"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Tuesday, 5 August 2014

Been there, done that!

This blog from a type 1 diabetic about losing her insulin while in the US reminded me of my own experiences. Here's the comment I left on that site (just in case it does not get past moderation).

I live in the UK and for five years I used to speak at US conferences four or five times a year. My T1D was usually not an issue, although there were a few issues - like security at Birmingham International telling me I had to put my insulin in the cargo hold and me demanding the airline book me an ambulance at Chicago because I would arrive "unconscious" without my insulin (OK, a bit over the top, but they "made an exception" for me).

On one occasion I was a bit lax. I had enough insulin for the trip, but on the way back the transatlantic plane was delayed and I had to stay overnight in a hotel. I needed to change the basal insulin in my pen and I did it in the bathroom. (Lesson: don't change cartridges in the bathroom, the floor is hard). I dropped the cartridge and it broke. This was my 'spare' (I was in the US for one day more than I had planned).

What to do? If you are a clinician, do not read on.

I had the same dilemma mentioned in the blog, except my only option was #3 - find a doctor and get a prescription. However, this was 1 am, so the choice of doctor and pharmacy was limited. I didn't want the option of spending hours and hundreds of dollars that it would cost. I had travel insurance, but the administration involved in getting the refund was far too much. Anyway, I had also spent a day travelling, I was tired from a week's work at a conference, and wanted to go to bed.

So I got a spare disposable syringe and sucked as much insulin as I could out of the smashed cartridge. (Lesson: carry disposable syringes, you never know when you'll need one.) There was enough for that injection. But what about the plane trip home? Usually, to take into account time zones, I would inject a half dose half way across the Atlantic. There wasn't enough remaining insulin in the smashed cartridge for that.

However, while travelling I had got into a habit when changing cartridge of putting the spent cartridge in my wash bag to dispose of at home. Except I didn't remember to dispose of the cartridges at home, so there was quite a collection in my wash bag. So I had spent basal cartridges from this trip, and from other trips in my wash bag. In each was a little bit of insulin and, with the syringe, I was able to draw out enough for the half dose on the plane. The insulin was old, and not stored at a cold temperature, but in that situation, any insulin was better than none.

Monday, 28 July 2014

I Want Personalisation Not a PHB

I have multiple long term conditions, one of which is hypothyroidism - my thyroid does not produce enough thyroxine and I have to take a replacement dose in tablet form. I take 175 micrograms in three pills 100mcg, 50mcg and 25mcg:


From the bottom upwards the dose increases, doubling each time. There is a clear danger here, while I know that the smaller strip is 100mcg, it is easy for me to mistake the 50 for the 25. Overdosing on thyroxine can have detrimental effects on the heart.

When I open a new box of pills, I personalise it:


Clearly, the best solution would be for the manufacture to print the dose in big numbers on the front (as opposed to the current situation of printing it in tiny numbers on the low contrast back).

Will a personal health budget deliver this? No.

Firstly, personal health budgets (at the moment) do not apply to medicines. This is a bit silly since people who have a PHB cannot use the money to pay their prescription charges. Yes, that's right, people can spend a PHB on reiki or some other nonsense that does not work, but they will not be allowed to spend their PHB on the government imposed sickness tax that is called prescription charges. As PHBs are rolled out to more people we will see cases where people will not take their prescribed medicines because of the cost of prescription charges, but will be able to buy ineffective "alternative" medicine with their PHB. Madness.

Secondly, and most importantly, I am an individual and drug companies do not listen to me. Giving me a PHB will not make the drug companies any more likely to listen to me. Indeed, the only way that the drug company will take any notice is if I accidentally take an overdose and die - at that point they may consider changing their packaging, if my death can be attributed to it. However, the drug companies will listen to the NHS, since the NHS represents a market of 50 million people in England. So if the NHS wants drug doses printed on the front of blister pack strips, it would happen.

People who have PHBs are effectively removing themselves from the NHS since they are purchasing healthcare rather than the NHS purchasing healthcare for them. In this example, under the current rules, medicines will still be NHS responsibility, but nevertheless the same principle applies: a PHB turns patients from part of the collective NHS into isolated individuals with less influence.

I really do want personalisation, but a personal health budget will not give it to me.

Tuesday, 15 July 2014

NHS Mutual Privatisations

The Coalition’s White Paper on the NHS in 2010 had this to say about the future of NHS Trusts and Foundation Trusts (section 4.21):
As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients. For many foundation trusts, a governance model involving staff, the public and patients works well but we recognise that this may not be the best model for all types of foundation trust, particularly smaller organisations such as those providing community services. We will consult on future requirements: we envisage that some foundation trusts will be led only by employees; others will have wider memberships. The benefits of this approach will be seen in high productivity, greater innovation, better care and greater job satisfaction. Foundation trusts will not be privatised. 
The government clearly intended for most Foundation Trusts to be “employee-led social enterprises” in other words, no longer state owned, but instead, become not-for-profit private businesses. The statement at the end that “Foundation trusts will not be privatised” is contradictory since if a state-owned organisation is taken out of state ownership and into private ownership (as social enterprises are) then this is privatisation. Although the clause mentions "social enterprises" the same statements hold for mutuals. Mutuals are not state owned, they are in private (if mutual) ownership.

