The Welfare State We're In, The website of the book by James Bartholomew
December 02, 2010
This is the kind of failure of the NHS that is hard to measure

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.

Posted by James Bartholomew • Indexed in NHS

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December 01, 2010
"Inequalities in health status tend to be lower in three of the four countries with a private insurance-based system"

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.

and again:

"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.

Posted by James Bartholomew • Indexed in NHS

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November 12, 2010
"elderly people with fractured hips who do not undergo surgery within 48 hours are less likely to regain full mobility"

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.

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November 08, 2010
Did Channel 4 know what it was doing when it commissioned this film?

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.

Posted by James Bartholomew • Indexed in Behaviour & Crime • Housing • Media, including BBC bias • NHS • Parenting • Reform • Tax and growth • Welfare benefits

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October 21, 2010
"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." The section on housing and social care in the Comprehensive Spending Review
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.

Posted by James Bartholomew • Indexed in Care for the elderly • Housing • NHS

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September 23, 2010
Replacing the NHS with a system which works better

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.

Posted by James Bartholomew • Indexed in NHS • Reform

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September 16, 2010
Abolish the NHS

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:

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.

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September 13, 2010
The Obama healthcare reforms

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.

Posted by James Bartholomew • Indexed in NHS

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The biggest NHS scandal in the last few years

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.

Posted by James Bartholomew • Indexed in NHS

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September 08, 2010
Where does the NHS rank in number of employees?

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.

Posted by James Bartholomew • Indexed in NHS

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Competition and the cost of an MRI scan

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

Brainscan £200

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.

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September 05, 2010
Abolishing the NHS

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.

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July 19, 2010
Lessons from Zurich

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.

Posted by James Bartholomew • Indexed in Education • NHS • Parenting • Reform • Welfare benefits

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July 05, 2010
Waste of resources in the NHS
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?

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June 09, 2010
The fallacy in the 'front line services' idea

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.

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May 25, 2010
Britain ten years behind in use of the Cyberknife to combat cancer

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.

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April 22, 2010
The NHS is the cinderella issue in this election (2)

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".

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April 21, 2010
Would you like to see an experienced doctor when you go to A&E?

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.

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March 29, 2010
The NHS versus French healthcare

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.

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March 26, 2010
NHS managers up 84%

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

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January 26, 2010
Ask your child not to be ill out of hours
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.

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December 11, 2009
'British cancer and heart attack victims are more likely to die than almost anywhere in the advanced world'

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.

The Daily Mail coverage.
Part two of Daily Mail coverage.
The OECD press release.

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December 08, 2009
No senior doctor on duty in nearly a third of A&E departments

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.

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November 20, 2009
Every other major country in the EU makes sorafenib available

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.

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November 13, 2009
Talking donkeys have victims

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.

- the European Union has sponsored a talking donkey.

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.

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October 26, 2009
Where the NHS money goes

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.

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September 30, 2009
A double layer of choice for better healthcare

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.]

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September 29, 2009
How do the highest ranking health systems work?

<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
2. Denmark
3. Iceland
4. Austria
5. Switzerland
6. Germany

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.

Posted by James Bartholomew • Indexed in Further research • NHS

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July 14, 2009
Two ways to reduce American healthcare costs,0,915371.story

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July 02, 2009
Obama's healthcare proposals

Interesting article about President Obama's healthcare proposals. It emanates from the Cato Institute.

Posted by James Bartholomew • Indexed in NHS

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June 29, 2009
Obama's healthcare reforms are advancing but here are the simpler reforms he should be considering

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:

Deregulation (mostly)

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 Kentucky.

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
higher premiums.

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
companies,hospital orhealthcompanies
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,
solvency, etc.”

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
reimbursement policies.

Unfortunately, not all of Sen. McCain’s
proposals are free-market oriented.

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June 25, 2009
The treatments that are not always easily available to NHS cancer patients

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.

Posted by James Bartholomew • Indexed in NHS

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June 10, 2009
What is the quality of treatment for prostate cancer in Britain?

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.

Posted by James Bartholomew • Indexed in NHS

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June 09, 2009
A disturbing story

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.

Posted by James Bartholomew • Indexed in NHS

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June 04, 2009
Lies, damned lies and NHS statistics

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.

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June 01, 2009
Not everyone thinks Obama will make things better

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.

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April 08, 2009
Damage done by targets and untrustworthy statistics

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.

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March 22, 2009
People still die unnecessarily from cancer because we have the NHS rahter than a better system

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.

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November 27, 2008
Heart disease - your chances are better outside Britain

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.

