw bricks at firemen. It is staggering and shocking. It is also, surely, something similar to the alienation of the French youths rioting in French towns at present.
A hospital consultant made the comment that he saw a proliferation of administrative or managerial non-jobs in hospitals - people involved in diversity or equality promotion.
Someone else suggested there was a great deal of over-qualification going on in the NHS. This applied not only to nurses but also to physiotherapists and all sorts of others.
Another woman expressed outrage and disgust that people with ordinary incomes, who were saving for their families, were now due to get hit with inheritance tax which would go to give money to young girls having babies out of wedlock. It was interesting to come across that kind of raw anger and sense of injustice. In The Welfare State We're In, I tried to avoid a tone of anger. I tried to keep as much as possible to the observable damage the welfare state has done to the whole of society, especially the poor. But the woman's anger is perfectly understandable and justified.
The working poor are now taxed quite heavily. For people to be angry at the misuse of taxpayers' money can no longer be described as merely the rich moaning about being made to give money to the poor. It is everyone showing a justifiable opposition to money being taken from the working and decent and spent on encouraging and subsidising others not to work or to behave in other ways which are damaging to themselves and others.
There is an extraordinary report in the
Daily Expresstoday. It starts off:
More than 60,000 hospital patients die unnecessarily every year from blood clots, a report warned yesterday.
The authority for this is apparently Dr Anders Cohen, "a leading authority on DVT and clots". He "insisted most of the deaths were avoidable". The use of the word 'most' makes me wonder whether he is making the more modest, but still astonishing, assertion that over 30,000 people die unnecessarily each year from DVT.
The Express report continues,
The Department of Health recognizes that about 20,000 patients a year die from hospital thrombosis. But the study is expected to show the real death toll is three times higher.
"If patients were given blood-thinning drugs before and after surgery, or during their stay in hospital, we wouldn't have such a large-scale loss of life," added Dr Cohen, a vascular surgeon.
"Everyone concentates their minds on travel DVT, but the real danger is much closer to home." Doctors have known for years that patients are at risk of clots in hospital because they are lying around in bed.
"Young, fit people are dying from clots in hospitals as well as those with known risk factors," said Dr Cohen, whose study will be published soon.
I have no doubt that there are indeed many unnecessary deaths from DVT in Britain. A close relative of mine had a major hip operation and was not, as far as I know, given any blood-thinning drugs either before or after the operation. Later, I noticed that her legs were swollen. I asked the doctor to visit. As I remember it was not, initially, easy to get the swollen legs taken seriously. I think it was only after I contacted the surgeon who had done the operation directly that the local doctor swung into action. It was then found that she did indeed have DVT. Treatment then swung into action quite fast and effectively.
The disturbing thing was that it did not seem to be part of the 'protocol' of dealing with patients who had had operations to watch out for DVT or try to prevent it occurring in the first place.
It would be good to know at what hospital Dr Cohen works and under what aegis his report will be published. If anyone knows, I would be grateful to hear.
All sorts of cutbacks are currently taking place in NHS services. These are not announced, of course. Newspapers and the rest of us find out or just hear about them incidentally.
Yesterday an osteopath told me that because of a £30 million deficit in the accounts of the Kensington and Chelsea Primary Care Trust, osteopathy services had been cut. She said that the introduction of osteopathy had cut the waiting list for physiotherapy services from 20 weeks to 6 weeks. It had prevented many people developing chronic muskulo-skeletal problems. They had been caught in time. Now they would not be.
A few months ago a physiotherapist in Hampshire told me of cuts in physiotherapy there. She was in despair at what was happening. These are just straws in the wind to add to what is in the public domain. A survey by the BMA last month found 385 of the 530 primary care and other trusts had deficits totalling £2.4billion. St George's Healthcare Trust in London is losing 60 beds, trying to reduce a £24.5million overspend. It is truly remarkable that at a time when far more is being spent on the NHS that such cuts should be occurring. Even I - convinced as I am that there is huge waste in the NHS and that state monopolies have a strong tendency to be incompetent and wasteful of people and assets - must conclude that the maladministration is worse than I had imagined.
A relevant article in the Times is here.
The Guardian has had a story that the Government is to lease NHS buildings to private healthcare providers. So the private sector will take over NHS assets and do work under contract there for the NHS. The Guardian also says that rules on 'poaching' staff from the NHS will be relaxed.
I am not sure why this story has not been followed up in other newspapers. It would appear that it might be significant - especially if the policy were to become widespread.
As to whether it is a good policy or not, the obvious advantage is that the private sector will have every incentive to operate efficiently and without wasting money. It will want to do procedures instead of, like many NHS hospitals, having an incentive to avoid doing procedures or even closing entire wards.
Another plus is that this kind of thing will build up the critical mass of the private sector in the UK which has been too small. (That is why there is not any really big private sector hospital with the capacity to deal with a large array of emergencies. Such hospitals are commonplace in the USA where the private sector is much bigger.)
But the drawbacks of the plan are substantial:
First, the real development of good quality care at the lowest possible cost only develops when there is choice for patients who can select between competing suppliers.
In theory this Government is in favour of choice and competition. In practice it is not. The only 'choice' a patient might get, even with new NHS-contracted private suppliers, is between one private supplier and one NHS supplier. That is not a real choice or real competition. What the patient needs - and what the system needs if there is to be a real improvement in performance - is competition between plenty of private suppliers. The money needs to be in the patient's hands and he or she needs to be able to choose anywhere in the country (or, indeed, outside the country).
Second, these private suppliers will be hedged in with rules and regulations about what they can and cannot do. So the advantage of having private suppliers will be severely reduced.
Third, in due course, these suppliers will not be given enough money to do the job well. So then they will - under Government pressure and inducement - cut corners and do the job badly. But the private sector will get the blame. When the private sector gets the blame and is considered to be part of the problem, then the general public will turn against it and the only real chance we have of moving to a much better system could be lost.
I took a close relative to see a consultant surgeon in Hampshire yesterday. I raised the subject of the NHS and with no prompting the consultant said that the NHS was in a terrible state and would go. He said that last weekend, he (and presumably his juniors) he had twelve people with fractures in an NHS hospital - in other words these patients had broken bones.
But while he wanted - as any humane person would - to operate on these twelve emergencies as quickly as possible, the hospital was still bringing him elective cases ('elective' means non-emergency cases suh as hip replacements). In describing this ghastly scene, he added that there were not even ward clerks to take notes.
It is horrible to think that you, me or one of our loved ones might break a bone and be sent - as we automatically would be - to an NHS hospital only to be left lying in bed for days of end with this broken bone. We would be in great pain, on strong pain killers that made us drowsy and there would probably be complications such as bed sores. That is not so much a health service as a torture service. The idea that non-emergency operations should take precedence is a sign that morality and decency have left the building. It is sick.
What is new is the way that an NHS doctor such as him is so passionately and openly critical of the NHS. Ten years ago, virtually every doctor or nurse I met was a committed supporter of the NHS. Now, increasingly, doctors I meet are sceptical about the NHS or downright hostile. This man was the most forthright of all and said that the NHS would have to go and it would go. It would be replaced by private sector supply, social insurance and pro bono work.
He said that he and his colleagues would be happy to spend time each week working for free for those people without funds.
Basically, the government has misled the public about how easy it is to get an appointment with a GP.
A YouGov poll for The Daily Telegraph suggests that almost half of patients cannot get an appointment to see a family doctor within two days, despite the fact that this is supposed to be a key Government achievement.
The survey of nearly 2,500 adults also indicates that there is little public support for Tony Blair's idea that patients should be given a choice of hospital.
The waiting time results are particularly embarrassing because Lord Warner, a health minister, issued a news release in May saying that "almost everyone in England can now see a GP within 48 hours". He put the figure at 99.98 per cent.
YouGov found that only 44 per cent of respondents said they were able to see a GP within that target.
Full story is here.
I know a few wealthy people who have been approached, from time to time, by hospitals to give money. Many NHS hospitals now have quite a considerable income from charitable gifts. Major donors can be tempted, too, by the offer of having a room named after them or being appointed to some kind of supervisory board. Then, perhaps, there is the possibility of appearing in the honours list.
Great Ormonde Street Hospital, since it caters to children, is a major recipient of charitable funds. My own father left money to it in his will. But this same hospital has closed beds - putting capacity into mothballs.
I admire the instinct to give money to improve medical care for the poor. Heaven knows, the NHS is still in major difficulties and the poor get the worst of the healthcare it provides. But there is a better way to improve healthcare for the poor - although it would take some work by someone to get it going.
The trouble with giving money to an NHS hospital is that it is likely to be used wastefully. A new MRI scanner might be bought, but it will be wasted if it is only actually used for, say, seven hours a day and not on Sundays.
It would be better to give money to fund a new charitable hospital or clinic. This could be part-commercial and part-charitable. It would be, in effect, like the 'voluntary' hospitals during the centuries before the creation of he NHS.
Equipment like MRI scanners could be fully used, perhaps even 24 hours a day. The 'doing good' bang for your buck would be much higher.
Panorama might be worth watching tonight at 9pm on BBC1. This report on the programme was in the Daily Mail today:
Disturbing evidence has emerged of hospital nurses failing to give even basic care to frightened and dying patients.
A TV crew working under cover has exposed how vulnerable cancer patients were left in agony for hours because staff were too busy to give them pain relief.
It also revealed that elderly people who were unable to feed themselves went hungry while nurses often ate patients' food.
The footage captured by a Panorama team will be shown on BBC1 tonight. It exposes wards so short of staff that elderly people were not given even basic care.
For several months, nurse Margaret Haywood, 54, filmed under cover at the Royal Sussex County Hospital in Brighton.
She worked a total of 28 shifts as a temporary nurse in the Peel and Stewart ward at the hospital between November last year and this May.
Miss Haywood and undercover reporter Shabnam Grewal, who delivered food and drink to patients, found:
- An 82-year-old woman dying of cancer who was left in almost constant pain because nurses were regularly late giving her morphine.
- Another woman with an infection who was left for almost nine hours without fluids and lying in urine because staff failed to fix a catheter.
- An 86-year-old with cancer who did not eat because no one was there to help feed her. She died alone with no one even noticing.
- Food that was thrown away because nurses were too busy to feed patients. And nurses eating patients' food.
The full article is here.
It looks as though the Government (via NICE, its inappropriately named agency for restricting treatment and drugs)is still flirting with the idea of not letting new patients have access to Aricept and other drugs for those with dementia.
It is a scandal. I believe, on the basis of the experience of a relative, that Aricept can make a significant difference to someone's mental condition. There is plenty of other data on this from scientific tests. Aricept is probably under-prescribed in Britain, rather than over-prescribed. Many thousands of people could hold onto more of their mental capacity if they were offered it, but they are not. To make matters even worse, the government - now the election is out of the way - still seems interested in seeking to prevent any new NHS patient at all from getting the benefit of it. When one thinks of the money that is wasted within the NHS, the idea that people should be denied something that actually does good, is distressing and infuriating. This is from the BBC Online report:
Charities have accused the government's costing watchdog of stalling over whether to quash dementia drug restriction proposals.
The National Institute for Clinical Excellence (NICE) proposed in March to restrict four Alzheimer's drugs because they are not good value for money.
A final decision on rivastigmine, memantine, donepezil and galantamine use was to be made this month.
NICE says it needs more time to check how much the drugs benefit patients.
It has asked drug companies for more data.
If it decides to go ahead with the withdrawal across England and Wales, thousands of patients will be denied the only drug treatment available to them, argue dementia charities and carers.
From the Guardian coverage of the Healthcare Commission annual report on the NHS:
Fifty-eight per cent of NHS dental practices are not taking on new patients, compared with 40% in 2001. But most people who do not have an NHS dentist would like one..
In London, patients found it equally difficult to register with an NHS GP, with four out of five practices unable to take on new patients
The Healthcare Commission report on maternity wards is covered by most newspapers today:
The lives of new mothers and their babies are being put at risk by poor care on maternity wards, the Government's health watchdog has said.
The Healthcare Commission criticised a chronic shortage of midwives, poor training, bad management and dirty environments.
Other failings included staff not having time to explain what was happening to worried parents, overcrowding on wards, faulty equipment and a lack of information for bereaved families.
Britain has one of the highest infant mortality rates in Europe, at 5.3 deaths per 1,000 births. Only Poland and the Slovak Republic are worse. Deaths in pregnancy and childbirth have risen from 30 in 1999 to 45 in 2003.
In the commission's most strongly-worded warning since it was created two years ago, chairman Sir Ian Kennedy said maternity services were not as "good or safe as they should be".
He added: "Our work has shown that there is too much poor practice that needs to be rooted out."
The above is from the Daily Mail article, the rest of which is here.
This story adds to the evidence that extra money is not curing the NHS of its ills. The NHS does not need more money. It is needs to be replaced with a different system.
The Mail today also carries a story on a Premalatha Jeevagan, who died of a massive internal haemorrhage after a Caesarian birth at the Northwick Park Hospital In Harrow. According to the Mail report, the locum did not diagnose the problem. No senior obstetrician was on duty. A consultant was contacted at home but did not come straight away. He eventually came and performed an emergency operation but the woman died. Ten women have died at the hospital in the past three years.
Last night I talked to an NHS surgeon about prostheses. Admittedly it is not everyone's idea of pleasant subject for dinner party chat. But the conversation revealed something I had not known before.
It is well known that the Government is buying an increasing number of operations from private hospitals. For those NHS patients who may be assigned to a private hospital it might seem like a win/win situation. They get private hospital standards - probably a private room with a proper TV and private hospital standards in the prevention of the spread of MRSA - but they need pay nothing at all.
While the NHS patients may feel well pleased, the private patients at the same hospital who are paying full whack in cash or else have paid thousands into health insurance schemes may feel put out. They are all likely to assume, as I did previously, that all patients are getting the same treatment.
But they are not. Let's take a typical couple of patients having hip replacements. They are in rooms side by side and the same nurses are looking after them. But the one being paid for by the NHS, despite being in a private hospital, is getting a lower-cost and potentially inferior service. This takes place in two ways:
1. The NHS will effectively require the private hospital to use a cheap prosthesis. The ball and socket will probably be ones that were designed quite a while ago because they are cheaper. My surgeon friend mentioned 25 years for the age of some designs. He added that it was arguable that the prostheses designed long ago were as serviceable as more modern designs. If I remember right, he mentioned a hip replacement design called 'Exeter' (because that was where it was designed). But the vastly different prices indicated that people believed that some new designs were better (otherwise no one would buy the expensive ones). The difference can be between £400 and over £2,000. The price which the NHS is prepared to pay rules out the use of any prothesis which is more expensive than the old designs. It was therefore likely, in general, that people getting hip replacements paid for by the NHS, would get less good prostheses than they would if going privately.
2. The NHS patient would be discharged from the private hospital at the earliest possible opportunity. This is again because the NHS is saving money. The surgeon said that it could be perfectly all right to discharge someone quickly. He did not suggest that there was a risk that some people might be discharged too early. However there must be potential risk of this.
If the NHS patient - even when at a private hospital - is at risk of getting less good prostheses, I wonder if he or she is also at risk of getting less good drugs or not getting certain drugs at all? This certainly happens to NHS patients generally, but does it also happen to them when they are in private hospitals? I don't know.
I have long been uneasy about private hospitals being used by the NHS. It is, of course, good that many patients are being treated more quickly (and more safely) than they would be if relying entirely on NHS hospitals. But I have been concerned that Governments are bad at most of what they do and that is likely to include the commissioning healthcare. It is better for patients and doctors to make decisions. Previously, that was all theory. But now we have added the knowledge that, in using the private sector, the NHS spreads its own lower standards like an infection. The NHS patient is not actually gaining the quality of care he or she assumes. The private hospital starts become accustomed to lower standards.
I am concerned that use of the private sector by the NHS might also give the private sector a bad name. At some point the slightly inferior standard of care given to NHS patients in private hospitals might cause someone a problem. This might get publicity. The NHS publicity machine would then put the blame on the private hospital, which would be depicted as selfish and mean. This would put back the cause of private and charitable care for all.
It is difficult for private hospitals to know what to do. If they turn away the business, they can lose out twice. First, they lose a money-making opportunity. Second, they take the risk that NHS commissioning of private hospital treatment will become so large-scale that it will cause a reduction in demand for fully private treatment. Their core businesses could be at risk. So I can't blame them for taking the NHS's business. But there are risks attached.
One of the areas of care for the sick that is still, as I understand it, largely run on a charitable basis is that of hospices.
Several newspapers today have obituaries of Dame Cicely Saunders who is regarded as the mother of the modern hospice movement. Hers is a story of an individual seeing a need, seeing a way of dealing with it and being determined to help. A wonderful story. But note all the admiration she gets and the contrast between her treatment in the popular imagination and the treatment given to, say, a leading consultant.
In the past, before the state took over, doctors as well as nurses were regarded with great admiration. They were, in large part, acting philanthropically. Now they are seen, to some extent, just as employees of the state working under contracts.
Many of our great hospitals - Moorfields for example - were created by inspired and determined individuals. They saw and responded to needs far faster than any government would have done. The survival and the good reputation of the hospice movement is a testament to the psychological effect (among others) on institutions of being charitable and independent rather than state-run and financed.
Here is an excerpt from the Telegraph obituary, touching on the usual difficulties she had in establishing her charitable hospice.
By this time, plans for her hospice were slowly coming to fruition. Her brother found her a site in Lawrie Park Road, Sydenham, and in 1963 the King Edward Hospital Fund gave her £63,000. Through a series of introductions, she went round charitable foundations and lured as many as possible to St Joseph's to see what could be done. They started building in 1965 and found more money as they went along.