The government received 6,000 responses to the White Paper and summarised these responses in a paper called “Legislation Framework and Next Steps”. Section 6.16 in this document comments on the plan to turn hospitals into “social enterprises”:
Regulating healthcare providers discussed the prospect of enabling FTs to have employee-only memberships. Not many respondents commented on this proposal but, with some exceptions, those that did were generally not supportive. The CQC said that staff-only models without patient and public involvement could be at odds with public accountability and should be avoided, while the BMA thought they would do nothing to improve patient care. The Government has considered these concerns and concluded that staff-only membership would not be compatible with the foundation trust model. 
The comments from CQC and the BMA are relevant not only for the government’s then plans for NHS hospitals, but also for social enterprises in general: there is no public accountability and the model does not necessarily result in better care. The final comment appeared to dismiss all possibilities of Foundation Trusts being taken out of public ownership. The policy was killed off.

A few weeks ago George Osborne made a curious and worrying announcement reported in the Daily Telegraph.
Ministers are drawing up radical measures, to be announced in George Osborne’s Autumn Statement, which will see widespread privatisations and at least one million public sector workers removed from the government payroll by the end of the decade. 
The Telegraph, slathering in its small-state dotage, misinterpreted what this statement meant, they thought the government would simply sack public sector workers:
Ministers have been told that the government workforce will fall by about one million between 2011 and 2019. At a rate of 36,000 per quarter, this is the equivalent of sacking one state employee every four minutes, every day, for the next five years. 
When you “sack a state employee” there is a good chance that at the same time you are increasing unemployment, and no government can survive on five years of increasing unemployment.

According to ONS there are 5.4 million people employed in the public sector (or 17.7% of the workforce). We have to be careful about what this figure means, because since 2008 it has included the workforce of the banks that were nationalised. These banks are only temporarily in public ownership, and anyway, they can hardly be regarded as providing a social good, in contrast to the NHS and education. Regardless of this issue, a cut of one million would be a fifth of all public sector workers. ONS provides a breakdown of this figure:


In March 2014 there are 1.6m people in the NHS, 1.5m in education and 1.1m in public administration (councils). Removing a million people from these figures will be ambitious and the resulting rise of unemployment figures would be catastrophic for any government.  The plan is clearly not to sack public sector employees, so what is Osborne planning?

If we go back to the first quote from the Telegraph there is a huge clue about what Osborne intends:
will see widespread privatisations and at least one million public sector workers removed from the government payroll 
The simplest way to reduce the “government payroll” is to privatise a service. In October 2013 the “government payroll” was reduced by 150,000 when the government privatised the Royal Mail. The problem for the government is that the majority of the public sector is in politically sensitive areas like the NHS and education: privatisations in these sectors can only be done piecemeal and is unlikely to yield the promise cut of a million jobs.

There is another issue to consider. The following graph is from Duncan Weldon, the Economics Editor of Newsnight:


(I have shifted the axes a little – specifically, the y axis starts at 10% not 0% in the original – so that the graph takes less space.) Duncan makes no comment other than the graph is interesting and he wondered “if the lines will eventually cross?”. The graph shows that the public sector workforce has reduced consistently since Q3 2009 and self employment has increased since at least Q4 2002. There is some connection between the two lines. The Coalition have cut the number of NHS managers since 2010, but it has appeared that many of those manager have been re-employed as self-employed “consultants”! The effect of the government's "sacking" of NHS managers was essentially to privatise them, turning a public sector employee into a private sector, cab-for-hire, "consultant".

So now let’s return back to the 2010 NHS White Paper. If a public service is turned into the more politically acceptable mutual or “social enterprise” then the people who work for the service are employed by the new organisation, not the public sector. (This is one reason why it is important to highlight these changes as privatisations, since the staff will no longer work in the public sector.) Osborne’s promised cut of one million public sector jobs can be achieved simply by turning public sector organisations into “social enterprises”.

