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Archive - Month: May 2017

May 28, 2017

Is the abandonment of the 18 week Referral to Treatment Target Illegal?
Filed under: Private Eye — Dr. Phil @ 12:08 pm

Legality of Dropping 18 week RTT target

A credible legal opinion that the government’s abandonment of the 18 week Referral to Treatment target is illegal. Why are opposition parties not making more of this? Will it be left to crowdsourcing citizens once again to try to hold the government to account for what is happening to the NHS?

May 20, 2017

Private Eye Medicine Balls 1444 May 17, 2017
Filed under: Private Eye — Dr. Phil @ 12:15 pm

Where is the promised parity for mental health care?

Promises to improve mental health services are likely to feature large in all manifestos, but who is most likely to deliver? Health Secretary Jeremy Hunt told Andrew Marr that the Conservatives would find another 10,000 ‘mental health workers’ but didn’t say what form they would take and whether this was an increase on the current figure, or the figure when the Tories took office (we have 6000 fewer mental health nurses in England since to 2010, and 170 fewer fully trained doctors specialising in psychiatry and psychotherapy). Hunt also refused to say if new money would pay for this, or whether it would be pinched from elsewhere.

Only the Lib Dems have thus far seemed prepared to back up pledges with transparent funding commitments. Some NHS staff will never forgive them for jumping into bed with Cameron and allowing Andrew Lansley’s disastrous Health and Social Care Act, but in now committing themselves to opposition, they can return to being an unelectable think tank. The Lib Dems have pledged an extra penny on income tax to raise £6 billion for the NHS and social care, have proposed a dedicated health and social care tax and an Office for Budget Responsibility for healthcare to link long-term NHS funding decisions to independent assessments. All very sensible and unlikely to happen.

Meanwhile, in parts of London, 20% of mental health nursing posts are unfilled, acutely ill patients are sent hundreds of miles for treatment due to bed shortages, or admitted to prisons. And those with life-long mental illness are having treatment withdrawn. Many trusts now use ‘short term recovery models’ for patients with long term problems. This is resulting in patients who are struggling with severe, and possibly drug-resistant mental illness, being discharged from community mental health teams, and often from consultants. The advice given is to apply for overburdened and underfunded adult social care – even when they do not need social care, and would not qualify for it. Failing that, to turn to the voluntary sector which is also overwhelmed by sheer numbers of people, many of whom need medical care, rather than what the voluntary sector offers – social inclusion, advice and some degree of support. Patients in rural areas are especially disadvantaged.

The alternative is to rely on overworked GPs to manage hugely complex conditions in 10 minutes. Recovery models rarely allow for long-term treatment, which used to be available where needed; even if re-referral by a GP is accepted (by no means always the case) it will be on a time-limited basis. One example of this method of delivering care is Cumbria Partnership NHS Trust. MD has been sent stories from three of their patients. One suffers from an uncommon psychiatric disorder and is unable to take medication following severe and incurable side-effects. She has managed, living alone, for many years with no medication but with regular treatment and support from community psychiatric nurses. Without warning she was informed she was to be discharged as the service no longer offers long term care. Her GP had not been informed that this was to happen. Her discharge letter stated she was at ‘high risk of self-harm and attempted suicide, likely to increase on discharge’. A GP re-referral has been refused and she has been left alone to reflect on her increased suicide risk.

The second patient has Bipolar Disorder with major depressive episodes. She is divorced, lives alone with no close family, but managed her life with long term CPN support. This has been withdrawn and she has to combat the mood swings of her illness with the added stress of a pattern or treatment-discharge-re-referral-treatment-discharge. This has had a seriously detrimental effect on her ability now to manage her life and cope with daily challenges. It would make far more sense to prevent her relapsing in the first place by providing long term support. The third patient has endogenous depression and an unsupportive family. Since discharge from long term care this patient’s illness has become extremely hard to manage. Many patients with mental health problems lose faith in NHS mental health care but are afraid to speak up and so suffer in silence.