The full article is here.
From yesterday's Guardian,
Several articles in Spanish newspapers have expressed shock at the time it has taken for information on the number and names of the dead to come out. Twenty-four hours after the train bombings in Madrid last year, Spaniards knew that at least 190 people had died. And by then most of the bodies had also been identified. Most were buried within three days of the attacks.
An Identification Commission, chaired by a coroner, is formally coordinating the naming of the London dead. Its work is being slowed by the fact that many of the victims' bodies suffered horrendous injuries. In many cases little is left to be identified
It may be hard to make a definite judgement. Yes, the Spanish were much quicker. But were the bodies easier to identify? And did they, in moving faster, make any mistaken identifications?
The very low numbers positively identified in the London bombings suggests a lower level of efficiency here. Yes, some of them were very probably more difficult to identify. But surely not all of them. The ones killed underground may well be the most difficult to identify. But I know of no reason why the ones on the bus would have been more difficult to identify than those who died in Spain.
It is hard to avoid the suspicion that the process in London has been inefficient and led to enormous suffering by the worried relatives.
In the immediate aftermath of the London bombings, politicians ritually praised the performance of the emergency services. I have no doubt that many individual members of all such services - the police, the NHS and so on - acted with genuine heroism. I would want to join in praise of such behaviour.
However it would be a surprise if these emergency services in their overall performance could have suddenly turned themselves into super-efficient machines.
It is hard to believe that the NHS could suddenly alter the fact that its hospitals have very little spare capacity. I was told by a consultant surgeon that after the Paddington rail crash, St Mary's Hospital nearby was not able to cope well with the sudden influx of casualties. He was highly critical of how the hospital had looked after the injured, some of them with desperate, life-threatening conditions.
British newspapers are reluctant to say a word against the performance of the NHS, the police or others at this time. However, gradually a few stories are beginning to emerge which paint a grimmer picture. Most such stories will probably never been seen.
The Daily Mail has been one of the few papers willing to mention that everything has not, after all, been quite perfect. It had an article on Tuesday starting,
"Families who have endured four days of despair and frustration voiced a growing fury last night at the lack of official information about those who died.
"Many have been unable to break through what they call 'a wall of incompetence' in their attempts to find out if relatives, partners or friends are dead.
"By last night, more than 100 hours after the attacks, only one victim had been identified to the satisfaction of the Westminster coroner Dr Paul Knapman."
Some newspapers have accepted the official line that this is all a matter of a coroner having to go through certain procedures and that all is for the best and quite right. Perhaps so. But the Mail story lets through some of the other side of the argument,
"But they [relatives] have been bitterly upset by the impression of incompetence and indifference left by organisations supposed to be helping them. One relative said calls to a helpline either failed to get through or were disconnected. Others had to do their own detective work."
and further on,
"Mr Ali...said hospital staff were cavalier about checking details. At University College Hospital, two men at the reception desk finished a conversation about the TV soap Hollyoaks before they attended to him.
"At the Royal London, when there was no trace of a Neetu Jain, he asked someone to see if she might have been admitted as Jain Neetu. 'I haven't got time', he was told."
"Melissa Lehrer, 31, is looking for her friend Miriam Hyman, 33, from North London.
"She said, "I lived in Israel and saw many bus bombings. There's no reason people should not be identified within 24 hours.""
I doubt if there will ever be a serious assessment of how well the services performed. How quickly were people rescued? How quickly were they treated? How quickly were they identified? How well were relatives kept informed? And how does the performance of the British services compare to that of other countries in similar circumstances?
There are plenty of comparisons to be made: with how Malaysia and Thailand performed after the tsunami, New York after the attack on the twin towersand Spain, after the terrorist attack there.
Sometimes it seems quite difficult to explain why the National Health Service fails to produce the quality service intended. There is a series of causes and effects. If you define just one cause and effect, you do not explain the whole thing. But here is just one part of the chain: the National Health Service wastes its own human and material resources on a vast scale.
This is a widely reported story in today's newspapers. This version is from BBC Online:
The Healthcare Commission found 45% of the theatre time in England allocated for day surgery was going to waste.
and further on,
The report, which examined 313 day surgery units in England, found one in 10 cancelled more than a third of the available operating theatre sessions and many patients had their operations cancelled at short notice.
In The Welfare State We're In, I looked at the story of how Capio, when it took over a hospital previously run by local government, significantly reduced the waste of time caused by cancelled operations.
Of course, government officials and those who still believe in state-run services will say, "OK, fine. I accept there is a waste problem here. We just need to focus on it and sort it out." Unfortunately this is a tempting and widespread self-deception. It takes us back to another part of the chain of cause and effect.
The waste arose in the first place - and has persisted for decades - precisely because the NHS is run by the state. The fact that hospitals are run by the state means that they do not have the right incentives to use their resources efficiently. A private hospital only makes money when the operation takes place. It has every reason to make sure everyone required for the operation is present. A state hospital can actually be better off when an operation does not take place.
"OK, fine. We will put in better incentives," say those who still want the state to run our public services. There is great reluctance on the part of many people to accept that the state is so bad and wasteful in its operations - and persistently, despite the best efforts of very clever and well-meaning people - that it is vain and silly to tell oneself and others that a solution has been found.
Those who believe the state is a good manager are like those who believe that Moggins the cat, can bark. First one of them goes to Moggins and say, "Bark for the public good". Moggins lies down and takes a nap. Then along comes a new minister and says, "No, no. I can make things much better. I can make Moggins bark. I have a new integrated barking programme driven by positive incentives." So the new minister says to Moggins, "I will give you half this meat now and the other half after you have barked". Moggins jumps up enthusiastically and eats the meat offered.
"OK, now bark and I will give you the rest!" Moggins looks longingly at the rest, circles a while, winds her tail around the minister, miaows in way that is as similar to a bark as she can manage. Then she becomes fed up, strolls off and turns her back.
And so and on it goes. We have had many successive health ministers, all clever people and all promising to make the NHS work well. And what have we got as a result of all their efforts? Operating theatres unused for 45 per cent of the time.
Isn't it about time we considered getting a dog?
The Healthcare Commmission press release is here.
I have now received a statement from St Thomas's in reponse to the allegations that were made to me (see previous posting). The hospital trust confirms McKinsey is involved and says the management consultancy is assisting with 'process re-design' and 'supply change management'. I confess I am not sure what these mean.
The hospital maintains that the instructions did not come from 'across the river' and that McKinsey does not have 'executive authority'. There is no direct response to the suggestion that services are being reviewed with the intention of only keeping 'core services' and farming out the rest to surrounding hospitals. This is probably the most noticeable omission in the response. One wonders whether the omission is significant.
This is the statement from the hospital:
Last year, Guy’s and St Thomas’ NHS Foundation Trust launched a Trustwide review of operational effectiveness and efficiency, spanning both clinical and non-clinical services. This Trustwide programme is known as Delivering Excellence and is led by the Chief Executive with close support from the executive team.
The programme aims to improve patient care and ensure we are making the best possible use of all our resources. Operational improvements are already increasing efficiency and benefiting patients, for example, where appropriate we have reduced the time that patients spend in hospital. The financial savings that result from the programme, for example as a result of improved procurement processes and contract renegotiation, are being reinvested in service improvements.
To help us achieve the ambitious programme we have set ourselves, we are using some consultancy support from McKinsey to support our inhouse teams. This is primarily to assist with ‘process redesign’ and ‘supply change management’, areas where McKinsey have particular expertise, as well as to provide training that will ensure our staff have the necessary skills to lead this work in future. McKinsey were selected following a competitive tendering process.
McKinsey staff have no executive authority and it is completely misleading to suggest that they are in control of any of this work. The Trust chose to launch the Delivering Excellence programme – and this has not been done in response to any external request. We are doing this because we believe it is right for the organisation and will bring direct benefits to our patients.
Further to my posting about the treatment received by a child at St Thomas's last week, I have received the following information which allegedly was told my informant by someone senior within the hospital:
...a large team from McKinsey’s has been working inside the trust for months, and will be there for another 6 months. The McKinsey consultants are being paid £1,000 per day. They have been given special powers to make any change, no matter how sweeping, to "make the numbers look right". They have drawn up a list of core services that the trust will offer in the future – everything else is to be hived off to surrounding hospitals. There are some very major changes happening, and a vast amount of money being spent – they have been given a large ‘special budget’ to do so. It is happening under direct control from just across the river.
I have contacted the press office of the hospital to get a response. I got no immediate response whatever to any of the allegations. The press officer said she would get back to me. I would be grateful if anyone with knowledge of the situation could contact me.
Of course, it is no crime to hire McKinsey. Reviewing what the hospital offers and what it does is perfectly reasonable, too. But is it true that services at Thomas's are going to be reduced? Is the bad experience of a child last week in any way indicative of general poor performance? I am content that people should remain anonymous. I can be reached by the email contact fairly low down in the column on the left.
Looking at the hospital trust's smart website, I see that some property re-development is under way. I wonder if that is any part of what is going on. New accommodation is being built for some of the tenants of the charity. What, I wonder, is happening to the old accomodation?
Looking for stories on St Thomas's on the BBC Online website, I came across this appalling story reported earlier this month. Of course, all hospitals make mistakes. But just think how this incident would have been plastered over the front pages if St Thomas's had been a private hospital.
A friend took a child to St Thomas's with stomach pain earlier this week at about two o'clock in the morning. Although the girl was the only one in Accident and Emergency, it was two hours before she was told she had a bed in....Lewisham. She was then, in the early hours, transferred by ambulance to the Lewisham Hospital NHS Trust.
The ambulance man told the mother that the cost of the transfer was £600. There was also a cost, of course, in terms of the comfort and convenience of the ill child and the parents, who do not live near Lewisham. The ambulance man also told the mother that the hospital in Lewisham had stopped recruiting ambulance men and was seriously under-strength altogether. He actually said '50 per cent' under strength, which must surely be a wild exaggeration. However my friend did indeed get the impression that the NHS at Thomas's and at Lewisham was 'creaking at the seams'.
Although, in theory, her daughter had been admitted to Lewisham by St Thomas's, in fact she had to wait another two hours in Lewisham's Accident and Emergency department. Again, no other patient was there. Doubtless the waiting at the two hospitals will go down on the records as two waiting times of under four hours. A success. In fact, the poor girl had four hours waiting plus the time in the ambulance - an ordeal for someone in her condition, which by now was labelled 'suspected appendicitis'. The girl was at Lewisham Hospital for 48 hours, yet never saw the same doctor twice. Each doctor who saw her asked the same questions. There was no continuity of care. The mother does not think her daughter was at any point seen by a consultant. (Incidentally, the girl was not X-rayed or given any other kind of scan. I don't know whether, according to best international medical practice, she should have received some diagnostic work of that sort.)
The hospital in Lewisham was so short of nurses that they positively wanted the parents there to be present and - effectively - to do some of the nursing. One parent came in with a baby and then left. The baby screamed and screamed. There was no nurse available to comfort it, so the screaming just went on for a couple of hours.
We were told that all that was wrong with the NHS was that it was 'underfunded'. Now it is not underfunded yet it still provides service like this.
St Thomas's was founded at an unknown date, it appears, but certainly before 1212. It was named after Thomas Becket. A little more on its long history is here. And here is a lovely picture of the old operating theatre in 1930, before the hospital was expropriated by the state. It has been a great hospital. It is deeply sad that, under state ownership, it should have reached the stage that it keeps sick children waiting and then sends them away to somewhere else in the middle of the night, allegedly using up £600 in the process.
I would be interested to have any comments from others who may have experience of the situation in Thomas's, Lewisham or, indeed, elsewhere in the NHS.
Here is an article from the Reading Chronicle, of all news sources. It draws further attention to the privileged treatment Mr Blair has been given by the NHS. Why do hospitals and consultants give him this privileged treatment? Why do they not say to Mr Blair, "We are sorry. But the NHS exists to provide equally good treatment for everyone. If we allow you to queue jump or get superior treatment, it would be wholly unfair to everybody else." Has the medical profession so little sense that people should be treated according to clinical need rather than status? Here is one of the people who was queue-jumped by Mr Blair. What makes the story so telling is that he suffers from a similar condition to Mr Blair.
A LIFE-long Labour Party supporter suffering from a similar heart condition to Tony Blair has been waiting more than a year for the same surgery which has changed the Prime Minister's life.
Grandfather Richard Brown from Thames Side in Reading suffers from atrial fibrillation - a condition in which the heart beats irregularly, leading to dizziness and blackouts.
He realised he was ill more than a year ago, when he collapsed while on a walk with wife Esme. But unlike Mr Blair, who was treated at an NHS hospital within hours of experiencing chest pains and dizziness in October 2003, Mr Brown was told by a Royal Berkshire Hospital consultant he would have to take medication for the rest of his life.
And it was not until the Labour leader underwent his second operation in less than a year that 67-year-old Mr Brown even realised his condition could be cured.
Now, after demanding a second appointment with his consultant, the retired computer programmer from Newcastle-upon-Tyne has been placed on a six-month waiting list for treatment at University College Hospital in London.
Mr Brown said: "It wasn't until I read about Tony Blair's procedure that I even knew my condition could be treated. I was given some pills to take and that was that.
"When I went back to see my consultant I was told the operation could only be carried out in London because not many doctors are trained to do it.
"Now I am on a waiting list for what is effectively a waiting list - I have been told I will be treated in six months but I will not be given the date of my operation until a month before."
Further on in the printed version of the story, a spokesman for the Royal Berks Hospital says that it was normal for someone with Mr Brown's condition to be given medication rather than being operated on. Only if the tablets did not work, would alternatives be considered. But the point is that finally - and only after prompting - the NHS did decide Mr Brown should have the surgery which appears to be of the same sort as Mr Blair had. But whereas Mr Blair had his surgery immediately, Mr Brown will have to wait six months - on a rather intriguing kind of non-waiting-list-waiting-list (part of waiting list manipulation perhaps).
So it remains the case, that Mr Brown waits whereas, apparently for similar surgery, Mr Blair was treated without delay.
Perhaps it will be said that Mr Blair is important and should be given priority. If so, then it could equally truthfully be said that certain industrial leaders are important, in which case presumably they should be given priority, too. It could similarly be said that dustbinmen are relatively less important and, therefore, according to this logic, they should be put right at the back of the queue. A whole peckng order could be constructed. Is this really what medical ethics have come to? Is it not appalling way to regulate NHS queues -according to the 'importance' of the patient?
It would also be salutary for Mr Blair, who has praised the NHS so often and who claims it is so much improved, to experience it as others do. Indeed, it is obnoxious of him to say it is good and then to avoid experiencing it as it really is. If he truly believes the NHS is in fine shape, why does he feel the need to queue-jump? The man is a hypocrite.
Original unedited version of article in the Daily Express today (and extra comment at the end)
One of the most basic things you would hope to get from the NHS is an appointment with a doctor. Yet now a survey suggests that 22 per cent of patients are not able to make an appointment two or more days ahead. It sounds crazy. Usually an appointment is easier to get the further away the date. Diaries are less full up. But in the NHS, it is now impossible to make a future appointment at all with many doctors. It sounds like something out of Alice Through The Looking Glass.
What has brought about this topsy-turvy situation? A target. If a GP agrees to see us more than two days in the future, he increases the risk that he will fill up his appointment book and then break a government target - that all patients should be seen within 48 hours. But for many people, a firm appointment a little further ahead is what they want. Absurdly, as a result of a government target, the service provided by GPs has actually got worse, in this respect, instead of better.
In the view of one senior government adviser, the NHS has two years in which to reach a good standard, otherwise the public is likely to lose faith in the entire system. Since 2000, the government has been putting huge amounts of extra money into the NHS. Many members of the public are willing to allow time for the results to come through. But not unlimited time. By 2007, a decade after Labour came to power, if the NHS has still not become world class, the public might stop believing that the only problem previously was lack of money. They may be ready to believe a state monopoly system is not a good system.
How, then, is the NHS doing? Is it going to deliver a first class service within two years?
Unfortunately the most conclusive statistics will not be available until much later. These are the proportions of people who survive for five years or more after contracting the various kinds of cancer. International comparisons of these 'five-year survival rates' have, in the past, been the most damning and incontrovertible evidence that the NHS has provided medical care that is amongst the worst in the advanced world.
In the absence of such emphatic evidence, though, there is much to suggest that a radical improvement of the NHS is just not happening.
In 2003, 72 per cent of cancer patients were not given curative radiology in a timely way. The figure was actually worse than in 1998, when 32 per cent were not treated acceptably.
There are still serious delays on all sorts of diagnostic work that has to be done for a doctor to establish what a patient is suffering from and how bad it is.
Recently a woman was told that she would have to wait for 18 months for an MRI scan. Many health authorities commonly quote a six month wait for such scans, which are used for assessing cancer, heart disease and damage to the brain among other things.
Many people assume that the NHS will give us the drugs we need, when we need them. This has not been the case for a long time. It still isn't. There is large scale under-prescription of Aricept, for those whose memories are fading, and of Cox-2 inhibitors for those with arthritis. In America there is a drug for colo-rectal cancer called Avastin has been in use for a year. In Britain, it is now possible to get it privately. But NICE, the government quango which assesses new drugs, says it will not decide whether or not NHS patients should have it until more than a year from now. Herceptin, a drug for breast cancer, is only given to about half of the women who would benefit from it. In America, virtually every woman who would benefit gets it.