Since the NHS White Paper was published the term “social enterprise” keeps cropping up when it comes to describing a Foundation Trust. This is naive, wrong and in some cases duplicitous. A Foundation Trust is owned by the taxpayer, just like an NHS Trusts: the clue is the bottom line of the annual accounts of both NHS Trusts and Foundation Trusts which lists a single figure that is the Taxpayers Equity. There is no difference in the ownership of NHS Trusts and Foundation Trusts. For this discussion, the only difference is that if an NHS Trust makes a surplus (that is, it spends less during the year than it receives in income) the surplus must be returned to the NHS (and ultimately, the government). If a Foundation Trust makes a surplus that money is retained by the trust and is used to provide healthcare. Some people claim that this is similar to social enterprises. It isn’t. However, the talk of Foundation Trusts being "social enterprises" persists, mostly because this is the eventual aim of policy makers.

The idea to turn NHS trusts into mutuals or “social enterprises” is a “policy zombie”: once you've killed it off it comes back to life a few years later. HSJ are now reporting that the Kings Fund are advising the Department of Health to re-introduce this idea.
Professor Ham says there should be an “option… for NHS trusts to become staff-led mutual… including trusts providing acute services”. He says another approach could see “emerging models of integrated care choosing to become mutuals where several organisations come together to create a joint venture to deliver services such as urgent care and care for older people”. The report says this should be voluntary for trusts. The DH has welcomed the report but HSJ understands it does not plan to respond by allowing NHS acute trusts to become mutuals. 
This plan appears not to be just the fantasy of Prof Ham, since HSJ reports
the DH is expected to identify around 10 organisations, including acute providers, to pilot greater engagement of staff. There will be £1m funding available for the initiative, jointly from the Cabinet Office and DH. The programme will begin this summer and last until spring next year. It is understood the DH will use the work to identify regulatory, legal and practical steps it could take to allow new ownership and governance models such as mutual in the future
Notice the phrase "practical steps it could take to allow new ownership". If you change the ownership of an organisation owned by the nation then this is privatisation.

The big sell off of the NHS will begin after the next election. Labour were keen on "public sector mutuals" in the last government and started the privatisation of Community Health Services into so-called "social enterprises". This process was halted when the current government tried to privatise Community Health Services in Gloucestershire and the plan was halted after a judicial review. The big question is, will Labour support the public sector and kill off Ham's zombie fantasy?

Sunday, 13 July 2014

Why John Rentoul is Wrong

Yet again John Rentoul is wrong.

In today's Independent John Rentoul describes an electoral scenario that he describes as "shocking", "alarming" and "one of the least attractive" electoral outcomes. While I agree with these statements (for purely polemic reasons, they suggest yet another coalition), I disagree with his naive arguments. Rentoul says that the situation will lead to "the Liberal Democrats might have even more of an influence on government than they have at the moment". I disagree, the result will be a short-lived and unstable government.

Let's look at the 2010 election results. These figures have changed a little bit since 2010, but not so much as to make any difference, I will use them because they describe the situation in 2010, rather than now.

Cons 306
Lab 258
LD 57
Others 28

Assuming that the five Sinn Féin MPs (included in Others) do not participate this means a majority coalition requires 323 MPs. For the Tories to get a majority of 323 out of these figures they needed 17 more votes.

The Coalition works because the Lib Dems provide 57 extra votes, right? Not necessarily. Over the last four years Lib Dems have voted against government bills, so the Coalition cannot rely on all of those 57 Lib Dem MPs (nor all the Tory MPs, but that is another story...). What if the Tory-majority government brings in a bill that goes against everything that the Lib Dems stand for, will the Coalition still have those 57 votes? No, but even so, the government (assuming it has the votes of all Tory MPs) will still have a majority. The reason is the "payroll vote".

The payroll vote are those MPs who hold government posts. These vary between paid ministerial positions to unpaid posts like chairing important parliamentary committees. If we just restrict ourselves to the paid positions, here are the figures from 2010:

Cabinet members (23); 18 Tory; 5 Lib Dem
6 Tories ministers also attend

Minister of State (32); 26 Tory; 6 Lib Dem

Parliamentary Under Secretary of State (33); 28 Tory; 5 Lib Dem

Whips (non-cabinet 5); 3 Tory; 2 Lib Dem

All of these people will always vote for the government. This is a guaranteed 93 votes for any government bill (88 ministers and 5 whips). Eighteen of these people are Lib Dem. So if the Coalition brings in a Bill that will turn the stomach every Lib Dem the vote will pass because eighteen Lib Dems are on the payroll and will always vote for the government.

Why are eighteen of the 88 ministers Lib Dems? This is because the Lib Dems have 16% of the Coalition MPs (57 out of 363) and hence have to have at least 16% of the ministerial positions. 16% of 88 is fifteen, rounding up judiciously. Since there are sixteen Lib Dem ministers it means Lib Dems are over represented in government, but this is advantageous because it guarantees the Coalition a majority. (Fifteen plus the five whips still gives a figure above that magical seventeen majority, but only just, hence the need to have an additional three guaranteed Lib Dem votes.)