There are some excellent examples of good mental health care, and NHS England’s snappy ‘Five Year Forward View for Mental Health – One Year on’ details how hard staff are working to improve the service. But without adequate staffing and funding, the mental health of the workforce itself is at crisis point. Staff simply can’t cope with the ever-rising demands of mental illness. Some patients fully recover but for those with life-long mental illness, a revolving door policy of referral, short term care, discharge, re-referral, short-term care, discharge etc is neither effective nor humane.

Private Eye Medicine Balls 1443 May 3, 2017
Filed under: Private Eye — Dr. Phil @ 12:04 pm

Labour’s Open Goal

Shadow health secretary Jon Ashworth could promise anything about the NHS without much fear of having to implement it, but the government’s screw up of the NHS and social care represents Labour’s best hope of staying alive. Andrew Lansley’s Health and Social Care Act has been a very predictable disaster, with billions wasted on commissioning, tendering, retendering and even suing the NHS because companies such as Virgin didn’t get the tender they wanted.

Aggressive austerity has probably been responsible for the spike of 30,000 extra deaths in 2015, albeit of people unlikely to vote Conservative. Admissions for malnutrition have trebled in the last 10 years. Mental health services are being savagely cut and there has been an increase in suicide rates in those struggling to cope, including female nurses. The sub-inflation pay rises and refusal to guarantee the rights of NHS and care workers from the EU has lead to record vacancies and ever more dangerous gaps in staffing levels. And the results are there for all to see. Nearly 4 million people waiting for an operation. Over 200,000 people waiting for four hours of more in A&E in February alone. The number of people waiting for 12 hours or more on trolleys doubled in a year. Some patients are waiting over 30 hours on a trolley, in scenes reminiscent of the nineties.

The government’s response has been to use NHS England CEO Simon Stevens as a human shield, announcing that the previously sacrosanct waiting time targets for non-urgent care were having to be abandoned to concentrate on the crisis in emergency care. The rota gaps in emergency specialties such as paediatrics are particularly alarming, not least because Jeremy Hunt’s clumsy attempts to crush the junior doctors has meant that 50% of them are refusing to go straight into higher specialist training. Not only is ‘death by corridor’ back, but patients are dying on waiting lists and the elderly are trapped in hospital for months – and even years – for the lack of social care. Hospital chief executives are being bullied into signing up to ‘cost control’ measures they know are sheer fantasy, to support the even bigger fantasy that the NHS can make a further £22 billion efficiency savings without causing widespread patient harm. In general practice, work related stress has reached record levels as staff struggle to cope with the ever rising demand. Labour could not have a bigger open goal to aim at.

Ashworth’s initial salvo was to guarantee the rights of EU workers. Good. Labour would ‘axe that Health and Social Care legislation that allows the NHS to be fragmented and sold off. Privatisation of the NHS will come to an end. We will reinstate the NHS – publicly funded, publicly administered and publicly provided.’ In reality, the NHS is likely to need the help of private providers in, say, psychiatry and surgery for the foreseeable future unless there is a massive investment. What needs to end is the enforced tendering of contracts to the private sector, apparently to comply with European competition law. One advantage of Brexit might be to remove this obligation.

Ashworth also announced Labour would scrap the 1% NHS pay cap, implement the recommendations of the independent pay review body, re-introduce bursaries and reinstate funding for health-related degrees. All of this is likely to improve recruitment and morale, if John McDonnell can get the maths right. Ashworth’s cleverest swipe at Jeremy Hunt was to commit to legally enforced safe staffing levels driven by evidence-based NICE guidance. Hunt made hay with the Mid Staffordshire disaster, blaming Labour for allowing such unsafe staffing levels to lead to such poor care. Hunt styled himself as a patient safety champion, committing to implement to recommendations of the Francis Inquiry before realising how much it would cost, forcing NICE to abandon its safe staffing work halfway through and allowing the dangerous rota gaps in hospital care that junior doctors felt strongly enough to strike about. The government still had the gall to pledge to make the NHS ‘the safest and most compassionate health service in the world’ in their 2015 manifesto, and has manifestly failed thus far. In taking over the ‘patient safety’ high-ground, Ashworth is committing Labour to putting a lot more money into the NHS, alongside all their other commitments. Again, it comes down to the maths.