The Picker Institute recently assessed the progress of the NHS and made the telling observation that it had improved where there had been a lot of political focus. But it had not improved - and in some cases had got worse - in areas that were out of the limelight.
It is not encouraging that so many doctors have recently been expressing disgust at the way the NHS operates. Mike Lavelle, a consultant surgeon, resigned from the NHS earlier this month saying "the delays in operating theatres are quite frankly scandalous".
Another consulant, Milton Pena, an orthopaedic surgeon, said that on his ward a "desperate shortage of nurses is putting patients' lives at risk".
The Government seems to be on a campagin - involving civil servants who are meant to be independent - to convince us that the NHS is getting better and better in every way. But it has reached the point where government claims and statistics are treated as less trustworthy than those from outside bodies. There has been plenty of evidence that waiting lists are manipulated.
Professor Karol Sikora, a leading cancer specialist, said yesterday, "we've got ourselves into a propaganda culture' and said that the government claim that 99 per cent of suspected cancers were seen by a specialist within two weeks is "just lies".
However much the government huffs and puffs about how well it is doing, the true quality - or lack of it - of the NHS can be seen by us all. It will certainly also be analysed by outside bodies. There is no hiding place if the NHS cannot match other systems in the world. And on present form, in two years' time, it still won't. Then we might be thinking quite hard about what sort of system would be better.
On reading through the rest of the Daily Express today, I find, in the very same issue, an example of a public servant - who should be independent of all politics - putting out more pro-NHS propaganda and thus acting, effectively, as a pawn of the Labour Party.
Dr Gill Morgan, the Chief Executive of the NHS Confederation, no less, has found time to write to the letters page of the Daily Express to correct a reader who, in her view misrepresented the true situation in the NHS. (What is the Confederation? "The Confederation brings together the organisations that make up the modern NHS across the UK.")
The reader is quoted as applauding a "surgeon's stand against empire builders". (Perhaps he was referring to Mr Lavelle, mentioned above.) Dr Morgan writes:
Your correspondent David Dowd misuses statistics in his letter.
Three per cent of the overall NHS budget is spent on managers.
To claim there is one administrator for every useful member of the NHS is wrong and also incredibly demoralising to the cleaners, porters, IT staff, managers and cooks who don't work directly with patients but without whom the NHS would collapse.
It is marvellous to behold Dr Morgan accusing a member of the public of "misusing statistics". Note her own careful use of the phrase "three per cent of the overall NHS budget is spent on managers". It is up to the NHS of course, what it defines as a 'manager'. If she is really willing to break down the entire budget, let us hear what percentage is spent on every other category of staff including 'administrators','office clerks' and suchlike who are not 'managers'. And when she says "overall" NHS budget, what is she including? Everything? In which case, let us have the relevant statistics just for hospitals.
I wonder if she herself counts as a 'manager' or whether her job description is something else, perhaps 'special adviser for refuting any criticism of the NHS'.
I fully expect that she, or Nigel Crisp, will be writing to the Daily Express again today to 'refute' my article. I wonder whether there will be meetings and consultations, perhaps with ministers, on how best to do it. (Well, as a way of spending taxpayers' money, it is alternative to hiring a nurse.) Will they go round to see the editor to re-educate him?
How sad it is, indeed, that public servants have become like this. I suppose it is simply that nowadya they will not given the top jobs unless they are willing to toe the (political) party line. It is a kind of corruption of the body politic.
Rather strangely, neither the Telegraph nor the Guardian appear to have covered a story made a big impact in both the Mail and the Express this week. It is not a trivial, celebrity story but one that goes to the heart of one of the big issues of the time: whether the NHS model of healthcare can ever deliver a first class service.
A consultant surgeon, Mike Lavelle, has resigned from the NHS and leaked a letter in which he made a powerful attack on the way the NHS works.
"The delays in operating theatres are quite frankly scandalous" he says.
"I have no doubt that the service is grossly overmanaged now.. there has been an almost unbelievable increase in NHS employees who contribute nothing to the treatment of patients. But if you go onto my ward the nurses are struggling to look after the patients..."
"For years now, I have been stopped from doing my job in the NHS by the lack of facilities, but in public, the politicians (in particular Alan Milburn and John Reid) have blamed the consultants for the waiting lists. This is extremely demotivating and demoralising", Mr Lavelle wrote.
"It seems the Government thinks that if only they could get the consultants in the NHS to work harder, then waiting lists would be a thing of the past.
"You may not believe this but I have found in the past 10 years or so that the harder I work in the NHS the gloomier managers get because I am spending the limited resources. The delays in operating theatres are quite frankly scandalous. I have complained about this for years, yet nothing has been done.
"In the end, the taxpayer is paying twice for the operation; once when I am sitting around doing nothing, either because of delays in getting patients to theatres or because of lack of beds, and then again when the operation is farmed out to the private sector."
The above quotes are taken from the limited version of the story on the Daily Mail website.
From the printed version, I would add that Mr Lavelle also criticised the employment of a 'Service Improvement Facilitator' who visited the the endoscopy unit to inquire about the number of endoscopes (in instrument for internal examinations).
"Everybody knows that to improve the service we need a second room up and running and some new endoscopes, but instead of that we employ these people to go around interfering and collecting inaccurate data."
"A year's salary for this person would probably but a new colonoscope and we could have a new scope every year for the next five years!"
"It is my impression at the moment that there always seems to be money available to appoint new managers, but if you go on to my ward the nurses are struggling to look after patients because the establishment is inadequate."
The criticisms of Mr Lavelle indicate some of the answers to the question which we can expect people to be asking more and more in the next few years: 'why has the NHS improved so little when so much has been spent?'
1. Waste of money when operating theatres are not used and highly qualified staff (not to mention the patient) are left hanging around
2. Waste of money on administrative staff which could be better spent on frontline staff.
Some politicians might respond, "Right-o, we will demand that operating theatres are used more efficiently and we will cut back on admin staff". They will imagine that yet another diktat from the centre will solve everything. How many times has this naive idea got to be tried out before it is understood that it will not work?
The problems identified result from a systemic problem. State monopolies tend to be extremely wasteful. They do not have the same incentives simultaneously to save money and serve the customer very well. Their 'customer' is the central government. Their employees' jobs depend on doing what central government demands. So they do what central governments demand. They fill in forms. They report back on how they have carried out instructions. They need more staff to do this. This is the priority and never mind the patients, the waste or all common sense. The NHS is an inherently bad system because it is a government monopoly. Only when the NHS is reformed in a way that it ceases to be a government monopoly - in other words completely breaks with the Bevan model - will it have the remotest chance of being good.
Incidentally, I would be interested to know what Mr Lavelle is going to do next. Neither the Express nor the Mail reveals that. Will he work in private practice, retire or work abroad?
The Daily Telegraph this morning celebrated the news that the NHS is starting a review to decide whether or not to switch to digital scanners for detecting breast cancer. The review will be completed by the end of next year. If the review comes out in favour of digital, then the scanners may start being ordered in 2007 and delivered in the following years.
But the impression that the NHS is at the forefront of modern scanning technology is the reverse of the truth. Here is a picture of the latest 64 Slice CT scanner at Mercy Hospital in Miami, Florida:
All the diagnostic scanning in this hospital is already digital. There is no need for photographic plates (which often get lost in British hospitals). All the material is on computers and can be transferred to other computers anywhere in the world.
It is extraordinary, to put it mildly, that the Daily Telegraph should present its story as a good news story about the NHS. In fact the story reveals that the NHS is years behind other countries in its scanning facilities. As a result people with serious diseases like cancer and heart disease are diagnosed late. Late diagnosis means a higher risk of death. Many people die in Britain each year because of the out-of-date diagnostic equipment.
The blog Once More Unto the Breach has an interesting posting and comments on the options and difficulties in welfare reform.
Below is a classic example of the Government's line on what is currently happening in the NHS. Basically, so it says, although there are a few little problems here and there, the vast majority of things are getting better.
Is the picture painted in this Department of Health press release accurate? If it is, then the extra money pumped into the NHS has 'worked'.
Consultant and GP numbers on the up
Published: Thursday 26 May 2005
Reference number: 2005/0190
New figures published today by Health Minister, Lord Warner show that there are more consultants and GPs working in the NHS in England delivering faster, better care for patients.
There are now 7,542 more consultants and 3,331 more GPs working in the NHS than were in 1999. These staff are helping to bring about big improvements to services for patients:
· improving access – waiting times are now falling consistently so that all heart bypass operations and angioplasties are now done within three months, compared to a two-year wait before 1997
· Almost everyone in England can now see a GP within 48 hours (99.98 per cent)
· GP practices are providing higher quality services, for example over 1.5 million people suffering from diabetes and 2.5 million suffering from asthma are now receiving care to best practice standards
· more than 99% of people with suspected cancers are seen by a specialist within a fortnight of referral by their GP.
Lord Warner said:
"These figures show a continued growth in the number of consultants and GPs working in the NHS. This is having a huge impact on patients, helping them to access treatment faster and get better care.
"It is these people who are responsible for the real changes we are seeing in patient care, the falling waiting times, the improvement in survival rates for cancer and coronary heart disease and the changing role of the NHS from being a sickness service to a true health service through community based initiatives such as our stop smoking services.
“This growth in doctor numbers – and the growth announced recently for the whole NHS – provides the platform for us to deliver a patient led NHS.
“We realise that some pockets of the NHS still struggle to recruit all the staff they need, which is why we are constantly trying to make the NHS a more attractive employer through improved pay and conditions, flexible working and increased access to childcare."
Notes to editor:
1. The number of Consultants in the NHS increased by 213 between September 2004 and December 2004.
2. The number of GPs in the NHS increased by 275 between September 2004 and December 2004.
3. The total number of Consultants in England as at 30 September 1997 was 21,474. As at 31 December 2004 this figure was 30,863- an increase of 9,389.
4. The total number of GPs (excluding GP retainers and GP registrars) in England as at 1 October 1997 was 28,046. As at 31 December 2004 this figure was 31,798- an increase of 3,752.
5. Further information about the mini-census can be found at the link provided:
One is so accustomed to spin, carefully selected statistics, misleading statistics, distorted statistics and so on from this government, that one is inclined to be distrustful. Yet since the government itself is in charge of the production of statistics, figures and explanations it is not so easy to produce a rebuttal.
Here, for the time being, are some off-the-cuff suspicions and comments:
1. I understand that it now takes less time to become a consultant. So not all consultants now would have been called consultants in 1997. The figures are not genuinely comparable. The big rise may not be what it appears.
2. The claimed rise in the number of GPs is much more modest at only 13.4 per cent since 1997. But these figures appear to be headcount figures, not 'full time equivalent' figures. More and more GPs are women working part time. So what is the change in full-time-equivalent GPs? Does the GP figure include or exclude GPs from other countries like Germany?
3. What has been the change in administrative staff, incidentally? A far bigger rise, I believe.
4. The claim that "more than 99% of people with suspected cancers are seen by a specialist within a fortnight of referral by their GP" is surprising. I was recently told by a cancer consultant that some 40 per cent of the patients at her hospital in London are not seen by a consultant but that the cases are discussed with a consultant. To a layman, there would seem to be quite a big difference.
5. Then there are all the figures which are not mentioned:
The waits for diagnostic procedures such as MRI scans which are still very long in many parts of the country.
The availability or otherwise of advanced diagnostic machines, new and better surgical procedures and the more expensive drugs.
As I have mentioned before, I visited one hospital in Miami on my recent visit there. That hospital had one of the latest 64 slice CT scanners. In Britain, only one hospital in the entire country apparently has such a machine. The underuse of many kinds of drugs from Aricept (for dementia) to Cox 2 inhibitors (for athritis) is spectacular in Britain.
GP services remain almost entirely reactive - even when it comes to the elderly. The regular health check-ups that are routine in some other countries are practically unknown here.
A physiotherapist who cares for NHS patients tells me that in her part of Hampshire, provision of NHS physiotherapy has significantly deteriorated in recent years.
I would be grateful for comments - favourable or otherwise - from medical practitioners on what they consider to be the reality of the new, well-funded NHS.
Comment from one doctor quoted in the Guardian today in an article about hip fractures:
Most patients requiring a so-called neck-of-femur repair to correct the injury are older women, and most already have other medical things wrong with them, says Christopher Bulstrode, professor of orthopaedics at Oxford University and a council member of the Royal College of Surgeons of Edinburgh. "They are very difficult to anaesthetise. You can lose them because they have dicky hearts, hypertension or are suffering dehydration. We give them to the most junior surgeons; we operate in the middle of the night and, surprise surprise, they don't do very well.
The article is part of an assessment of NHS performance. It is probably valuable in assessing the performance of NHS trusts in comparison with each other. Unfortunately it is not focused on NHS preformance compared with the past or, most important of all, other countries.
I went to an event at the Institute of Economic Affairs last night at which several of the authors of a new book, Margaret Thatcher's Revolution, including Norman Tebbitt, spoke. Here are some of their remarks:
Dennis O'Keeffe: "much 'special needs' is about children who have not been taught to read".
David Marsland: Privatising the supply of healthcare (ie hospitals and doctors) is relatively easy. Privatising demand is more difficult. But a start could be made by using tax rebates to enable people to opt out of state-financed care.
James Stanfield: He went to a comprehensive school. He did GCSE in English Literature and did not do any Shakespeare at all. The year after he left, the headmaster was punched by a pupil as order faded. He reckons he got out 'just in time'. He wanted governments, if they are subsidising education, to subsidise the consumer, not the producer. He said he had been to Kenya and was appalled that the British government was exporting the failed British model of 'free and compulsory' education. He said, "British money is destroying education in Africa."
Norman Tebbitt talked of the huge transfer of assets that took place under Thatcher from the public sector to the private sector. He reeled off a list of companies privatised that was far longer than most of us can easily remember. On top of that was the sale of council homes. He said these things combined to make a big difference in social attitudes.
He admitted some failures.
He said, "we failed in the non-economic aspects of policy" and "I bitterly regret that we weren't bolder in our programme in 1987 - particularly in health reform and education reform".
On Europe, he suggested the policy now should be to describe a European Union of a kind that we would like and, if we cannot get it (or, presumably, something close, that we should leave the EU. He said that Thatcher tried to make the European Union into more of the kind of place she wanted with the Single Market. But this had not worked: "Have we got a single market? Have we hell!"
He was asked what was the biggest mistake of the Thatcher years. He had no doubt that it was joining the Exchange Rate Mechanism. Up until the ERM fiasco, the Conservatives were ahead in virtually every opinion poll on the question of which party would be better at running the economy. Ever since the ERM, the Conservatives have been behind on the same question.
In describing Margaret Thatcher's view of things, he said, "she believed fundamentally that people behave logically". He said approvingly that she was "predictable". You know what she would think on any issue. You did not have to ring up Number Ten and ask. When she and he were both making speeches on the same night, they did not need to exchange speeches to ensure they would not contradict each other. The line was clear and predictable. He pitied those who worked for Blair who would have no such certainty. [For example, does he believe in the state running things or private companies? One minute Railtrack is nationalised, the next he is contracting out hospital operations to private companies.]
The evening brought home how many radical things she did - things that are easily forgotten like removing exchange controls, pay limits and dividend controls. Tebbitt remarked, "we were thinking so many unthinkable thoughts we almost frightened ourselves".
Dennis O'Keeffe said that under the Thatcher administration he came to be proud of Britain. In looking to a future leader of the Tory party, he thought we would need one who could make us proud again.
From today's Guardian:
A new strain of a hospital-acquired infection has claimed 12 lives at the specialist Stoke Mandeville Hospital in Buckinghamshire and infected more than 300, the Department of Health confirmed last night
And further down the story:
But incidences of Clostridium difficile have risen quickly in England, Wales and Northern Ireland from 10,000 a year in 1995 to more than 40,000 in 2004.
In MRSA, as in so much else, government is not the answer. It is the problem or, to be more precise in this case, the obstacle getting in the way of solving the problem. This article from the Guardian tells heavily against government in general and the European Union in particular. (This, in itself, is something to be treasured.)
Researchers at the University of Manchester said European Union regulations were holding up clinical trials to test the effectiveness of three essential oils, usually used in aromatherapy, in tackling superbugs.
The team tested 40 essential oils on 10 of the most dangerous bacteria and fungi including MRSA (methicillin-resistant staphylococcus aureus) and E coli. Two of the oils killed the bugs almost immediately, and a third was found to have a beneficial effect over a longer period of time.
Researchers now want to carry out trials on healthy volunteers who are carrying MRSA but are not infected by it. It is estimated that between 20% and 40% of people in the UK carry MRSA, mostly in their noses or on their skin, without any ill effects.
But nurse and aromatherapist Jacqui Stringer, clinical head of complementary therapies at the Christie hospital in Manchester, said the European clinical trials directive was slowing their progress. The directive was applied in the UK a year ago by the Medicines and Healthcare Regulatory Agency (MHRA).
"We are trying to do this in the right way so it is evidence-based and there is all this red tape preventing us," Ms Stringer told Hospital Doctor magazine.
"It seems crazy. The MHRA has put all this legislation in place and it is an absolute nightmare trying to start the trial. We are trying to hack through all the directives."
The full article is here.
Dinner last night with about 17 Conservative Party parliamentary researchers, local councillors and activists. They were generally under 40 and, though, they had a variety of views, I was struck that quite of few of them showed a robustness in their free market views that has not been widespread in the Conservative Party since the days were Margaret Thatcher was leader.