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September 01, 2008
One reason why the public does not fully understand the inadequacy of the NHS

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.

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July 18, 2008
The USA saves more people from cancer than Britain

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.

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June 01, 2008
A mean and nasty aspect of the NHS

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.

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May 26, 2008
More than 30,000 hospital beds have been lost since Labour came to power
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.

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April 19, 2008
Britain spends less on cancer drugs per head than France or Germany

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.

Posted by James Bartholomew • Indexed in NHS

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February 26, 2008
"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"

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.

Posted by James Bartholomew • Indexed in NHS

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January 08, 2008
NHS to be preventative - again

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.

Posted by James Bartholomew • Indexed in NHS

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December 18, 2007
Administration, targets and regulations have made NHS care 'worse than five years ago'.

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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November 20, 2007
"The death toll in a year is greater than that from breast cancer, Aids and traffic accidents combined."

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.

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November 08, 2007
"In 1990, for example, only five per cent of a dentist's income came from private patients. Today it is nearer 60 per cent."

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.

Posted by James Bartholomew • Indexed in NHS

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July 29, 2007
Private emergency healthcare apparently growing in Australia

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
Gairdner hospitals."

Posted by James Bartholomew • Indexed in NHS

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3,000 die each year because the NHS does not screen for aortic aneuryms

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.

Posted by James Bartholomew • Indexed in NHS

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Forty per cent of GPs 'regularly' have their referrals of patients to hospitals blocked

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.

Posted by James Bartholomew • Indexed in NHS

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July 13, 2007
Mapp and Lucia had a local hospital

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.

Posted by James Bartholomew • Indexed in Charity • NHS

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July 05, 2007
Which is better, British or American healthcare?

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

Posted by James Bartholomew • Indexed in NHS

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July 04, 2007
Britain well down the league table in care for those with dementia

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.

Posted by James Bartholomew • Indexed in NHS

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June 08, 2007
No surprise: after the extra billions, many still have to wait over a year for treatment

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.

Posted by James Bartholomew • Indexed in NHS

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May 14, 2007
Waiting lists are on the front page, the elderly are not

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.

and later,

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.

Posted by James Bartholomew • Indexed in NHS

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MRSA deaths seriously understated

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.

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May 10, 2007
If you get cancer, it is better to live in France, Switzerland or probably any advanced country rather than Britain

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.

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April 17, 2007
The NHS computer fiasco: why do governments keep wasting such vast amounts of money?

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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March 26, 2007
"the NHS is administering only about half the amount of radiotherapy needed to treat British patients properly"

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.

Posted by James Bartholomew • Indexed in NHS

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March 22, 2007
'If I had not been around, my mother would now be dead'

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.

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March 19, 2007
I considered myself a socialist before...

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.

Dear Sir,

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.


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March 06, 2007
The NHS messes up the hiring of junior doctors

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:

Posted by James Bartholomew • Indexed in NHS

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January 30, 2007
Bits being lopped off the NHS

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.

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Lest we forget how bad European communism was

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.

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December 20, 2006
It is good to see the NHS being sued over MRSA

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."

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November 25, 2006
In Italy

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:

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October 16, 2006
A new bureaucracy to reduce access to consultants?

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:

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June 28, 2006
'This letter is granted to the applicant in being poor. Its acceptance therefore by anyone not really poor constitutes an abuse of charity.'

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?

Posted by James Bartholomew • Indexed in Charity • NHS

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June 26, 2006
Dealing with the argument that the private sector is incapable fo providing emergency care

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.

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June 25, 2006
More deaths due to our healthcare system

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.

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June 21, 2006
MRSA in the NHS

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.

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June 08, 2006
"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"

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.

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June 06, 2006
The crass-mismanagement of the NHS: No job for newly qualified consultants.

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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This man would have died if he had relied on the NHS

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.

'Excruciating pain'

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.

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June 05, 2006
Politicians waste the money of the poor - this time it was Tony Blair and NHS computerisation

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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May 26, 2006
'Excellent' care but not enough nurses on the ward? Surely some mistake?

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.

Posted by James Bartholomew • Indexed in NHS

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May 05, 2006
The Department of Health has 'lost control of the system reform agenda'
...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.'

And later,

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.

Posted by James Bartholomew • Indexed in NHS

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April 24, 2006
How the NHS has wasted the extra money

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."

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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March 14, 2006
Yes, it gets as bad as this.

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.)

Posted by James Bartholomew • Indexed in NHS

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March 06, 2006
Not 'to the grave'

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.

Posted by James Bartholomew • Indexed in Care for the elderly • Media, including BBC bias • NHS

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February 23, 2006
Slow take-up of new cancer drugs by the NHS

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.