As for Hunt, his best hope for this election is to go into hiding and let Simon Stevens take the flack. Stevens loves his strategy, and spinning dreams of new models of care, Vanguards, Five Year Forward Views, Sustainability and Transformation Plans and Accountable Care Organizations. Some of these may be good ideas, but all will flounder if they can’t be safely staffed. Ashworth has hit the nail on the head. He needs to keep hitting until his thumbs are purple.

Private Eye Medicine Balls 1442 April 18, 2017
Filed under: Private Eye — Dr. Phil @ 11:58 am

Assisted Dying

We’re all going to die, but sadly not all quickly or with dignity. The provision of good palliative care in the UK remains patchy but even with the best that palliative care has to offer, some deaths remain very protracted and distressing. As Professor Ray Tallis puts it: ‘Unbearable suffering, prolonged by medical care, and inflicted on a dying patient who wishes to die, is unequivocally a bad thing.’ MD would willingly assist such deaths were it legal to do so, but the High Court has repeatedly made it clear that any change in the laws would have to come from Parliament, and it seems unlikely that politicians will ever enact the overwhelming will of the people to have the right to exit with dignity. And so the pointless suffering continues.

One of the strongest arguments against assisted dying is whether it could be legally and practically introduced in an understaffed NHS that struggles with assisted living. If we can’t give many patients decent humane lives, what chance decent humane deaths? To counter the concern that assisted dying would become the ‘go to’ option, we would need to offer everyone excellent palliative care first, and there is little sign the government wishes to invest in this.

In countries and states that have legislated for assisted dying, there has usually been increased investment in palliative care services. In Oregon the proportion of people dying in hospice care increased from 37% in 2002 to 52% in 2009 – one of the highest rates in the USA. And nearly 90 per cent of those seeking assisted dying do so from within those services, proving the point that even with the best palliative care, some people still suffer and wish to choose when to die.

The BMA conference regularly votes against assisted dying, worried that it would damage trust in doctors. But a survey of nine European countries put levels of trust in the Netherlands at the top. Countries with assisted dying are generally more open and transparent about death and end of life care, and offering patients the choice of a humane death may enhance rather than diminish trust.
Dr Ann McPherson died in 2011 from pancreatic cancer and fought hard but unsuccessfully for the right to have an assisted death. As her husband, Prof Klim McPherson, observed: “There is nothing humane about forcing people with terminal illness to stay alive for as long as they can — no matter how good the care they receive from a profession forced into cruelty by an inadequate law.”

In countries with a mature attitude to death, well-regulated assisted dying and good palliative care, the number of assisted deaths has remained low. In Oregon it has been legal for terminally ill, mentally competent adults to have an assisted death since 1997, without any of the predicted dire consequences and – thanks to strict safeguards – no proven cases of abuse. The 2013 Oregon report showed 71 people had an assisted death. 90% were receiving hospice care, and the majority had terminal cancer. Assisted deaths are 0.2% of total deaths in Oregon, a number that has remained stable over the last 5-6 years. 122 people requested life-ending medication in 2013. 51 did not take the medication – many of them took comfort in knowing the option was there. Around 90% of people who had an assisted death were also enrolled in hospice care. And the majority of people who had an assisted death had terminal cancer and were aged between 55-84.

An undignified, unpleasant death is the biggest failure of medicine. It is usually avoidable. Healthcare professionals can legally hasten death by withdrawing or withholding of treatment, or through the principle of ‘double effect’ where a treatment given to relive suffering ‘inadvertently’ hastens death. Patients are usually excluded from these decisions. It would be far kinder and more ethical to allow – within a proper legal framework – for the wishes of terminally ill, mentally competent adults to be respected. Assisted dying has always, and will always, occur but not always humanely. As Tallis observes: ‘Death from dehydration and starvation in patients, who have no means of securing an end to their suffering other than by refusing food and fluids, or botched suicides, reflect the unspeakable cruelty of the present law.’ And not everyone can afford, or is able, to make the grim pilgrimage to Switzerland. Time to legislate for kind deaths for all.