One of them said that Rudi Giuliani, the former Mayor of New York, wanted to introduce vouchers for schools. His advisers said that some other word should be found. I think he said 'grants' was suggested. But Giuliani said, no, our opponents will call them vouchers whatever we call them, so lets call them vouchers ourselves. The difference between this kind of approach and that of much of the leadership of the party since Margaret Thatcher, is that it reflects real belief.
Much of the leadership since her has spent its time apologising and agreeing, like Theresa May, that the Conservatives are seen as 'the nasty party'. But there is nothing 'nasty' about trying to make Britain a better place. If supporters believe that, they should stand up for those beliefs. To accept media and Labour Party attempts to smear the Conservatives is to surrender and, worse still, concede that there is substance to the attacks of your enemies. This acceptance that the Conservatives have been unappealing and done a lot wrong is inaccurate and highly damaging to the reputation of the party.
In retrospect it seems that the defeat in 1997 was a trauma which wholly deflata ed the self-confidence of the party. Michael Portillo was the prime example of someone who had been a Thatcherite but whom defeat changed into a neo-Blairite. Even David Willetts, as nice and intelligent a politician as you could find, has spent a large part of his time in the post-Thatcher years compromising the passion and belief of the past in desperate attempts to appease the enemies of what he used to believe in.
What came through last night was a suggestion, at least, that there is new generation of younger Conservatives out there who have had enough of appeasement, who are not marked and wounded by that 1997 defeat but, instead, increasingly are outraged by the failure of Tony Blair and Gordon Brown's socialism-lite. They believe that free markets work better. They believe it matters and is absurd that the poor are heavily taxed. They want to cut waste and hand back responsibility to people for their own lives.
And if people say, 'you want to dismantle the NHS' they are prepared to say, 'Yes. We do. It is a lousy system. Why wouldn't anyone sensible want to replace something that has failed - that causes thousands of unnecessary deaths a year with something much better?'
Some of them were also arguing that the party needs to be saying such things for years and that, as the failure of the NHS model - for example - becomes still more apparent, then the party's idea will be seen to be vindicated and the Conservatives will be perceived as the right organisation to do something about it.
It is interesting and encouraging to see some of the Cosnervatives, at least, getting their guts back. It makes quite a background to the leadership contest. The fight can be seen, in part at least, as one between the appeasers and the believers.
The husband of a trainee nurse emailed me and mentioned that a third of the trainees drop out after only eight months. I asked why. This is his reply, which makes it appear that the training of nurses has gone beyond absurdity into a scandalous misdirected use of taxpayers' money:
They just appear to get fed up and wander off! There doesn't seem to be a "reason". The practice part of the job was hard work, but they were dropping well before that. One left four days after the start of the course.
To be honest, it's a complete skive as far as I can see. On Monday, she does about 90 minutes. Tuesday is a full day, Wednesday about half a day, Thursday is a "study day" e.g usually nothing, and Friday is a full day.
I reckon it is about 40% of "full time" study, most of which is lectures. A "full day" is more like 10:00 to 3:00 not what you are I would consider a full day. If they got on with it, they could probably do it in 2 years of full time courses.
The essays are short and easy (2 x 3000 word essays per year) and you get 6 weeks to do them in (and more time off to do them in). It's not particularly high level stuff at all; you can't write anything in depth in 3000 words really, and the essays are multiple-topic, so you are really only writing a few hundred words on each part. The hard part is fitting it into 3300 words (you can go 10% either way). I spent an hour pruning her first essay just to get it down to size.
I *think* they are used to having things on a plate and can't cope with being expected to work for it, be marked on their essays and so on, general lack of gumption, and I suspect they think it's going to be like "Casualty".
Like any other caring job, there's a fair amount of messy stuff and that puts people off.
And I suspect it's the old "instant gratification" requirement. I
suspect you've read "All Must Have Prizes", it's like that but worse. It's also the move towards degrees in Nursing, i.e. an academic qualification. Nursing is not an academic skill really IMO.
The work appear to bear little resemblance to actual "nursing" ; it is all the codswallop about "facilitation" groups, they have discussions and presentations a lot of the time, there are reams of documentation which seem to be box ticking jobbies of the type that the DfES produces daily, producing evidence that course targets are met presumably to be fed back purely to tick more boxes. A background in teaching was handy for me to translate this into coherent English ;-) [smile] I think the end of year "exam" is a
short multiple choice test.
There was no training (literally) in actual useful skills - taking
pulses and so on - until the week before the first placement, when they had a few days of crash training. Not a good way to learn a skill really.
The bit that is hard is the practice ; this has involved 8 or 9 consecutive 10 hour days with awkward shift patterns apparently constructed at random - and lots of weekends ; my wife has said that there seems to be more students about at weekends, and certainly she's worked for more Saturdays and Sundays than anything else -
but she can't really complain. Certainly her shift pattern would be
unworkable over a long period ; you would just simply collapse. She says friends of hers have done 7 days in a row 12 hour shifts. But I don't think this has made a massive difference, people were dropping out on the above timetable.
I don't think it is at all unusual. A friend of ours is in the last year of a Mental Health Nursing course at the same hospital reckons about a third of the students are left from the start 2 1/2 years ago.
No-one appears bothered about the dropout rate. It appears to be
accepted as the norm.
Part of a Help the Aged report, quoted on BBC Online.
Older people who die in hospital often endure their final days in dirty and noisy wards, where busy medical and nursing staff can devote little attention to them
How are the elderly treated in different countries and in Britain in particular? There is an interesting selection of letters in The Times today which raises a lot of the big issues in a short space. Does government involvement do more harm than good? How much damage to provision has been done by government regulations? Should people be looking after their aged parents themselves? Is it better for the elderly to be in their own homes, rather than in a care home (the cost is not very much greater)? Here is one of the letters:
MY 98-year-old grandmother has been in residential care since a fall in September left her unable to care for herself. The care home is under-staffed and under-resourced. The food is awful and there is real lack of warmth. She cannot walk and has been given a room two floors up, so is forced to sit all day in a lounge with others or be left in her room alone as there is not the staff to move her. It makes me very sad and angry that her life has come to this.
I looked at several other homes during her initial 12 weeks. I was appalled: many were dirty, smelt awful and the patients were left to sit and stare into space. We have more compassion for animals in this country than our elderly. If I could have had her living with me, then that is what I would have done rather than subject her to this.
My dad is also in a nursing home; at just 56 he had diagnosed a degenerative brain disease. Thankfully his experience has been better and the home is wonderful. The catch is that he is 35 miles away in Milton Keynes, as that was the nearest place that could care for him.
At nightime in certain NHS hospitals,
Trainees are cross-covering specialties for which they don't have the necessary experience, delegates heard at the BMA's juniors' conference last weekend. In one of the most shocking examples, an SpR in geriatrics told the conference how he was forced to resuscitate a neonate, despite no previous training.
It seems the problem is at least partly due to implementation of the European Union Working Time Directive. This is from the Hospital Doctor website.
One of the assertions in the book is that at least 15,000 people a year die premature deaths in Britain because we have the NHS rather than an averagely good system. Normally the deaths don't get into the newspapers but this one did (see below). The child who died would probably have had his operation in good time if he had been one of Tony Blair's children. If Tony Blair himself needed a similarly important operation, there is no question that would get it promptly (see earlier posting on his back injection). So, we have a medical system under which children can die from from lack of timely treatment but in which the prime minister always gets timely treatment. Is that what he calls 'social justice'? Is that what Nye Bevan, that passionate defender of the working man, had in mind when he created the NHS?
A nine-year-old boy has died after an operation to treat his severe epilepsy was cancelled because Britain's top children's hospital had run out of money.
Peter Buckle, from Evenwood, in County Durham, had a massive seizure and died last Monday. He had been waiting to undergo surgery at Great Ormond Street Hospital for Children in London.
The brain operation which might have saved his life had been cancelled twice. The first time, on March 15, Great Ormond Street cut back its operation lists after finding that it had treated more children than its budget allowed for. The operation was rescheduled for April 22, but cancelled three days beforehand when a ward was closed after staff contracted a viral infection. It had since been rescheduled for June 10.
See full Sunday Telegraph story here.
The French healthcare system undoubtedly provides better care than the NHS. But in France, too, there are problems.
An intriguing sentence in the Daily Telegraph report of Tony Blair's back injection:
The hospital said he had been given "priority treatment" but no other patients had been affected.
This is not absolutely unambiguous. It could mean that he was given 'priority treatment' because of the seriousness and urgency of his condition. But the impression I get, especially from the following phrase 'but no other patients were affected', is that he was jumped to the front of the queue or else given a more precise appointment time than everybody else.
If this is the case, it marks the introduction of a new, three-tier health system.
Some people go to the NHS and get a service which may involve delays and not seeing a specialist but is free. A second lot of people pay fees, in addition to their taxes, to go private and get seen by a specialist fairly soon. Now it seem we may have a third tier of the health system. If you are Tony Blair, you get priority treatment, you are seen by a specialist and it is free.
Perhaps this is what Tony Blair when he boasted he would introduce a new Third Way in British politics.
Don't bother asking if you, too, can have 'priority treatment' which does not affect other patients. Only Tony Blair, and perhaps other members of the Politburo, receive this.
It is surprising that the news media have not investigated this 'priority treatment' further.
I suppose the origin of Mr Blair's 'priority treatment' is this: as a busy man, he could not be kept waiting for NHS treatment like an ordinary citizen. As a Labour Party leader, however, it would look bad if he went private. So he has now experienced a kind of fake NHS treatment in which he was rushed to the front of the queue. It is, bluntly, a corruption of power and an insult to the intelligence of the populace. If he believes the NHS is a good system and that the billions of extra taxpayers' money he has taken has been well spent, he should be prepared to experience the reality of the NHS, not a fake version of it.
UPDATE: I have just talked to one of the authors of the Daily Telegraph story who tells me that Downing Street gave few details of what had happened but he understood that Mr Blair got a 'swift appointment'. In other words, he got treatment at a speed and with a convenience not available to everyone else.
An email received today:
I've recently read your book and you raise a lot of good points. I teach in a college that retrains unemployed disabled adults and it is only too apparent that the welfare system has hindered as well as helped a large number of our students in the ways in which you describe. For many the financial incentive to work just isn't there, especially those with families, although often we are sucessful in changing peoples outlook and raising their aspirations.
In a lot of cases the disability, physical or mental, is secondary to the problem of a poor basic education in the first place. Without basic literacy, numeracy and organisational/reliability employment prospects are massively limited. We are certainly seeing a large proportion of youngsters for whom you wonder what they actually did at school.
It's pretty clear that for a long time gov't thinking was on inclusion in mainstream education and organisations, charity based and specialised like ourselves, were not flavour of month. There is now a realisation that this approach does not work for everyone and has left many people marginalised as mainstream providers have not got the resources or skills to give the level of support necessary. This seems to be changing but the problem that a lot of charitable organisations have when applying for funding is the enourmous levels of beaucacy that accompanies any application e.g. setting targets,
review procedures, equal opps, inspection and auditing etc. In other words, introducing the same levels of inefficieny and inflexibility that the state insists on for itself!
An audit by the Royal College of Physicians has highlighted dangerous delays in urgent scans for stroke victims. The study found more than 40% of patients were not given the test within 24 hours, the limit specified in college guidelines.
Part of an article in the latest Sunday Times.
Read posting with reference to MRI scanners in the USA here.
One of the reasons US health insurance is so expensive is that the states tend to insist on certain kinds of coverage. So it is an advance that Texas appears to be relaxing its requirements. The interesting and valuable result is that more of its citizens can afford some insurance.
This from the Daily Policy Digest via the NCPA idea house.
Not all medical care in the USA is very expensive. How about 50 blood tests for US$90?
It is mentioned in an essay on the rise of patient self-management written by Dr Herrick for the National Center of Policy Analysis. Also mentioned are the Health Savings Accounts which, he predicts, will grow dramatically in numbers in the coming years.
Thess enable people to save for future medical treatment yet keep control of how the money is spent. Because the money comes out of their own savings, people have an incentive not to waste money (something that happens quite often in the French system and indeed in many insurance-based systems).
Incidentally, when in Miami recently I asked about how many MRI scanners there are. I was told that there could be as many as five in a single street. There were competing MRI scanning centers. How long do you have to wait for a scan?
You could have one today. (In the NHS, you can be asked to wait six months or more.)
I don't think that the American healthcare system is good. It isn't. It is a mess in many ways. It is just that the NHS is a much bigger mess and thousands of people die premature deaths each year because of its marked inferiority to the systems in practically all other advanced countries.
Treatment of intensive care patients is sometimes so poor it is contributing to their deaths, a watchdog has warned..
Half of patients who died had had "less than good" treatment, and in a third of those cases it may have been partly to blame for their death, its study found
This is a shocking report. What we do not have, unfortunately, is a report done with the same methodology on, say, four or five other countries. So we know the NHS treats people who are in crisis in a poor way. We don't really know how much worse it is (assuming, as I do, that it is worse) than in other advanced countries.
The NHS is the world's third-largest employer with a million people on its books, second only to the Chinese Army and Indian railways. We spend some £80 billion a year on the NHS, equating to £1,400 annually for every man, woman and child. Despite this the number of NHS beds in England has halved in the past 25 years.
The average British woman will have 2.2 healthy pregnancies in her lifetime - almost enough to keep the UK population stable - but will give birth to only 1.7 children. The difference is accounted for by the number of abortions.
The number of people working in the public sector has increased by 10 per cent since 1998, accounting for some half a million of the new jobs created since Labour came to power.
Total public sector employment in 5.29 million, up from 4.71 million in 1997.
In 1981, 600,000 people claimed incapacity benefit. Now it is 2.2 million.
The greatest increases in recorded crime since 1997 have been in drug offences (509 per cent) and violence against the person (281 per cent) and there has been a drop in burglaries by nearly a fifth.
More than half the households in Britain have less than £1,500 in savings, and a quarter have no savings at all.
Teenage birth rates in Britain are twice as high as in Germany, and five times as high as in Holland.
150,000 children are educated at home, and the figure is rising. Bullying, harrassment and religion are the reasons most cited by parents for taking their children out of school.
From Britain in Numbers published by Politico's and serialised in today's Daily Mail.
This used to be the St George's Hospital. It was built and paid for by charity, and sold off by the NHS. That is why it is now known as the Lanesborough Hotel. If mememor serves, Macmillan, when he was in the House of Lords, once referred to the privatisations that went on under Margaret Thatcher as 'selling off the crown jewels'. In healthcare, it has been the NHS that has sold off the crown jewels, closing hundreds of hospitals that were created with charitable funds.
There is still a St George's Hospital, of course, but it is in Tooting. It is the result of a 'merger' of over 10 hospitals including the original St George's Hospital (now The Lanesborough Hotel) at Hyde Park Corner. The two sites are miles away from each other and on opposite sides of the Thames.
One of the arguments put forward in The Welfare State We're In is that in the National Health Service, the old are discriminated against. Here is further evidence:
Patients could be denied certain health treatments because of their age, according to a government agency's draft discussion document.
The National Institute for Clinical Excellence (Nice) has raised the question of social value judgments for the first time in its talks over what should be allowed on the NHS.
The document says members of Nice's citizen's council believe "where age is an indicator of benefit or risk, age discrimination is appropriate".
When the document was released for consideration last month, Nice stressed that it was not seeking to formulate guidance for the NHS but for its own committees when they were making recommendations on drugs or treatments.
The document also asks whether patients' lifestyle or habits, such as smoking or over-eating, should be a consideration. Age Concern said about 80 per cent of GPs already believe there is discrimination against older people within the health care system.
Jonathan Ellis, the policy manager for health and social care at the charity, said: "To suggest that anyone should receive less care and attention simply because they happen to be older is blatant discrimination.
The full article in the Telegraph is here.
NICE has already shown discrimination against the old by suggesting lately that dementia drugs like Aricept should no longer be prescribed. This would be an outrage if it ever happened.
The Daily Mail today carries a short account of how Aricept has changed the life of one man, Keith Turner:
Since his diagnosis a year ago, his condition had slowly declined. 'I could not remember three words in a row,' said Mr Turner, 66, from Hastings. 'I feel asleep in front of the TV because I couldn't remember what I'd seen and I gave up reading. I couldn't go out on my own because I would get lost.'
But since starting on Aricept four months ago he has started to believe in 'life beyond dementia'.
I feel almost back to normal,' he said. 'I can read a book, watch TV, have a conversation, go out on my own and drive the car.'
His wife, Lilian, 66, said: 'Without the drug, people with Alzheimer's will again be second-class citizens.'
It should be said that it is not claimed that Aricept acutally reverses dementia at all. The biggest claim for it I have heard made by a doctor is that it can arrest decline. However there is occasional evidence, like that of Keith Turner, that in a minority of cases (probably a small minority) it can actually improve matters. But even if that is exceptional, an arrest of decline is extremely valuable and important to the individuals concerned and it may also reduce healthcare costs because people can remain independent for longer.
But there I find myself lapsing into the mind-set of the NHS: taking for granted that money is very tight and there must be severe rationing and so simply treating people is not good enough as an ambition by itself and must be supported by the idea that money would be saved. This is the mindset that leads to the idea that is so prevalent in the NHS - that the old have only a few years left and so are 'not worth treating'.
For those who think the nursing crisis is over, some anecdotal evidence:
A hospital consultant put his career on the line yesterday by warning publicly that a desparate shortge of nurses is putting patients' lives at risk....
Mr [Milton] Pena, an orthopaedic specialist, is a surgeon of more than 30 years' experience.
He revealed the crisis at Tameside General Hospital, Ashton-under-Lyne, Greater Manchester, after warning for two years that nursing levels on three wards which deal with his patients as well as some with acute chest pain or head injuries were dangerously low.