Posted by James Bartholomew • Indexed in NHS

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January 31, 2006
Patricia Hewitt is going to make things 'even better'

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.

Posted by James Bartholomew • Indexed in NHS

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January 26, 2006
52 per cent have temporarily closed wards

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.”

Posted by James Bartholomew • Indexed in NHS

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Ward closures reported by the NHS Confederation

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.

Posted by James Bartholomew • Indexed in NHS

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In some areas, most patients get in Herceptin. In others only 10 per cent
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.

Posted by James Bartholomew • Indexed in NHS

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January 24, 2006
Welfare reform Green Paper comes out today

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.

Posted by James Bartholomew • Indexed in NHS • Welfare benefits

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January 23, 2006
Somehow it is never pay or pensions that get cut for government employees

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:

Posted by James Bartholomew • Indexed in Education • NHS • Pensions • Waste in public services

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January 18, 2006
Why are British doctors and nurses paid more than their eqivalents on the Continent?

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@


US: £88,000
UK: £83,000
Germany: £64,000
France: £49,000
Italy: £28,000


US £31,000
UK £25,000
Germany: £18,000
France: £23,000
Italy: £13,000

Hospital specialists:

US: £190,000
UK: £60,000
Germany £47,000
France: £32,000
Italy: £30,000

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.

Posted by James Bartholomew • Indexed in NHS

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Confusion over average waiting times

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:

Outpatient treatment:
1999: 7.7 weeks
2005: 6.6 weeks.

Inpatient treatment
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?

Posted by James Bartholomew • Indexed in NHS

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'Half the extra cash has gone on staff pay'

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.

Posted by James Bartholomew • Indexed in NHS

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January 13, 2006
Not in some newspapers - people are dying because of delays in radiotherapy in the 'new improved' NHS

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.

Posted by James Bartholomew • Indexed in NHS

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January 06, 2006
Hospitals in two counties on brink of collapse, says Audit Commission

The above is the headline of a Guardian story here.

Posted by James Bartholomew • Indexed in NHS

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Average waiting times for NHS patients have gone up

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,

Posted by James Bartholomew • Indexed in NHS

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January 05, 2006
Cameron rules out the best chances of real reform

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.

Posted by James Bartholomew • Indexed in NHS

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December 15, 2005
BBC tries to imply that private hospitals have equally low standards of cleanliness as NHS ones.

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?

Posted by James Bartholomew • Indexed in Media, including BBC bias • NHS

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'Don't do any non-urgent cases until May'

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

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December 14, 2005
Why is the NHS back in crisis?

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.

Posted by James Bartholomew • Indexed in NHS

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December 13, 2005
Patricia Hewitt admits that the NHS has been appalling - until now

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,

Posted by James Bartholomew • Indexed in NHS

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December 09, 2005
Yes, our premature deaths from heart disease are better - but the same is true in many other countries

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
Netherlands 113
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.

Posted by James Bartholomew • Indexed in NHS

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December 07, 2005
Recording a talk for the BBC

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.

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December 06, 2005
A brief reminder of where one of leading teaching hospitals came from
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.

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December 05, 2005
Fast diagnosis depends on quick access to things like scanners and we don't have enough of them - the latest statistics

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:

Japan 84
Italy 24
Switzerland 18
Germany 14.7
United States 13.1
Canada 10.3
France 8.4
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:

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December 02, 2005
Censored - the waiting times for radiotherapy

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

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How many households have private medical insurance?

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.

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December 01, 2005
Under-prescription of drugs in Britain

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 and comes from the EURASPIRE II Study Group (2001)

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November 30, 2005
There were fifty-five per cent more NHS beds in 1988/89 than now

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.

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November 24, 2005
Too many administrators compared to nurses

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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November 15, 2005
How much has the NHS improved after getting all that money? Part 3.
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:

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November 14, 2005
Another 'eye-catching initiative' that is going nowhere

A doctor concisely describes what many others, less qualified, suspect about Patricia Hewitt's latest intiative:

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How much has the NHS improved after getting all that money? Part 2.
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.....

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How much has the NHS improved after getting all that money? Part 1.
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.

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November 09, 2005
Throwing bricks at British firemen - an echo of the French riots

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.

Posted by James Bartholomew • Indexed in Behaviour & Crime • NHS • Waste in public services • Welfare benefits

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October 31, 2005
Many unnecessary deaths in the NHS from DVT, too?

There is an extraordinary report in the

Daily Express
today. 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.