Private Eye Medicine Balls 1441 March 30, 2017
Filed under: Private Eye — Dr. Phil @ 11:52 am

It’s still not safe to speak up in parts of the NHS – and the staff know it

The risks to the NHS of Brexit are well known. The promised extra £350 million a week to fund the service was never likely to materialise, but a staffing crisis may well do. There are currently 24000 unfilled nursing posts in England alone. The failure of government to guarantee a right of remain for the 140,000 EU nationals working in the NHS and social care system has bred further insecurity. In one survey, 42% of European health staff working here said they are now thinking of leaving the UK. Many have protested about being used as bargaining chips and almost 5,500 have left since the Brexit vote according to NHS Digital, a 25% increase on the 2015 figures. Coming in, only 96 European nurses registered to work in the UK in December, compared to 1,304 last July. Vital EU research funding streams could just disappear, as could EU collaboration on infectious disease control, licensing and regulation of medicines and public health initiatives. These risks are very real and present, yet the government’s latest mandate to NHS England made not a single mention of Brexit.

As usual, it will be left to whistle-blowers to tell the truth about the state of NHS and social care, and the effect of Brexit on it. The Care Quality Commission believes they are now well supported, publishing the following statement from Dr Henrietta Hughes, its National Freedom to Speak Up Guardian on its website on March 21. ‘Since the tragic events of Mid Staffs we have made considerable progress to making the NHS the safest healthcare system in the world including appointing a National Guardian and making sure every NHS Organisation has a Freedom to Speak Up Guardian.’ The NHS whistle-blower Minh Alexander spotted this statement was identical to a department of health press statement from the day before. It suggests that the far from being independent regulator, the CQC writes and regurgitates DH propaganda to give the impression that NHS whistle-blowers are well supported and the NHS is becoming the safest system in the world.

Many whistle-blowers want their ‘National Guardian’ to have statutory independence and powers, but Dr Hughes is housed within and beholden to the CQC, making it particularly difficult for whistle-blowers such as Dr David Zigmond who is campaigning for an investigation into how he was treated by the CQC. Last summer, the CQC and NHS England rapidly closed his highly regarded practice in Bermondsey despite a previous excellent CQC report, very high levels of staff and patient satisfaction and no serious complaints, GMC or coroner’s referrals in an otherwise unblemished career. Dr Zigmond sent detailed and thoughtful analyses of his situation and how he believes he was unfairly treated by the inspection team to the CQC, and has yet to receive a response (Eyes passim)

Henrietta Hughes is unlikely to be much help. She has arbitrarily capped her case load at 20 cases a year, thus shutting out the majority of whistle-blowers who will need help. She refuses to support law reform and claims that she is not in a position to seek statutory independence for her role, which contradicts her job description, and has been unable to help individual whistle-blowers such as Dr Chris Day (Eyes passim), although at least recognising he is ‘very brave.’ As for the Freedom to Speak Up guardians, one has been jailed for fraud. Jon Andrewes faked his CV to obtain employment as chair of Royal Cornwall Hospitals NHS Trust, Torbay Care NHS Trust, its successor Torbay and Southern Devon Health and Care NHS Trust and chief executive of St. Margaret’s Hospice in Taunton, Somerset. He obtained over £1 million in salary from his fraud.

Dr Day’s brave* attempt to ensure all 55,000 junior doctors have proper whistleblowing protection is the most important whistle-blowing case of recent times. He has the support of many grass roots doctors but, incredibly, not the British Medical Association. He is at least being supported by Public Concern at Work, who helped draft the original whistle-blower protection law (the Public Interest Disclosure Act), the stated intent of which was to support all whistle-blowers in the workplace ‘such as trainees, homeworkers and professionals in the NHS who are not normally protected by employment law.’ Dr Day has discovered to his detriment that he had no protection when he raised concerns, and it is shameful that the National Guardian and the BMA are not supporting his case. Who wants to encourage pesky junior doctors to speak up in the dangerous, post-Brexit NHS? The annual NHS staff survey shows 30% of NHS staff still do not feel safe to speak up. In some trusts, as 45% of staff do not feel safe to speak up. Hardly ‘on track’ to be the safest health service in the world.

*now successful – well done and thank you Dr Chris Day

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