Yesterday he said he feared that someone would die. His concerns were echoed by the Royal College of Surgeons who warned of a severe shortage of nurses in the NHS nationally....
...he could now face disciplinary action for making his fears public...
Tameside General Hospital had the 11th worst nurse-to-patient ratio in England in 2003 at 102.8 staff per 100 beds, compared to the national average of 131.7.
Mr Pena alerted bosses in 2003 after 14 separate occasions when there was just one qualified member of staff on duty to cover 28 patients.
Yesterday he said he had decided to release the confidential nursing logs from the wards because the situation had not improved two years on.
"...I felt I had no choice but to speak out on behalf of my patients and I'm prepared to take the consequences - if they suspend me then so be it."
"When I retire, I don't want to feel that I knew about the problems here but did nothing about them."
Some of the comments from the hospital in reply to the story which appear in the Daily Mail (not online as far as I can find, unfortunately) are most revealing:
"Last year we employed external consultants who recommended that we increased staffing levels on the orthopaedic wards. This was done and we do not currently have any nursing vacancies."
"Unfortuantely we have recently been affected by sickness and that has made it difficult to meet those levels".
The comments reveal that the hospital:
a) needs external consultants to realise it needs extra nurses, even when one of its own consultants has been telling it this for two years.
b) spends some of its budget on consultants that might better be spent on the extra nurses needed.
c) is unprepared for the eventuality that sometimes nurses become ill.
The hospital, according to the Daily Mail, has not ruled out disciplinary action for Mr Milton Pena.
The public does not understand the true level of the inadequacy of the National Health Service partly because doctors and nurses are contractually bound not to speak out about it. Like Mr Pena, they fear they might be disciplined.
Here are a few of the 2005 nursing records publishing by Mr Pena:
January 27 2005: Two trainees, three qualified staff on duty: '28 very dependent patients. Unable to carry out basic needs for patients; pressure care, nutritional needs, continence care, observation, unable to carry out four-hourly observations. Complaints from relatives. Will put in letter of concern.'
February 12: Trainee absent. Three qualified nurses, two trainees on duty: 'Patient care, drinks, toileting, medications late. Wound care and care plans not done.'
March 17: One qualified nurse sick. Two qualified and three trainee nurses: 'Unable to take patients to toilet. Nutrition needs not properly met.'
Not being a nurse or doctor, I cannot properly describe the health implications of what is described. But it sounds as though people who are very seriously unwell have not been fed properly. They have even gone without fluids to drink. They have, perhaps, lived with unemptied bags of urine. They have not been given the drugs they need which, presumably, have been prescribed to reduce their pain, to prevent them getting dangerous infections or to help cure them.
It is appalling for those who may depend on this hospital to think that they or perhaps their elderly loved ones might be treated in this way.
The media - especially the broadcast media - coverage of this election has been trivial and misled people about the importance of the differences between the parties.
BBC Television News last night was dominated by its senior political journalists traipsing after the three party leaders like lap-dogs. Andrew Marr, a clever, sophisticated journalist, was reduced to showing pictures of Tony Blair and Gordon Brown getting out of a helicopter and someone who used to be a Labour supporter expressing discontent to Mr Blair.
The newspapers concur with the idea that there is not much difference in the 'vision' of the parties. But that is nonsense.
The Conservative Party has proposals which are radically different from those of Labour.
If it actually got into power and gave people the right to use tax money to buy private education (at a school charging no more than the cost of state education) it would transform schooling in Britain. The supply of cheap private education would increase from its small base and over a period of, say, ten years, the landscape of schools would be very different.
The Conservatives also proposed to give people money towards operations in private hospitals (half the cost of the NHS operation). That would dramatically change the balance between government-supplied and private hospital care - especially because private care is already quite substantial.
These policies would have their drawbacks and problems but they offer the prospect of more choice for more people than anything equivalent in, say, the United States. They would enable healthcare and education in Britain to regain something of their former world standing.
It is true that the Conservatives themselves have not put these, their most radical policies to the fore. One gets the impression that the leadership believes in the policies but fears they do not have big electoral appeal. But the media should be zooming in on them, because they do represent a radically different vision. The Labour Party thinks that another few quangos and another few billion pounds will fix the lamentable performance of government-supplied medical care and schools. The Conservatives don't. They are offering a chance of private-provided healthcare and education for those who cannot easily afford to buy their way out already.
They are offering a life-line to people whose lives are educationally impoverished and physically endangered by the current government-dominated system.
While in Miami earlier this week, I visited the Mercy Hospital, a Christian hospital much like the hospitals that used to be be normal in Britain until they were taken over by the state in 1948.
Among the things I saw was a brand new 64 slice CT scanner made by Siemens which had been installed the day I arrived. This scanner can take an image much faster than the old 16 slice scanners. Among its advantages is the way it should be able to reveal pretty accurately the extent to which plaque is obstructing arteries. The blocking of the coronoary artery can lead to a heart attack and death.
The beauty of the CT Scanner 64 is that in a certain number of cases, there will therefore be no need to do an angiogram - an invasive and unpleasant test to discover the extent to which arteries are blocked.
This, in turn, means that those people who shied away from an angiogram and therefore were not accurately diagnosed, will now be able to get a good diagnosis without undergoing any unpleasantness. Lives will be saved.
The machine I saw, please recall, was in the only American hospital I visited on this trip. It seems likely that many American hospitals have this excellent new piece of equipment.
But will you, as an NHS patient, have access to this machine in the UK?
Yes, if you live in East Sussex and can go to the Conquest Hospital at St Leonard's-on-Sea. And maybe soon you will also have access to one in Colchester. There was big fuss about the one coming to East Sussex in January and it was said it would be the first one in Britain. By implication, there is no machine of this sort in London.
In other words, a voluntary hospital in a suburb of Miami now has a scanner of a sort that people in the very capital of the United Kingdom do not have access to.
This is one example of how the NHS is behind the curve in the giving its patients the benefit of the latest technology and treatments.
...belief in restoring people to 'self-respect and self-support' has led compassionate conservatives to reject the de-humanising 'feed-and-forget' philosophy that has come to characterises the welfare state's attitude to its dependent clients. Compassionate conservatives want to see 'help-to-change' charities becoming an increasing feature of society's response to poverty.
Compassionate conservatives are then faced with something of a dilemma.
They want 'help-to-change' charities to receive more resources but they fear that they will lose their salty distinctiveness if they become too close to government. The most dynamic charities have always feared becoming dependent on a funding stream that is controlled by a bureaucracy. Experience teaches that the money may come with few strings in the first year but by years three, four and five, the conditions have begun to re-shape the charity's original mission. Catholic Chareities USA is held up as an example of a religious charity that has become little more than a 'government programme wearing a clerical collar'.
This is from Whatever happened to compassionate conservatism? by Tim Montgomerie, published by the Centre for Social Justice.
The corruption of charities by the state is something that has happened in a big way in Britain. The state originally was going to fund church schools but leave them pretty independent. That independence has since been so thoroughly eroded that there is not much left. Charitable hospitals were simply expropriated by the state in 1948. The King's Fund was meant to fund charitable hospitals. But after the charitable hospitals were taken over by the state, the King's Fund became a think-tank for the NHS. It receives government funding and generally takes a pro-NHS line. An organisation that was meant to fund charitable hospitals, now does not do so. I know of no reason why it should not, even now, help to establish and then support charitable hospitals.
Tim Montgomerie edits his own website now called conservativehome.com.
I will be flying to Florida today to give a short talk at a conference in Miami organised by the Heritage Foundation. I will be on a panel alongside Jason Turner, a man who has been there and done it - he reformed welfare benefits in Wisconsin and then was hired by Rudolph Giuliani to do the same in New York.
On Monday, I will be visiting the Mercy Hospital in Miami - a 483 bed Catholic hospital which offers subsidised and sometimes free treatment to the poor. This is the section of the hospital's website dealing with this aspect of its activities.
Why Joy Harper, a senior orthopaedic nurse, left the NHS last year:
The moment I knew I had to leave the NHS came when I spoke to a very dignified old man who had spent three days lying in a bed with a fractured hip. He was a war veteran in his 80s and his operation had been cancelled twice. He'd been lying there quietly, getting some pain relief, but otherwise unnoticed by the rest of the medical staff because they were too busy tryng to cope with the rest of the ward.
I was taking his temperature when he turned to me and said quietly, uncomplainingly: "I had been wanted to go to my veterans' day in Arnhem, but I suppose I will miss that now."
Something inside me snapped and I knew I couldn't carry on working in a system that was no longer helping such a man. The war vereran waited so long for his hip op' that he contracted a chest infection which turned into pneumonia.
He recovered and eventually had the operation.
I went into nursing to help people, but I ended up having to wake a senile old woman with cancer at 11pm to make her move wards because her bed was needed....
I routinely saw operations cancelled, people left on trolleys instead of beds and people who had been waiting over a year for an operation being told there was no room on the theatre list. A lot of cancellations were coverd up by managers, because they wouldn't have hit government targets.
This is from page 38 of the Daily Mail today, alongside the stories of three other nurse who have left the NHS.
One of them, Jodie Gange, 23, has resigned as a junior staff nurse at St Thomas's Hospital, London.
I wouldn't mind if the job itself was rewarding, but it's not. Basic nursing, which I was trained to do, is being squeezed out by bureaucracy. At the end of each shift, I have to write out a nursing evaluation and patient assessment forms. That can take up to three hours of the shift. It seems as if we have to write down everything we ever do to cover our backs, just in case someone makes a complaint.
Here is a Labour health minister, Lord Warner, discussing the record of the National Health Service: "We have had 50 years of very, very long waiting lists."
It is a curious thing that such an admission is made about the NHS by a member of the Labour Party which, simultaneously, is trying to argue that:
a) the Conservative Party is trying to destroy the NHS and,
b) this would be awful.
The reason he was willing to make his criticisms of the NHS was that he was trying to justify to British orthopaedic surgeons the Government's drive towards contracting out operations - mainly hip and knee replacements - to Independent Treatment Centres (reported in the Daily Telegraph today).
Immediately after his remark on "very, very long" waiting lists for the past 50 years, he said, "...we are talking about a Government that does not accept that. I realise that may be uncomfortable to people who have grown to love waiting lists."
Some the assembled surgeons booed and hissed. That was probably because of the apparent implication that these surgeons actually wanted people to wait and suffer on the lists in order for the richer and more desperate among them to pay the surgeons for private operations instead. In other words, Lord Warner may have been portraying the surgeons as greedy people unconcerned with the speedy curing of ill people. (Those among the surgeons even more wedded to the old NHS model than the Labour minister might have also been angered by the idea of undermining it by contracting-out operations. Some of them certainly also have believed that the contracting-out operations does not serve patients well.)
The sight of a Labour minister insulting doctors is a bit of a change from 1943, when the Labour Party produced its original pamphlet calling for a National Service for Health. The pamphlet is generally flattering to doctors and included these words: "The Voluntary Hospitals have rendered great service, and have been maintained by devoted effort, much of it unpaid."
But even then, there was a subtle sneer at the motives and backgrounds of doctors soon after: "Much of the medical work in these hospitals is done by "honorary staff" who receive no monetary payment, but who may thus gain prestige and reputation: generally it is those who can afford to take this road who find their way to Harley Street and to highly-paid consultant practices."
Not the use of the words "may" and "generally" to cover over the fact that this assertion (that the top doctors were greedy toffs) was far from universally true. Note, too, the way in which the pamphlet entirely glossed over the fact that through this system, poor people were seen by the best doctors in the world at no charge - and, of course, without the long waiting which the Labour minister now, 50 years later, admits.
And note, too, the way that it is suggested that an advantage through family wealth and education is wrong and that seeking to be well-paid is wrong. We have since seen dynasties of Labour politicians - the Benns and the Morrisons (Peter Mandelson is the grandson of Herbert Morrison). Mandelson is also someone who has become rich out of his politics, being handed a high-paying job at the European Commission by his friend and patron Tony Blair, who himself has been the recipient of many free, luxurious holidays and can expect a huge income from speaking engagements and his auto-biography. If family advantage and seeking financial gain is evil, what does that make the modern Labour Party?
More evidence that the Government four-hour waiting time limit target for dealing with accident and emergency patients is manipulated as well as - or perhaps instead of - motivating hospitals to look after urgent cases within that generous time-frame:
Researchers from Sheffield University found, however, that one patient in eight is moved out of emergency departments in the 20 minutes before the four-hour deadline expires. While most emergency departments achieve their targets, it is increasingly claimed that patients are being admitted to wards inappropriately as a result.
Elderly people and mentally ill people were particularly vulnerable to the long wait and last-minute admission, one recent report said. The Sheffield researchers detected a flurry of activity in the last 20 minutes before the deadline is reached with "most impact on older patients and those being admitted to hospital".
Dr Suzanne Mason, a clinical senior lecturer in emergency admission, measured the treatment of more than 400,000 patients. "We found that with patients who were admitted and discharged there is a sudden leap in the number dealt with between 220 and 240 minutes.
She added: "This study certainly raises a number of questions about how time targets contribute to the quality of patient care."
It also 'raises questions' about discrimination against the elderly and the mentally ill in the NHS. (The subjection of discrimination against the elderly is discussed in chapter 3 of The Welfare State We're In.)
The full article cited above is the Daily Telegraph.
Over time, people will try to find ways to get round the poor and mis-directed delivery of services by the welfare state.
In education, since many schools are ineffective in their teaching, a large minority of parents now resorts to private tuition.
Since some schools are now places to be apprenticed in crime-craft, a small but fast-growing number of people - including those who are poor and thus condemned to the worst state schools - are moving their children to low-cost, fee-paying schools. These are often religion-based and teach good behaviour.
I wonder if the news that part-time further education has dramatically grown is another example?
This is from Guardian Online:
The number of part-time undergraduate students leapt by more than 80% last year, according to the first official figures detailing who went to university in 2003. Numbers of part-time students increased from 13.1% of all undergraduates in 2002 to 23.2% in 2003, today's figures reveal.
In total, there were 188,360 part-timers studying for first degrees in 2003 compared with just 103,545 in 2002.
Today's figures show that 41.7% of all students in higher education now study part-time. And, while the number doing postgraduate courses has remained static at 31.2%, the bulk of those studying on a part-time basis are working to secure programmes for sub-degree courses, such as foundation degrees and higher national diplomas.
Part-time students are more likely to be women (62.4%) and are expected to be aged 30-plus (71.1%).
Previous studies have shown that more than half of part-time students chose to study that way so they can continue their careers, or advance their career prospects.
It could be that the sudden growth in part-time courses is a response to tuition fees. However, part-time further education was clearly a major part of further education even before that.
It seems that people who either never had further education, or else had what was prescribed by the Government and found it did not achieve what they wanted, now increasingly use education for something that they do really want: getting a better job. They may well be finding that when they choose the course themselves with a specific purpose in mind, that they get more out of it.
They are therefore, it seems, more willing to pay:
Part-time students' fees are already deregulated
This phenomenon, incidentally, of people fending for themselves and being prepared to make sacrifices for what they really want, suggests part of the answer to the paradox noted in a previous posting: that now the government controls the training and employment of doctors, there is a shortage, yet when doctors had to finance their own training (aided to some extent by donations) and they were employed by charitable and other hospitals, there was no shortage.
(The Guardian article, of course, is phrased in terms of how universities want more government subsidies but that could well damage the flexibility and quality of the courses and the commitment of the students.)
According to research by Paul Burstow, the Liberal Democrat health spokesman,
- Patients are waiting for MRI scans for six months or more in 40 per cent of NHS trusts.
- Patients are waiting for CT scans for four months or more in almost a third of NHS trusts
- Patients are waiting for endoscopic investigations for six months or longer in over a quarter of NHS trusts.
This waiting for diagnostic tests is one of the reasons why the government's boasts about reduced waiting lists are wholly misleading.
The wait that people have between being seen by a GP and getting a diagnostic test is not included in the official figures. As Mr Burstow explains:
The government's waiting list figures neglect a major part of the patient journey - the time in between referral from a family doctor and diagnosis. The government's waiting times figures are calculated only, in terms of inpatient waitis, from the time a decision is taken to admit a patient to hospitals to the date the patient is admitted for treatment.
This hidden waiting is just as dangerous to a patient's well-being and, indeed, life, as any other waiting that causes a delay in appropriate treatment. MRI and CT scans are used in the investigation of serious and life-threatening conditions such as cancer and heart disease. Inevitably there will be people suffering and dying because of these waits.
A fortune in extra money has been spent on the NHS over the past few years. The service it provides should now, if the NHS is a good model, should be up to international standards. The government boasts that the waiting lists have been reduced and that more doctors and nurses have been recruited. Most of the media is happy to accept the story.
It would be surprising if there had not been some improvement at least. But the money has been directed at the measures of performance which have become politically sensitive. Important areas of performance, as far as patients arem concerned, have received less money. Their performance is still very bad by international standards.
Mr Burstow's paper is here.
The star rating system for hospitals is being phased out. It has been a flop but that does not mean that money has stopped being spent on it. It also does not mean that money will cease to be wasted (often actually doing harm, in addition to the waste of money).
This from BBC Online:
"Star-ratings have had their day," said Michael Dixon, of NHS Alliance. "This year we will have star ratings without them being taking too seriously."
However the Healthcare Commission said the ratings were still relevant.
The last star-ratings will be published during the summer, but experts have said they will not be taken seriously because of the changes.
Star ratings, only introduced in 2001, have been overhauled after complaints they were too onerous and target-driven.