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October 13, 2005
NHS cutbacks

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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September 23, 2005
Government to contract out NHS hospitals to the private sector

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:

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September 02, 2005
Twelve broken bones? Put them to one side and do some hip replacements.

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.

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August 22, 2005
Seeing a doctor

Basically, the government has misled the public about how easy it is to get an appointment with a GP.

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August 18, 2005
Charitable gifts to NHS hospitals

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.

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July 20, 2005
It is a nightmare to become old and ill and then find yourself being treated like this.

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.

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July 19, 2005
Arciept - the government is still flirting with denying this drug to patients who need it

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:

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Four out of five London GPs will not take on new patients

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


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July 18, 2005
Giving birth on the NHS is not as safe as it should be

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.

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July 16, 2005
Heard the one about the old prosthesis?

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.

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July 15, 2005
The part of healthcare that is still mainly charitable

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.

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July 13, 2005
How well did our emergency services really perform (2)?

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.

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July 12, 2005
How well did our emergency services really perform?

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.

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July 11, 2005
45 per cent of operating theatre time is wasted (and trying to get a cat to bark)

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.

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July 06, 2005
What is going on at St Thomas's Hospital (2)?

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:

Posted by James Bartholomew • Indexed in NHS

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July 05, 2005
What is going on at St Thomas's Hospital?

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.

Posted by James Bartholomew • Indexed in NHS

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July 01, 2005
We told that the NHS just needed more money...

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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June 26, 2005
Blair queue-jumps Mr Brown - but not that Mr Brown

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.

Posted by James Bartholomew • Indexed in NHS • Politics

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June 22, 2005
Government is hiding the truth about the NHS

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?

Posted by James Bartholomew • Indexed in NHS

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June 18, 2005
A consultant gives an insight into why the NHS will not deliver, despite all the extra money

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..."

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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June 16, 2005
The NHS has out of date scanning equipment

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:

Posted by James Bartholomew • Indexed in NHS

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How to do welfare reform.

The blog Once More Unto the Breach has an interesting posting and comments on the options and difficulties in welfare reform.

Posted by James Bartholomew • Indexed in NHS • Politics • Reform • Welfare benefits

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June 14, 2005
The NHS gets better and better. Is the government's claim true?

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'.

Posted by James Bartholomew • Indexed in NHS

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June 07, 2005
The Thatcher years by Norman Tebbitt and others

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.

Posted by James Bartholomew • Indexed in Education • European Union • Housing • NHS • Politics

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June 06, 2005
It is not only MRSA. Here is another bug you could get in an NHS hospital

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.

Posted by James Bartholomew • Indexed in NHS

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May 31, 2005
European Union obstructs efforts to save people from MRSA

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.

Posted by James Bartholomew • Indexed in European Union • NHS

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May 28, 2005
The return of belief to the Conservative Party

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.

Posted by James Bartholomew • Indexed in NHS • Politics

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May 25, 2005
Training nurses: 'a full day is 10 to 3'

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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Who would be old in the welfare state?

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

Posted by James Bartholomew • Indexed in Care for the elderly • NHS

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May 24, 2005
'We have more compassion for animals in this country than our elderly'

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.

Posted by James Bartholomew • Indexed in Care for the elderly • NHS

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May 22, 2005
Lack of cover at night in hospitals

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.

Posted by James Bartholomew • Indexed in NHS

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A child died. If only he had been a child of Tony Blair he would probably have had his operation.

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?

Posted by James Bartholomew • Indexed in NHS • Politics

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Problems in French healthcare

The French healthcare system undoubtedly provides better care than the NHS. But in France, too, there are problems.

Posted by James Bartholomew • Indexed in NHS

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May 20, 2005
Tony Blair adds a third tier to the British medical system

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.

Posted by James Bartholomew • Indexed in NHS • Politics

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May 19, 2005
The state finally realises that charities can do better but then spoils this breakthrough by forcing its own inefficiencies onto them

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.

Posted by James Bartholomew • Indexed in Education • NHS • Waste in public services • Welfare benefits

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May 16, 2005
Delays for MRI scans
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.

Posted by James Bartholomew • Indexed in NHS

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Reducing the cost of US health insurance

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.

Posted by James Bartholomew • Indexed in NHS

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May 13, 2005
Fifty blood tests for US$90

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.

Posted by James Bartholomew • Indexed in NHS

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May 12, 2005
Poor treatment may contribute to one in six deaths in intensive care
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.

Posted by James Bartholomew • Indexed in NHS

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May 11, 2005
NHS beds halve and crimes against the person up 281 per cent
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.