All 572 trusts faced three-yearly inspections, costing £150,000 a go.
The government commissioned the Picker Institute to do a study of patient perceptions of the NHS. The report on this in BBC Online paints an improving picture. However there are two important things than are not in the BBC report - and perhaps were not in the Picker report either and perhaps were not in the Picker report because the government did not particularly want such things mentioned.
First, there is no mention of the Picker Institute having made - at the same time and in the same way - investigations of perceptions in other countries. In the chapter on the NHS in The Welfare State We're In, I describe some patient perception reports - including at least one by Picker - in which the same questions were asked in different countries. From this it became obvious that the British experience was seriously inferior to that of patients in other countries.
Second, patient perceptions should be used very cautiously when judging a health-care system. If a patient is asked, "did you get good care in hospital" they bring to the answer all sorts of assumptions. An American going to a hospital who was put in a ward with 25 other people might be appalled and answer "no". A Briton might take the large numbers for granted and answer "yes".
So assumptions about what level of care can reasonably be expected can strongly affect the result. Also, patients often do not really know whether they are getting good care. They often don't know what drugs, treatment, advice or operations they should be offered. So they don't know when they are not getting them. In view of these factors, the most valuable parts of these patient surveys are the ones in which a patient is asked more precise questions like "Did the doctor give you full advice about what you should do at home to minimise the chances of your medical problem recurring?". A further degree more reliable are factual questions like, "How soon after you first contacted the medical services, did you see a specialist?"
I have been on holiday in Malta for the past ten days and while here I have done a bit of medical tourism. I have had three moles removed.
My initial consultation was directly with the surgeon (no need to pass through the 'gateway' of a General Practitioner). Then, a few days later, I had an appointment to have the moles removed. The operation took place in a full-scale operating theatre which is sometimes used for much more serious orthopaedic operations. It had a large air control system with 'walls' of perspex descending a few feet from the ceiling. The system drew out air and blew in clean air. This is to reduce the risk of infection. It was not necessary for my minor operation. From memory the manufacturer's name was Howorth or something similar.
The local anaesthetics and the cutting and stitching must have taken about 20 minutes to half an hour.
What was the price?
The initial consultation cost Maltese pounds 15 (equivalent to about £24) and the operation, including both consultant's time and the use of the hospital, was Maltese pounds 100 (equivalent to about £160). Total overall cost, £184.
I wonder how much it would have been in Britain or elsewhere?
Incidentally, in some other respects, Britain and Malta are similar. Malta, too, has a kind of National Health Service. Despite this free medical service, private, paid-for care is thriving and appears to be growing in size? One hospital and clinic group, St James, has grown to the point where it operates from five different locations on these small islands.Why?
I asked a relative of mine who lives in Malta. He told me that he was told by his doctor that he was gong to need a lens for his eye. The doctor said he had better put my relative on the waiting list straight away because it was three and a half years' long.
Of course, if my relative was willing to pay, the lens could be supplied as soon as he liked.
Another reason is the usual incompetence and waste that take place when the state runs healthcare: a large new replacement hospital is being built in Malta called Mater Dei. The cost was originally estimated to be 80 million Maltese pounds. It is now expected to cost 200 Maltese pounds. (That sort of thing used to happen a lot in Britain. But the Private Finance Initiative, though it doubtless has some serious faults, does appear to have reduced that kind of overrun. The financial risks are run by the private company, rather than the government. I was recently told by someone involved in PFIs that the private companies involved make only modest profits out of them.)
Another reason for the modest cost of private healthcare here is that wages generally here are lower than in Britain. Also there is no shortage of doctors, as in Britain. Britain has had government planning of doctor numbers for decades and the training is paid for the government. As a result, instead of having a sufficiency, we have a chronic shortage. Why this is not also the case in Malta I am not sure.
But it is an interesting paradox. When doctor numbers were unplanned and the training had to be paid for and worked for, Britain had no shortage of doctors. It is only post-NHS, when there is planning and training is free that we have a shortage.
The incident last week (see previous posting) does not appear to have been an isolated case. There was also a crowding crisis in February, as recently reported in the Epsom Guardian:
Patients were put at "serious clinical risk" when they were forced to stay in the day case unit at Epsom General Hospital instead of waiting for treatment in accident and emergency, according to official documents.
Desperate staff asked patients to leave A&E and go to the day unit or another room in order to hit Government A&E waiting time targets.
Among the patients was one described as having "copious diarrhoea" and another with an infected wound.
I have been contacted by a medically-trained person who tells me that what happened in Epsom hospital last week was even worse than what Theodore Dalrymple referred to in the latest Sunday Telegraph.
My informant's account comes from a second medically trained person who works in the hospital:
Casualty was busy and there was a management determination not to breach the government target that people should not be kept waiting in casualty for more than four hours.
To make room for patients to be admitted, four patients were moved to the combined ante-natal and post-natal ward. This ward was told that the patients coming would be gynaecological patients. In fact, they were not.
"They were four elderly medical patients, including one with bed sores and on IVs [intra-venous drips] - an infectious risk. An agency nurse was sent to nurse them as the midwives did not have the experience to cope."
The transfer of these patients caused "idiotic risks" potentially exposing to infection new-born babies, their mothers and also women just about to give birth. My informant continues, "As to moving around sick elderly in the middle of the night - words fail me."
The next morning, the staff at the ante-natal and post-natal ward, including senior midwives and consultants, "went ballistic".
"The patients were moved out by 4 pm but the bay couldn't be used until it was disinfected on orders from the microbiology department."
Word about the danger to women about to give birth spread so that the department was taking calls from concerned pregnant women, working in the hospital trust, who had heard about it on the grapevine.
"The phone calls were naturally responded to in a downplaying way as it is natural to try and calm troubled waters. Explicit orders were not given, nor had to be as one tries not to upset the boat. Any midwife who blurts out the truth loses her job/prospects fast - it's a true culture of fear."
"All this came about because of the four hour rule."
My informant urges me to maintain strict confidentiality. The story has been told to me because of concern for patient safety. But this sort of thing is normally kept quiet. Those who know what has happened fear for their jobs if they tell the press. This is an occasion when a member of the medical profession has felt strongly enough pass on the story. As my informant concludes,
"These things need to be told."
An interesting sidelight on why it is that MRSA kills thousands of people a year in NHS hospitals but none in those private hospitals run by BMI Healthcare:
"There is no financial imperative in the NHS to find a solution to superbugs," Mr Adams said. "That's because if you get sued the litigation all comes out of a central fund."
The Mr Adams in question is chief executive of Bioquell which makes a device that uses hydrogen peroxide to clean hospital rooms. He was quoted in the business pages of the Daily Telegraph.
The excellent Sunday Telegraph package on the NHS last weekend included an article by Theodore Dalrymple.
He included two ways in which waiting lists are manipulated:
1. "asking local general practitioners to delay referral to specialists."
2. "not ...put[ing] patients on such [waiting] lists until they have replied to a letter from the hospital telling them that they have been referred. Since a substantial number of people reply late, or not at all (some because they are too ill to do so), waiting lists are substantially reduced."
These methods should be added to those mentioned in chapter three of The Welfare State We're In .
The government waiting list figures are lies. We don't know what the real number waiting is. The fact that we have a government that knowingly lies with its statistics reflection extremely badly on it. A judge the other day referred to Britain being like a 'banana republic' because of the absence of proper attempts to prevent electoral fraud. Britain is again like a 'banana replublic' in that official statistics are no longer trustworthy.
The next time Mr Blair or any other Labour Party propagandist boasts that waiting for more than four hours in accident and emergency departments is a thing of the past, remember this testimony from a registrar who has recently completed a posting at an NHS hospital in the North West of England:
"I am increasingly dismayed and terrified by current political targets - I am worried because the four-hour A&E wait is used as a way to maintain and increase funding. This is affecting patient safety, especially in some trusts.
"I have just finished working in ********* Hospital and the situation there is dangerous and intolerable. The trust is under-bedded and has a substantial number of blocked beds. A&E will not breach the four-hour targets under any circumstances - when a patient gets to three hours they must be moved to hit target. As a result, A&E patients are poorly assessed and then sent to the MAU [Medical Assessment Unit] to sit in the corridor or day room. Since Christmas, there have been more than 10 extra patients on the corridor on a regular basis. I have, over the past two months, had a patient with severe DKA [out-of-control diabetes requiring emergency treatment] sent up and admitted to ICU [Intensive Care Unit] from a chair in the day room. I have a dossier of cases not fit for the corridor [these include heart failure, severe pneumonia, a heroin overdose and an epileptic fit lasting at least 30 minutes]. The wait for a bed is then often more than four hours. A&E remains empty.
"They cannot be cared for safely and it is only a matter of time before someone dies. I am not advocating a return to the old days with massive A&E waits but don't see why patients should move from an acute area to an unstaffed corridor to hit targets. I can even tolerate 'well' patients sat in a corridor but some of these are critically ill." The registrar's words, and in particular the example of a patient with life-threatening, out-of-control diabetes sent from casualty to sit in a day room to meet a target, and then admitted to intensive care, are shocking.
There are three key points from this story:
1. The statistics on waiting should not be trusted. Just because you are moved to a corridor, does not mean you have stopped waiting. The statistics are useless as a measure of performance because they are being manipulated.
2. The Government's use of targets can actually endanger life. It certainly causes a lower standard of care. Leaving seriously ill patients in unstaffed corridors, is a reckless, ruthless, uncaring way of looking after them.
3. There is a culture of fear now in the NHS. This registrar did not want to be named. For more evidence of this culture of fear, see chapter three of The Welfare State We're In.
The registrar's testimony appeared in The Sunday Telegraph.
The most common medical reason given for people being incapable of work and therefore entitled to incapacity benefit is now depression. It has overtaken musculo-skeletal problems. This is a competition between two conditions that have one thing in common: in neither case is it easy to prove that someone does not have it.
It is a curious thing that the prevalence of these two conditions - that cannot readily be disproved - has soared over the past generation. Meanwhile conditions which are easily verifiable, such as ear infections, have shown relatively little change.
See the chapter on social security in The Welfare State We're In for other evidence - circumstantial and otherwise - for believing that a large proportion of those claiming incapacity benefit are not genuinely incapable of work. Even the government has recently recognised this.
Strange, then, that this BBC report does not even mention the possibility and, instead, concentrates entirely on the idea that employers are at fault and should improve counselling for their workers. When the BBC - and perhaps the BMJ writers on whose work the BBC was reporting - appear to be so naive, there is little hope for realistic discussion.
How demands for governments to 'do something about it' work:
With a few exceptions contemporary commentators on economic problems are advocating economic intervention. This unanimity does not necessarily mean that they approve of interventionistic measures by government or other coercive powers. Authors of economics books, essays, articles, and political platforms demand interventionistic measures before they are taken, but once they have been imposed no one likes them. Then everyone - usually even the authorities responsible for them — call them insufficient and unsatisfactory. Generally the demand then arises for the replacement of unsatisfactory interventions by other, more suitable measures. And once the new demands have been met, the same scenario begins all over again. The universal desire for the interventionist system is matched by the rejection of all concrete measures of the interventionist policy.
This is from Kritik des Interventionismus, 1929, republished in 1976 as A Critique of Interventionism, Translation copyright 1977 by Margit von Mises. It appears in full on the Ludwig Von Mises website here.
A key issue for those of us who believe the state is bad at looking after people, is whether or not individuals are any good at it either.
This is Tim Congdon in the Telegraph today on the competence or otherwise of people in saving:
Much of economic theory is concerned to establish that people are rational. But theoreticians and practitioners do not always see eye to eye. When confronted with real-world problems, economists are inclined to forget that they live in a world of rational agents.
Indeed, they are quite unembarrassed about offering recommendations to politicians which make sense only if people are rather silly. A good example is the recent report from the Pensions Commission, under the chairmanship of Adair Turner.
It says flatly: "Most people do not make rational decisions about long-term savings without encouragement and advice.'' The report proceeds from this patronising remark to recommend increased state involvement in pension provision, with a consequent enlargement of the government's role in the economy and a rise in taxation.
Professor Congdon goes on to look at the overall savings people make including saving that is not labelled "pension saving" but which nonetheless can be used for that purpose. He concludes that people are perfectly rational. His analysis may be open to challenge. But I want to mention another area in which the rationality of people in looking after themselves may be in doubt.
In America, people have to pay for their own healthcare. But in the same country, the incidence of obesity is very high. Why, when they must know that being fat increases their chances of premature death and early use of expensive healthcare, do so many Americans allow themselves to become fat? It does not seem sensible or rational.
One possible answer may be that American laws - particular tax laws - incentivise people to have company healthcare plans which apply to everyone in the company in similar ways, regardless of their lifestyles and obesity. So although American healthcare is mostly privately paid-for, it is far from operating in a free market. In a free market, health insurance premiums would be lower for those who were not fat and so being thin would be financially rewarded. The same would go for those who have no insurance and pay for healthcare as and when they need it. On this basis, people are still perfectly rational. Their behaviour has just been distorted by government interference.
A second possible answer is that people just can't help themselves. The lure of salt, sugar and fat are just too great for human beings after millions of years of evolution in which our bodies were trained to go for sweetness and fat at any opportunity.
I have not done enough work on this to have a strong view and would welcome comments on this and also other areas in which individuals have or have not shown themselves to be capable of looking after themselves.
This is from a Sun online article about a Sky News question and answer session with Tony Blair about healthcare.
Mr Blair also defended the Government’s Private Finance Initiative, insisting: "We have got to work out how we fund this in a way that is sustainable for the future."
Hospitals used to be completed "over budget and behind time" but were now completed on time and on budget, said Mr Blair.
He added: "Since the NHS was created until just recently, over half the NHS stock was actually built before the NHS began.
"Within a few years, as a result of PFI, it’s going to be the other way round."
This is about as near as any government gets to admitting that the NHS depends heavily on the premises and land that were established before the NHS existed at all. In fact, of course, Mr Blair understates the case. Having expropriated an enormous amount of land and buildings from charities and municipalities, the NHS has sold off literally hundreds of hospitals.
It then spent the money raised to finance current expenditure, instead of renewing the capital stock. And until it started letting private sector companies do much of the work, it was particular incompetent and wasteful in its new projects - as even Mr Blair now acknowledges.
My thanks to a visitor to this site for pointing out Mr Blair's remarks.
While more than 95% of NHS trusts had been judged to be meeting the four-hour waiting target for treatment, just 70 trusts - fewer than half - were achieving it every week.
From the BBC coverage of a new Public Accounts Committee report.
One of the purposes of the NHS was to improve the service provided by General Practitioners - making sure that everyone was included. The 1943 document in which the Labour Party proposed a National Service for Health went so far as to propose that people should readily have visits by consultants, let along General Practitioners. But the actual outcome of the NHS has been that we have among the lowest number of doctors per capita in the advanced world. One of the consequences of this is that visits to the home by doctors have dramatically declined. The percentage of GP consultations in the home has slumped from 22 per cent in 1970 to four per cent today. For the details in Social Trends, click here.
Lunch with a senior official of the Hong Kong government. Hong Kong still has a relatively low burden of government, but the weight has got a lot heavier since John Cowperthwaite's day. (Cowperthwaite is the hero of the chapter on tax and growth in The Welfare State We're In). Whereas government activity used to account for 14 per cent of gross national product. It is now up to 22 per cent. Of course, that is still miles better than our 40 per cent and rising.
The official admitted that the big rises in spending happened in 1993-1996, when Chris Patten, the Conservative politician, was there. Mr Patten played a strong political game in Hong Kong. But he was, of course, a British centrist. Under him, Hong Kong welfare state spending rose. It comes as no surprise that unemployment after Patten has been higher than it was before he arrived.
My lunch companion offered some other reasons apart from the Patten-effect why the Cowperthwaite inheritance was spoiled. With Chinese control imminent, the British were offering a bit of democracy and, in a democracy, of course, people are in favour of what they they perceive as 'free' benefits and services from the government. Also, times were good. The government was almost embarrassed by the amount of money it was raking in from property sales and so on. These three factors were a a bad mix (my view, not the official's): a British politician, a bit of democracy and rising prosperity.
Looking back, the big picture is that Hong Kong became prosperous through small-government and then, influenced by that very prosperity, started to give up small government. One measure of the success of the achievement of small government came when the official told me that a secretary in central London gets paid less than one in Hong Kong. And of course the London secretary has to pay much more tax.
Hong Kong retains a massive advantage over Britain in that the government role there is still small compared to what it is in Britain. At the same time, the Hong Kong government provides state schools, state hospitals and welfare benefits. How, I wondered, does it manage to do this for so much less money (as a percentage of GDP)than the British government?
Part of the explanation is that government-funded healthcare in Hong Kong only costs 2.7 per cent of GDP whereas in Britain the cost is in the region of 9.0 per cent. One reason for that big difference is that the Hong Kong government does not do much primary care. There are some government clinics. But the general practitioners are private. (This is not a great burden for patients since a visit to the GP only costs HK$120 (about £8). Seeing a private GP in London, in contrast, is about £60. But then the private GPs in London are aimed at the top of the market and offer plush premises in high-rent parts of town and leisurely consultations - so they are not exact equivalents. You could argue that the Hong Kong prices reveal how cheap GP consultations could be in a genuinely free market.)
Another possible explanation for the lower cost of the Hong Kong welfare state is that all the welfare benefits are means-tested and you do not need much in the way of 'means' to be disqualified. You will not qualify if you have more than about HK$50,000 (leaving aside your own property, if you have one). This is equivalent to only £3,400. Also the measurement of your means is 'family-based' not individual-based. So a young son at home with no money gets nothing if he is living with parents who have some savings. So, too, an elderly parent living with a high-earning son or daughter. On top of that, the welfare benefits are pretty low. I think HK$5,000 a month was mentioned, which is equivalent to only £340. So the benefits are low enough not to distort the behaviour of most people. (Although it must be mentioned that £340 goes further in Hong Kong. It apparently can buy you a place at a very basic old people's home.)
Because you are required to have very little in the way of 'means' and you only get a modest amount of benefits anyway if you qualify, only 15 per cent of people over 60 are on welfare benefits. This compares with virtually 100 per cent of people over 65 in Britain, since we have an insurance-based system in which everyone is required to be covered. The saving in Hongk Kong from this alone must be substantial.
But I got the impression that the Hong Kong government, at least, believes that its services are good and it is therefore seeking to provide more - in care for the elderly, for example. This is worrying. It is reminiscent of the early days after the second world war when it was thought, too, that the government was pretty good at education and healthcare. It was not appreciated that the hospitals and schools were benefiting from their inheritance as private and charitable institutions. Their deterioration took place through two processes: 1. Time and 2. Increasing state control. Both those processes are inevitable once the state has taken over the purse-strings. They will happen in Hong Kong. But it takes foresight for policymakers to realise that they will happen. Civil servants, like Cowperthwaite, can be capable of such long-term foresight. Politicians rarely are.
Already there are aspects of the social policy that have the potential, if they become more significant, to do social damage. It would be a pity if welfare benefits assessed on a family means test became valuable enough to influence families to encourage, for example, the grandparents to leave the family home. That kind of thing was reported both by George Orwell, in The Road to Wigan Pier, and in the 1834 Royal Commission report on the operation of the Poor Laws.
Hong Kong is still one of the few places where the welfare state has not been too pervasive and where, as a result, there has been a wonderful growth in prosperity and relatively little societal breakdown. But it is on a slippery slope.
Vastly more money is being spent on the NHS and yet...I learn from an osteopath today that the Primary Care Trust of the Royal Borough of Kensington and Chelsea is £9 million in debt. The decision has therefore been taken to curtail the provision of osteopathy paid for by the NHS in Kensington and Chelsea. Meanwhile the provision of Accident and Emergency services at the Chelsea and Westminster Hospital is being cut back. Where does all the money go? See the entry on the Great Ormond Street Hospital in the NHS section of the Discussion Forums by clicking here or going via the link in left column.
The conversation came on the same day that the Daily Telegraph reported:
One of the biggest deficits, £21.5 million, was at St George's Hospital, Tooting, south-west London. It intends to leave unfilled 100 vacant posts and has closed 24 out of 1,100 beds.
Peter Homa, the trust's chief executive, said: "These are serious measures and we do not take them lightly. St George's faces difficult financial problems and for the long-term good of the hospital we have to solve them."
Another trust in great difficulty is South Tees Hospital. It has an under lying annual deficit of £20 million to £25 million and a year-end deficit of £13 million. Recruitment has been frozen and savings are being made on equipment and drugs. There are also to be management savings and "tighter housekeeping".
Analysts say the problems have many factors, including NHS inflation of nine per cent. The consultants' contract, giving pay rises over three years of up to 20 per cent, was not fully budgeted for and a nine per cent increase in demand in A&E departments has added to costs.
The full Daily Telegraph article is here.
A former consultant has sent me the following email:
"I don't know whether you have had a chance to look at the King's Fund report which is reported in the Sunday Times, but is available on the Fund's website. The wording of the report is very biased in favour of Labour.
"For example, what their own figures and histograms show is that the number of patients waiting is now the same as in 1987, the median and average times for in-patient waiting has actually increased and is now about the same as in March/Sept 1996.
"Since 1999, the number of intensive care beds has increased by just 200! and the overall bed numbers has remained static, but managers have increased from about 22,000 to 35,000 since 1997. Its fairly obvious what has happened, most of the money has gone on administration, but reading the King's Fund report, that is not what they say!
"I leave you to look thro the rest, there is plenty to go on!"
The King's Fund "audit" of the NHS under Labour is here.
With an election is coming up, the state of the NHS is one of the most important issues. But the electorate will not be allowed to hear anything against it from those who know best what is going on: the doctors and managers. They are under contract not to speak out of turn.
One instance of this was mentioned in the Daily Mail today. A confidential memo to senior managers at the Scarborough, Whitby and Ryedale Primary Care Trust told them that they must not speak about the coming closure of some services. The maternity and minor injuries departments at Whitby Community Hospital, North Yorkshire, are scheduled to close as part of a cost-cutting exercise. The memo stated, "Nothing must hit the press this side of the election".
I have spoken to senior consultants who have been carpetted for saying something against the NHS. One consultant whom I quoted in the book did not want to be identified, saying "I am too young to lose my job". A BBC survey of managers showed that they felt they could tell their superiors about failings in the service. Meanwhile they are under pressure to manipulate the figures. There is a culture of fear and lies in the NHS. The Labour Party propaganda machine must not be contradicted.
This is a perversion of democracy. The Labour Party should be removed - if for nothing else - for the way it has turned doctors, as well as press officers and other civil servants, into fearful parts of its propaganda machine - whether they actually promote the propaganda or just stay silent when they know it is misleading.
It is quite astonishing that Great Ormond Street Hospital, the most famous children's hospital in the world, has had to turn away patients and close wards. The idea of ill children being refused admission to hospital is sickening.
Great Ormond Street says it is short of £1.7 million. How can this be, at a time when the Government has devoted so much more money to the NHS?
The budget has soared from £33 billion in 1996/97 to £64.5 billion in 2004/05. Great Ormond Street is a flagship hospital with immense goodwill. In addition to the £177million it receives from the NHS each year, it gets another £20million to £25 million in charitable donations.
The explanation goes to the core of why the NHS as a whole has been such a disappointment as a system. It is not only Great Ormond Street that is short of cash. There are plenty of other hospitals in the same boat. Why?
There are two main reasons. The first is very simple: under the traditional NHS system, every operation and every scan or blood test costs a hospital money. This means that the basic question a hospital must ask itself before it undertakes an operation is: "Can we afford it?"
This is in contrast with other systems around the world in which every time a hospital does an operation or a diagnostic text such as an X-ray, the hospital receives money. The hospital is paid by the patient, by the patient's insurance company or by the government's insurance scheme.
In the NHS, operations are a drain on a hospital's resources. In most other places, operations increase a hospital's income. It has an incentive to be as productive as possible. It should therefore come as no surprise that in other countries and systems, the throughput of operations and procedures is more efficient. That is a fundamental reason why Britain has long been the odd-one-out in having waiting times for treatments that would be considered a disgrace elsewhere.
The second explanation is that the NHS, like other state monopolies, prodigiously wastes and misdirects money. Dr Maurice Slevin, a consultant oncologist, made a careful study of the ratio of managers, administrators and support staff to nurses in the NHS. He found that, even on the most conservative basis, there were eight administrators for every ten nurses. Of course hospitals do need management and support staff. But he went on to establish the comparable figure for a private hospital. It was only 1.8 administrators and so on for every 10 nurses.
The enormous waste in the NHS - in this and other ways - is not because any individual is deliberately profligate. It is partly because many well-meaning people, including government ministers, give out targets and tell other people how to do their jobs. In one leading London hospital, a team of 30 spends its time showing the government that is meeting targets. How much better it would be if the hospital was employing 30 more nurses instead.
To give it its due, the current Labour Government is trying to deal with the first of the two core problems. Though it ditched the 'internal market' created by the Conservatives when it came to power in 1997, it is now trying to introduce something similar. It is called 'payment by results'. The idea is that hospitals should receive specified sums of money for particular procedures. This, in principle, should give hospitals a positive incentive to do operations. However the new plans are not going well and have been delayed.
The prices are specified by the government so there is no competition based on price. Instead, some hospitals can find themselves making a profit on certain operations and others making a loss. Much depends on the government correctly estimating a price that will balance supply and demand - something governments are not good at.
The government has also put a spanner in its own works by continuing heavily to limit the freedom of hospitals to manage their own affairs - notwithstanding the development of Foundation Hospitals. The government has imposed, among many other things, the contract for consultants and pay scales for other staff. How can hospitals become more productive and well-managed if they are still continually told what to do and if many of their costs are determined by central government (not to mention the European Union)?
If a commercial company announced that its hospitals were short of cash and had to turn away ill people, despite a Â£31 billion increase in its budget, the directors would be sacked. But in state monopolies, no one gets sacked. That is another reason why, without a wholesale change in the system, there will always be a shortage of money in the NHS, however big the budget. And we will also have to accept that sick people - including sick children - will continue to be turned away from hospital.
The above is the unedited version of the article which appeared in today's Daily Mail. After it was too late to change anything, I wished I had found space to say that when govenments try to cook up ersatz market systems, they inevitably cannot capture all the the benefits a market system brings. There are various distortions, unintended consequences and misdirected efforts. Others, of course, will say that ersatz market systems are able to avoid some of the drawbacks of a true market system. One day perhaps we should list the advantages and disadvantages of each. But in any ersatz system, you are dependent on the cleverness and understanding of the designer. One of the advantages of a market system is that you avoid the risk of a designer who comes up with a dud.
This excerpt from the Daily Telegraph story on the state of the NHS today tells us something fundamental about why the NHS will always provide an inferior service to other countries with systems that have a large proportion of private or charitable hospitals:
A study published yesterday based on figures from strategic health authorities showed a predicted deficit of £341 million at the end of this month. Yet again the deficits will be shuffled across into next year's accounts, storing up trouble for the future.
Attempts to reduce them have a direct impact on patient care. Wards are closed, non-urgent operations are put on hold, money is not spent on improving services like extra intensive care beds and the staff to man them, which would have avoided the seven cancellations of Mrs Dixon's operation.
It is simple really: if an NHS hospital does an operation, it costs the hospital money. But if a private or charitable hospital does an operation, that (usually) brings in money. All institutions need money. Under one system, the pressure leads to fewer operations. Under the other system, it leads to more. Where are you more likely to get more operations and less waiting?
Also in the story:
This year, 2004-05, nearly £64.5billion will have been spent by the Government on health services.
In 1996-97, £33 billion was spent. An accompanying chart says that this is an increase of 53 per cent after allowing for inflation.
What has been the increase in 'finished consultant episodes' per annum? Only 10 per cent. It does look, on the face of it, as though productivity has gone down.
The waiting times for operations and for diagnosis are shown. Most of the operation waiting times are shorter. Most of the waiting times for diagnosis are longer. It is noticeable that one of the best reductions in waiting times is for a relatively minor operation - cataracts. The waiting time for the major procedure of hip replacement, in contrast, is up from 198 days to 217 days. After all that money spent, it is not much of a return.
Professor John Appleby, the chief economist of the King's Fund, said that productivity in some areas was going down, "But the measurements used are deeply flawed. Essentially we do not have a good measure."
Perhaps that is one reason why the problems of Margaret Dixon - who says her life-threatening operation has been cancelled seven times (so she has said her goodbyes to her family seven times - a ghastly experience) - has grabbed the headlines. When the statistics may not be reliably meaningful, anecdotes become powerful.
The appalling proposal of NICE to stop new patients from getting the Alzheimer's disease drug, Aricept, is, fortunately, getting plenty of coverage. With an election coming up, I expect the Government to announce to that it will not accept NICE's recommendation on this. There are too many people with access to the media who know that Aricept is genuinely beneficial. If the NHS does not provide Aricept, these people (whatever their previous views) will know that the NHS is a very long way from offering first rate health service. They will know that the extra money has not worked.
The full Daily Telegraph story is here.
I gave a talk at Civitas yesterday. Afterwards, Julian Le Grand who is a senior adviser to the government on the NHS, said that it had been an insult to the intelligence of those assembled. Fortunately it was an insult they bore bravely - all of them, except Mr Le Grand, staying to the end, offering compliments and, in several cases, buying two copies of the book.
His substantive points were - and please forgive me if I am unable to remember them all or to do them justice:
1. MRSA is an even bigger problem in Japan and some other country which I am afraid I forget. So 'what do you make of that?'
2. Britain's record on heart disease is improving faster than in any other country.
On the first point, I would be interested to know more about the circumstances in those other countries. I have not seen the research he is basing his remarks on. Meanwhile, there is no proper and reliable evidence of the number of deaths from MRSA in Britain to compare with those in other countries. In its reports, the National Audit Office demands a proper system of reporting but so far has not got one. It is therefore difficult to claim that MRSA is worse in other countries when we do not really know how many deaths it causes or contributes to here. In fact we have the word of various doctors who have said previous and very recently that it is perfectly possible for MRSA to contribute to or cause the death of someone without it being recorded as the cause of death.
In the book, among the many pieces of research I referred to was that in the European Microbial Resistance Surveillance System bulletin, 2002. That shows that the percentage of Staphyococcus aureus samples taken in hospitals that are resistant to antibiotics (ie MRSA) is vastly higher in the countries around the Mediterranean than in those in northern Europe. But there is one exception to this rule. In Britain, the proportion of MRSA was 46.3 per cent - above the levels even of the Mediterranean countries and far higher than that of other northern countries. In Finland and Sweden there was one per cent. In the Netherlands, there was zero.
Meanwhile BMI Healthcare, which runs a large number of private hospitals in Britain, has publicly declared that it has had absolutely zero cases of blood-borne MRSA. This suggests that the problem of MRSA in Britain is mostly something to do with the NHS rather than something to do with the character of Britain. I know excuses will be found. The 'patient mix' is different in NHS hospitals. But the difference between thousands of deaths a year in NHS hospitals and none in BMI hospitals is surely too great to be explained away just by 'patient mix'.
Mr Le Grand's second argument, that Britain's record on deaths from heart disease is improving faster than anywhere else in the world, was undermined by his subsequent aside: "admittedly from a high base". It is rather like a man saying, "I am getting sober at a faster rate than anybody else". An extremely drunk man could say that, while someone sober would regretfully have to admit no improvement at all.
Going to the underlying thrust of Mr Le Grand's remarks, which probably is that the NHS is improving, I would say:
- in some areas, especially those on which the Government and the press are focused, it probably is indeed improving.
- much of the improvement, in waiting lists for instance, is largely due to buying in operations from the private sector, hardly a vindication of the NHS model.
- the NHS remains very much inferior to other medical care systems around the advanced world
- other areas of medical care that are not the focus of Government and press attention are probably continuing to deteriorate. Only today we learn that NICE intends to recommend that the NHS should stop offering drugs which reduce the impact of Alzheimer's disease.
- the improvements so far are not commensurate with the large amount of money spent.
- as Reform has demonstrated, there have been far bigger increases in management and administrative staff than in medical staff. This does not augur well.
A friend who is close to one or two of the senior people in charge of NHS tells me that there is a view in those quarters that this is the last chance for the NHS. If it does not show major improvement over the next two years, its reputation may be damaged terminally.
Some people treat the word 'privatisation' as if it was akin to fascism or racism. In healthcare, the Government has apparently promised that it will not use the private sector for more than 15 per cent of what it does. That reflects the horror that core Labour supporters would feel if any higher percentage were contemplated.
But those who are appalled by the word miss the difference between good privatisation and bad privatisation. They are poles apart and the argument is impoverished and confused by not recognising the fact.
Good privatisation has the following ingredients:
- Consumers, not governments, do the buying
- Choice for the consumer
- Competition between providers
- Little or no regulation
- Low costs of entry for new competitors
Privatisation becomes less advantageous according to the extent to which:
- The Government or a state agency is doing the buying
- The Government is writing the contract under which the work is done
- The Government is regulating the company(ies) doing the work
- Regulation is heavy
- No choice for consumers
- No competition between providers
- The barriers to entry to new competitors are high.
What is frustrating is when there is a privatisation of the bad sort which goes wrong and gives privatisation as a whole a bad name. Rail privatisation, for example, was heavily regulated. The contracts to run railway lines were written by the Government. The Government chose which companies would get the contracts. And Railtrack was a monopoly.
Privatisation of telephone services, freight transport and car manufacture, in contrast, have been far more successful. In all these cases, the consumer has been the buyer and has had choice. Only in telephones was there heavy regulation and even that has been reduced.
For short, you might call privatisation of the better sort 'Triple C Privatisation' - because it has the elements of Consumer buying, Choice and Competition.
Why do the differences between good and bad privatisation matter?
Because if there is choice and competition, the providers have a powerful incentive to provide the best possible service (or product) at the lowest possible price. Consumers will choose providers on the basis of some trade-off between quality and price. No one will choose an expensive, low-quality product. They will go for the opposite. Tesco comes to mind.
Meanwhile the Government is a bad buyer. Look at how it buys computers. Look at how it does major projects (the Dome comes to mind). Look at how it buys cleaning services in hospitals - often without even consulting the anti-infection team.
Now that the Government is putting money into private 'treatment centres' and trying to set up neo-markets within the NHS, one should apply the good/bad tests. It seems, at present, that this privatisation is not 'Triple C' by any means. It is heavily Government controlled and regulated. With treatment centres, of course, the Government is to a large extent the real buyer.
Some of the use of the private sector in healthcare will almost certainly work better than what the NHS does. But it is worrying that the state is so much in the driving seat. It would really be a pity if the private sector was so badly deployed that it added yet more bad publicity to privatisation as a whole.