Posted by James Bartholomew • Indexed in Behaviour & Crime • Education • General • NHS • Parenting • Waste in public services • Welfare benefits

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May 09, 2005
Lanesborough Hotel

0406 Lanesborough Hotel 009.jpg

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.

Posted by The Blogmaster • Indexed in NHS

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May 06, 2005
Discrimination against the old in the NHS becomes something like official policy

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.

Posted by James Bartholomew • Indexed in NHS

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May 04, 2005
The nursing crisis goes on

For those who think the nursing crisis is over, some anecdotal evidence:

Posted by James Bartholomew • Indexed in NHS

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This election is not trivial

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.

Posted by James Bartholomew • Indexed in Education • NHS • Politics

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Suburban Miami has got what London has not

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?

Posted by James Bartholomew • Indexed in NHS

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April 30, 2005
The dilemma of charities
...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.

Posted by James Bartholomew • Indexed in General • NHS • Welfare benefits

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April 28, 2005
Visit to Miami

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.

Posted by James Bartholomew • Indexed in General • NHS

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April 26, 2005
Why nurses leave the NHS

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.

Posted by James Bartholomew • Indexed in NHS

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April 23, 2005
'The NHS has meant 50 years of waiting lists', Labour.

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.

Posted by James Bartholomew • Indexed in NHS

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April 21, 2005
More manipulation of hospital waiting times

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.

Posted by James Bartholomew • Indexed in NHS

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April 20, 2005
Getting around the failures of state education

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?

Posted by James Bartholomew • Indexed in Education • NHS

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April 19, 2005
Six months wait for an MRI scan

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.

Posted by James Bartholomew • Indexed in NHS

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April 18, 2005
One of the ways the NHS wastes money

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.

Posted by James Bartholomew • Indexed in NHS • Waste in public services

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A Picker Institute report on the NHS

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".

Posted by James Bartholomew • Indexed in NHS

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April 17, 2005
How much for removing moles in Malta?

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?

Posted by James Bartholomew • Indexed in NHS

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April 16, 2005
Overcrowding and infection risk

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.

Posted by James Bartholomew • Indexed in NHS

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April 15, 2005
What really happened at Epsom Hospital

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".

Posted by James Bartholomew • Indexed in NHS

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April 14, 2005
MRSA and incentives

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.

Posted by James Bartholomew • Indexed in NHS

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April 13, 2005
More ways in which waiting lists are manipulated

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.

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April 10, 2005
The waiting isn't over

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:

Posted by James Bartholomew • Indexed in NHS

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April 08, 2005
Depressing depression figures

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.

Posted by James Bartholomew • Indexed in NHS • Welfare benefits

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April 07, 2005
The Government should do something about it

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.

Posted by James Bartholomew • Indexed in General • NHS

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April 04, 2005
Are people able to look after themselves?

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.

Posted by James Bartholomew • Indexed in General • NHS • Pensions • Welfare benefits

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March 30, 2005
The NHS has been living off expropriated capital stock

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.

Posted by James Bartholomew • Indexed in NHS

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Delays in accident and emergency
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.

Posted by James Bartholomew • Indexed in NHS

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March 24, 2005
The decline of home visits by doctors

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.

Posted by James Bartholomew • Indexed in NHS

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March 22, 2005
What Patten did to Hong Kong

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.

Posted by James Bartholomew • Indexed in NHS • Tax and growth • Welfare benefits • Welfare benefits

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March 21, 2005
Cutbacks in NHS provision

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."

Posted by James Bartholomew • Indexed in NHS

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March 20, 2005
Labour is King

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.

Posted by James Bartholomew • Indexed in NHS

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March 09, 2005
Doctors and managers in the NHS are gagged by the government

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.

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March 08, 2005
Why has Great Ormond Street Hospital run out of money?

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?

Posted by James Bartholomew • Indexed in NHS

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March 04, 2005
Basic hospital economics

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:

Posted by James Bartholomew • Indexed in NHS

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March 02, 2005
Improvement in the NHS

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:

Posted by James Bartholomew • Indexed in NHS

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February 27, 2005
Good privatisation good, bad privatisation potentially damaging

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:

Posted by James Bartholomew • Indexed in General • NHS

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February 25, 2005
Innovation in US healthcare policy

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 don’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.

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Healthcare systems in other countries

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.

Posted by James Bartholomew • Indexed in NHS

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February 22, 2005
The Reform manifesto

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.

Medical care

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:

Posted by James Bartholomew • Indexed in Education • NHS

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Perhaps I was too hard on American healthcare

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 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.

Dennis Duggan
by email

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February 21, 2005
Which is better, American or British medical care?

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?

Posted by James Bartholomew • Indexed in NHS

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