Interesting things are happening in US welfare policy, though they seem to go pretty well unreported in the British press. This is from an article on the Galen Institute website about healthcare policy reform:
"Health Savings Accounts are the bright new star in the consumer-directed health care universe. They work much like 401(k)s or IRAs. HSAs allow individuals and/or employers to put money aside tax free to pay for routine health costs. Consumers pay directly for the health services they prefer while still having protection against high-cost medical care. Whatever people donâ€™t spend in their accounts can be rolled over year to year and saved for future needs. HSAs are portable and can stay with a worker even when changing jobs.
To enhance HSAs, President Bush wants to allow anyone to deduct the cost of the health insurance policy they must buy to open an HSA.
So what is some of the early experience with HSAs, and their sister Health Reimbursement Arrangements?
* Companies that have instituted consumer-directed plans have seen their health costs moderate, level, and even fall when they engage employees as partners rather than adversaries in managing health costs.
* HSAs and other consumer-driven plans have built-in incentives for prevention, and early experience shows use of preventive care up 25% or more.
* Plans have new incentives to offer consumer-friendly options, like better chronic care management or a nurse hotline that a mother with a sick child can call to get advice that might save her an emergency room visit in the middle of the night.
Consumer-directed care is starting to reshape the health sector around the needs of people, not bureaucracies. "
The full article is here.
For those who want to know more about the healthcare systems in other countries, the Civitas website has some useful descriptions which can be found here.
I went to the launch of the manifesto of the think-tank, Reform, today. Reform is an excellent organisation - very professional and with an effective approach. It closely analyses what is wrong with various parts of state provision, particularly healthcare and education so far. It offers key facts to opinion formers such as journalists. It offers a very useful daily email summary of the news. But the tough bit is when it comes to suggesting what should be done to make things better.
Reform proposes: "Patients would be funded - either through the tax system or by way of universal insurance - to purchase healthcare from providers of their choice"
I am sure that a system such as Reform proposes would be an improvement on the NHS. But I fear there would be problems:
1. NHS hospitals would remain dominant and they are chronically inefficient. I wonder about the accountability and incentives of those who would be working in an NHS hospital which - under the Reform proposals - would no longer run by the centre and would also have no shareholders and not be a charity. Reform suggests that staff and managers would have a 'right to buy' their hospital, thus giving them a commercial stake in its success. But that could be a slow process and might not happen at all. If the staff was allowed to buy, say, St Mary's Hospital in Paddington, they would either not be able to afford it (if they were allowed to sell off some of the property assets) or else they would be highly resticted as owners (if they were not allowed to sell off some of the property assets).
2. As long as the Government was providing the money, it would call the shots. It would regulate and tell people what to do and how to do it - causing damage to the provision. Even though this is not what Reform intends, it is what would happen in due course. When some hospitals failed, there would be irresistible demands for the government to step in and take control. We would be back to square one - state management.
3. If a social insurance model is chosen (which Reform offers as a possibility), there would be a cost problem. In France, for example, the freedom of choice of patients has resulted in huge and growing costs which which the French government has been battling.
4. Those of us who want medical care of a sort that the State is unwilling to approve and pay for, would have to pay for it. We would therefore, as now, have to pay twice for medical care. Once through taxes and once through direct payment.
5. Reform suggests 'co-payment' - in other words getting the patient to contribute to the cost of treatment. Co-payment can get very complicated. It tends to be means-tested, one way or another - otherwise the impoverished person may not be able to afford any treatment. Means-testing by hospitals and doctors would be a major bureaucratic problem. Previous Governments after the war repeatedly looked at charging people for visiting a General Practitioner. Each time it was decided that the costs of administering small co-payments would be so high as to make such a system absurd.
Reform proposes: "school funding would follow parental choice and allow children to be sent to state or independent school, topping up the fees if they so choose".
1. State schools would remain dominant and they have major failings.
2. Once Government money was going to private schools, the Government would, in the end, demand more control over what private schools teach, how they teach and what exams they take. This would damage education.
3. Those who gave their children education that was not officially approved would - as now - have to pay twice (once through taxes and once through direct payment). This would apply, for example, to those who chose to educate their own children at home.
The key point with both medical care and education is that the Reform proposals would still leave a major role for the state. In fact, in one respect the state's power would be increased: much of the money curently spent directly by customers on private provision would be replaced by state funding. The true freedom, power and independence this offers - which lead towards competition and high standards for the lowest cost - would be compromised.
The history of the welfare state tells us over and over again that one bit of state interference - however innocently intended - leads to another. It was intended in 1917 that the Government should fund universities but still leave them fully independent. But gradually the independence of universities has been thoroughly undermined. Once the Government provides money, it wants to control how that money is used. It faces criticism if any of the money - taxpayers' money - is used in a way that the public does not approve. So it feels it must control the use of the money. So we are back to state control and the damage that state control causes.
Subsidies by Government to schools in the 19th century led, inevitably, to the demand that the schools accepting Government money should be inspected. Inspection, in turn, led to demands for changes to the schools. Those schools that would not accept the changes demanded, were not approved and therefore did not get the subsidies. Thus Government control arrived though, originally, it was not intended. One piece of State involvement leads to another.
I applaud Reform's courage in making concrete proposals. I readily agree that there is no such thing as an ideal system and that Reform's ideas would be a considerable improvement on what we have now. It is true, too, that we should not get hung up on the idea of a perfect system. It was the idea of perfection that led to state control of both health and education. The result has been much suffering, tens of thousands of premature deaths and mass illiteracy. So we should never be led astray by the vain idea that perfection is possible.
But Reform's ideas in a very particular political context. It is more and more widely agreed and understood that the welfare state has failed. People are therefore casting around for ways in which to change it or roll it back. There may indeed be movement on this at some point in the next decade. It is important that the proposals that eventually carry the day, should have been carefully analysed to see how they might fail to achieve what is intended.
Reform's website, with links to its manifesto, is here.
Three letters in last week's Spectator responded to my article the previous week (see posting below) in which I argued that American medical care is markedly superior to the NHS. All three letters were supportive. Two told dramatic contrasts in treatment received in American and British hospitals (good in America and bad in Britain). The third was as follows:
James Bartholomew's description of US healthcare was generally accurate except for one thing. The statistic that over half of American personal bankruptcies are caused by medical bills was cooked by the study's authors, who are well-known evangelists for an Amerian NHS (see Gail Heriot's article in National Review at www.nationalreview.com/comment/heriot200502110735.asp). They admitted that for half of the people supposdly wiped out by medical bills, those bills amounted to only about US$1,000 over two years. Since the median American family income is over US$50,000, very few American families who are at all fiscally prudent could be bankrupted by an unexpected bill for US$1,000. Almost all American adults have credit cards and personal bankruptcy laws allow Americans to cancel all their credit card debt while keeping a vehicle and a house. Yes, medicine is overpriced here for all the reasons Bartholomew describes, but our bankruptcy rate is due more to easy credit and bad banruptcy laws than the price of anything.
If a defender of the National Health Service wants to win the argument against a free market alternative, he declares, "You wouldn't want healthcare like they have in America, would you?"
That is the knock-out blow. Everyone knows the American system is horrible. You arrive in hospital, desperately ill, and they ask to see your credit card. If you haven't got one, they boot you out. It is, surely, a heartless, callous, unthinkable system. American healthcare is unbridled capitalism, red in the blood of the untreated poor.
For goodness sake, the American system is so bad that even Americans - plenty of them anyway, if not all - want to give it up. They want to turn something more like the Canadian system or our own National Health Service. That is what Hilary Clinton wanted and there are still plenty of people like her around. Tony Judt, in a recent edition of the New York Times Review of Books, was damning about American medical care and glowing about European healthcare. Think of all the money that wasted in America invoicing patients and administering lots of separate, independent hospitals.
At the same time, we can't help being aware that back here in Britain, the NHS is still not exactly perfect. The waiting lists have come down, according to the government. They have probable come down somewhat in reality, too. But they still exist and, come to that, there is the worryingly high incidence of hospital infections.
So is British healthcare better than American? Or the other way round? And how do you judge?
Let's try the simple way, first. Suppose you come down with one of the big killer illnesses like cancer. Where do you want to be - London or New York? In Lincoln, Nebraska or Lincoln, Lincolnshire? Forget the money - we will come back to that - where do you have the best chance of staying alive?
The answer is uncompromisingly clear. If you are a woman with breast cancer in Britain, you have (or at least, a few years ago you had, since all medical statistics are a few years old) a 46 per cent chance of dying from it. In America, your chances of dying are far lower - only 25 per cent. Britain has one of the worst survival rates in the advanced world and America has the best.
If you are a man and you are diagnosed as having cancer of the prostate in Britain, you are more likely to die of it than not. You have a 57 per cent chance of departing this life. But in America, you are likely to live. Your chances of dying from the disease are only 19 per cent. Once again, Britain is at the bottom of the class and America at the top.
How about colon cancer? In Britain, 40 per cent survive for five years after diagnosis. In America, 60 per cent do. With cancer of the oesophagus, survival rates are low all round the world. In Britain, a mere seven per cent of patients live for five years after diagnosis. In America, the survival rate is still low, but much better at 12 per cent.
The more one looks at the figures for survival, the more obvious it is that if you have a medical problem, your chances are dramatically better in America than in Britain. That is why those who are rich enough, often go to America, leaving behind even private British healthcare. George Harrison, Ian Holm and Koo Stark are just three celebrities who thought it best to take advantage of higher American standards.
One of the reasons is wonderfully simple. In America, you are more likely to be treated. And going back a stage further, you are more likely to get the diagnostic tests which lead to treatment.
Fewer than one third of British patients who have had a heart attack are given beta-blocker drugs, whereas in America, 75 per cent of patients have them. In America, you are far more likely to have your heart condition diagnosed with an angiogram - a somewhat invasive but definitive test. You are far more likely to have your artery widened with life-saving angioplasty. In Britain not very long ago, a mere one per cent of heart attack victims had angioplasty. You are dramatically more likely to have heart by-pass surgery. In 1996, British surgeons performed 412 heart by-passes for every million people in the population, less than a fifth of the 2,255 by-passes performed in the United States. America has many more Lithotripsy units for treating kidney stones - 1.5 per million of population compared to 0.2 in Britain.
It is true that in America they overdo the diagnostic tests. In one hospital, they did a CT head scan on absolutely everybody who came in complaining of a headache. Even some of the doctors began to think this might be over the top when they realised that only in two per cent of cases was anything found. But in Britain, the problem is the other way round. Having any diagnostic test beyond an X-ray tends to be regarded as a rare, extravagant event, only to be done in cases of obvious, if not desperate need.
Peggy, an American radiologist, came to Britain to meet her English boyfriend's family. A pall fell over the visit when the boyfriend's father brought up blood in his urine. He went to the local NHS hospital. Peggy knew that blood in the urine could mean something worryingly serious or could be utterly minor. A few tests could make things clear: a CT scan or cystoscopy for example. That would be routine in the USA. But no such tests were done by the NHS hospital in Welwyn Garden City where the father was a patient.
Tests are routinely left undone in Britain, first, because there is a shortage of equipment and, second, because the equipment is under-used. Britain has half the CT scanners per million of population that America has (6.5 compared to 13.6). It also has half the MRI scanners (3.9 per million of population versus 8.1).
In Britain, these machines are generally used during business hours only, regardless of the fact that some are extremely expensive. At the Mayo Clinic in America, meanwhile, an MRI scanner is in use around the clock.
If, in Britain, if you get your X-Ray scan at least, it may well be done with an old machine. Dr Colin Connolly carried out an audit of behalf of the World Health Organisation and found that over half of British X-ray machines were past their recommended safe time limit. Come to that, he found plenty of other machinery out of date, too. More than half of the anaesthetists' machines needed replacing. Even the majority of operating tables were over 20 years old - double their safe life span.
Look at any proper measure of the capacity or success of a medical service and one finds, again and again, that America comes out better. In Britain, 36 per cent of patients have to wait more than four months for non-emergency surgery. In the USA, a mere 5 per cent do. While in Britain, the Government celebrates if the waiting times get a bit lower, in America they don't do waiting.
There are more American doctors per patient so, not surprisingly, patients in the US have more time with their doctors. American patients also get to see specialists as a matter of routine whereas, in Britain, 40 per cent of cancer patients, for example, don't see a cancer consultant. There are shortages of specialists in many areas of medicine in Britain.
The father of Peggy's boyfriend, had asthma that was getting worse. In America, he would have been seen by an asthma specialist while in hospital. They would have thought it convenient to do any necessary tests while he was readily available. Not in Britain. He lay in his hospital bed with breathing difficulties but still did not see a specialist. He was told it would be six weeks.
Peggy was surprised by how "accepting" her boyfriend's family was. She didn't say too much because she did not want to come across as a pushy, arrogant American but she was thinking how "in America, we'd go nuts if we were told we would have to wait six weeks to see a specialist. Expectations are so much higher."
Shortly afterwards, her boyfriend's father was discharged from hospital. Back home, before his appointment with a consultant came up, he died of an asthma attack
"Ah yes," comes the knowing response. "But what about the poor? The rich might get great care in America, but the good thing about the NHS is that everyone gets treated equally. The care is, in the hallowed phrase, 'free at the point of delivery'."
Before going into any detail, let us remember one thing: all those figures at the start about death rates from various forms of cancer were not just for the rich. They were for the whole population, poor included.
That said, yes, it is true that American healthcare is expensive. It is true, too, that the financial burden on people is awesomely unequal. But not in the way you might expect. The seriously poor do not get the worst of it. They get treated for free.
They get Medicaid, the national subsidy for healthcare for the poor. Their treatment is paid for by the state and subsidised by the hospital, or rather its other patients and - if it is a for-profit hospital - the shareholders. The poor might not get showered with as many diagnostic tests as those with full insurance, but they get treated and without the delays that are normal in Britain.
No, the people who get the worst of the cost of the American healthcare system are not the poor. They are not the rich either, of course. Come to that, they are not the old, who are covered by Medicare, another Government programme. And they are not the majority of people who are in jobs and have company health insurance.
The ones who can face major problems are somewhere between being middle-income and poor. They are the ones who are not earning enough to take out an insurance policy - or not one with a high limit on medical expenditure. So if they come down with an illness which requires a long - and therefore ruinously expensive - stay in hospital, their insurance may run out and they may have to sell their homes or even go bankrupt. Those who are temporarily unemployed, between jobs, are similarly vulnerable.
The numbers are not large in relation to the whole population of American. We are talking about a minority of the American population (figures of 35 to 45 million are mentioned) which is not insured and which is not covered by Medicare or Medicaid. Of that minority, only a tiny minority will need fairly long term hospitalisation. But financial disaster can happen and sometimes does. People lose their homes, their savings, their everything. Half of the bunkruptcies in America are of people who had previously been ill. In Britain, the system might kill you. In America the system will keep you alive but might bankrupt you.
So there is no doubt that the American system is lousy in certain ways. Actually it is lousy in lots of ways. The insurance policies which cover most people are extremely expensive. They can be as much as US$8,000 a year. Part of the problem is that the various states of America dictate what must be in such policies, thus raising the cost and reducing the competition among providers. A young man can be obliged to pay for a policy which insures him against getting pregnant. State interference means that people cannot easily get the kind of insurance they would really like and which could lead to the most economical healthcare. That could be insurance with a large 'excess' - offering coverage against real disasters but not against regular bills for ordinary visits to a doctor.
The tax rules in America are also highly favourable to insurance provided through a company but offer little of the same advantages to anyone taking out insurance personally. That gives rise to the 'between jobs' period of danger for falling ill.
If you want to know what is wrong with American healthcare, you need to be ready for a long list. The cost is boosted by restricted entry into the medical profession. It has been pushed up by the courts which have given gigantic damages for medical negligence. The doctors have to insure themselves against such damages and and so the insurance premiums they pay are huge. The doctors can only pay the insurance by charging high fees. The risk of being sued is also an important reason why American doctors would rather give you too many tests than too few.
Let's face it. The American system is a rotten. It is not even a system. It is a hotch-potch. Most hospital provision is by not-for-profit, private hospitals. But the biggest buyer of medical care is the Government. Through Medicare (for the poor) and Medicaid (for the old) and other schemes, the Government pays for 45 per cent of all healthcare. (The British assumption that American healthcare consists of an unfettered free market could not be more wrong.)
Most British people do not realise that the non-private hospitals in America are not run by the federal government. They are local government hospitals. The San Francisco General is run by the City of San Francisco. And another unexpected thing, for Brits, is that even in such local government hospitals, treatment is not free to those who can afford it.
Incidentally, all sorts of American hospitals - especially the not-for-profit ones - receive large sums of cash from charitable benefactors. And if you think all the above is confusing, that is hardly even the beginning of the bewildering diversity and contradictions of American healthcare. It is a muddle.
Actually, the British system was a muddle, too, until Aneurin Bevan came along in 1945. As Secretary of State for Health he set about un-muddling it. We, too, used to have local government ("municipal") hospitals like America until he took them over. He took over the charitable hospitals too - like St Mary's and Moorfield's and many other famous ones. He made it not confusing at all. What could be simpler than the central government being in charge of everything? Over time, the government put itself in charge of all the doctors, too. So all was made simple and clear.
But the curious thing is, the new, improved, simple state system of Britain does not work as well as the American muddle. You have a better chance of living to see another day in the American, mish-mash non-system with its sweet pills of charity, its dose of municipal care and large injection of rampant capitalist supply (even despite the blanket of over-regulation) than in the British system where the state does everything. It is not that America is good at running healthcare. It is just that British state-run healthcare is so amazingly, achingly, miserably and mortally incompetent.
(The above is an article which was edited and appeared in the Spectator edition of 12th February.)