Now onto why John Rentoul is wrong. He quotes a "prediction" that at the next election the breakdown will be:

Cons 295
Lab 296
LD 31
Others 28

Rentoul says that this will make the Lib Dems much more powerful than they are now. It won't, all it will do is create an unstable government and make a new election much more likely.

To get a 323 majority one or the other of the two large parties would have to find 27 or 28 votes. They cannot get these from the Lib Dems because they cannot guarantee that all Lib Dems will vote for the resulting coalition. Let's assume that Labour form the next coalition. This will mean that 9% of the coalition's 327 MPs will be Lib Dem hence 9% of the payroll vote, or eight MPs. Add this to the whips votes and the Labour-led coalition will have 309 votes, well short of the 323 needed. Essentially, this will be a minority government, not much different to what we would have now if the Lib Dems pulled out of the Coalition. It would be unstable.

So Rentoul is wrong to say that "the Liberal Democrats might have even more of an influence on government than they have at the moment" since that government will be short-lived and probably will achieve nothing for the Lib Dems to influence.

Sunday, 29 June 2014

Name and Shame and Patient Choice of GP Practices

Jeremy Hunt's latest announcement is that GPs should be "named and shamed" for poor cancer referral rates. (The article is in the Mail on Sunday, I won't link to it here, but you can find it through an internet search.)
"Under the Government’s planned reforms, surgeries will be ranked as ‘green’ for cancer on the NHS Choices website if they quickly refer patients to hospital when they are showing possible signs of cancer. But if they miss too many cancer cases – or if patients have to return numerous times before being sent for tests – they will be classed as ‘red’."
This plan has been criticised by doctors,
"the Royal College of GPs has criticised the proposed rating system as ‘crude’ and said the Government should be ‘supporting GPs, not criticising them’"
This sentiment was repeated on BBC Broadcasting House on Radio 4 by Dr Sarah Wollaston, Chair of the Health Select Committee and a GP. Dr Wollaston said that the policy could lead to over-referral which would "clog up the system".

There are other reasons to reject this idea. Over-referrals are bad for patients because they cause anxiety to "false positive" patients, cause unnecessary tests and potentially damaging interventions.

The announcement also doesn't recognise that cancer is more effectively beaten with improved public health.

The whole "naming and shaming" idea is flawed. At present GP patient lists are geographically based, and while there is some choice at the boundaries, most patients are registered at the practice in the area where they live. It is well known that this ideologically-driven government want to change this.

What happens when the cancer diagnosis rankings appear on the NHS Choices website and a patient finds that their practice is 'red' rated? Hunt's gut feeling is that the patient will move to another practice with a better rating, and this "market" behaviour will improve incentives and quality. However, under current situation, this will not happen because changing practices is not a simple thing for patients to do. A 'red' rating will cause unnecessary anxiety amongst a community who will have no choice other than the practice badly rated (even though it may well be unwarranted). So why has Hunt come up with this policy?

In the 2010 Health White Paper the government said:
"Give every patient a clear right to choose to register with any GP practice they want with an open list, without being restricted by where they live. People should be able to expect that they can change their GP quickly and straightforwardly if and when it is right for them, but equally that they can stay with their GP if they wish when they move house."
So what has happened to this policy? The results are mixed. The BBC, as ever acting as the mouthpiece for the Department of Health says:
"The lead author, Prof Nicholas Mays, said: "While demand for the pilot was modest, our evaluation found that patients had positive views of the scheme."
However, Pulse Magazine, the trade magazine for primary care, is less enthusiastic:
"The long-awaited report into pilot sites concluded that, despite positive feedback from users, there was little demand from patients or practices and called on the Government to consider alternatives to support increased access."
Pulse reported figures from the study that the BBC chose to ignore: "More than a third of the practices taking part in the Government’s ‘choice of GP practice’ pilots failed to register a single patient from outside their area". This is hardly the "modest demand" that the BBC reported, it is a wholesale rejection of the idea.

There are good reasons why this idea should be rejected. Pulse says of the study:
"It also found that commissioners had big concerns about the potential destabilisation of general practice and impact on the wider health service if it was to be rolled out nationally."
Commissioners are under immense pressure at the moment to meet increasing demands due to an aging population, government diktats about integration and moving care out of hospitals, while at the same time having to meet unachievable targets to reduce A&E attendances. All of this must be done with a budget that is static and inadequate. The last thing they need is one more destabilising policy.

The "choice of GP practice" pilot has shown that few people want to change practice, so it is possible that someone in the Department of Health has said: if there's no demand for this policy, why not create it? If a GP practice has been labeled "poor" at cancer diagnosis then there will be demand from some worried patients to change to a practice that has a good rating. Thus cancer diagnosis rating has a potential to create the demand for patients to practices.

It is not too far fetched to suggest that the whole point of Hunt's cancer rating announcement is to create the demand needed for the failed "choice of GP practice" policy.

UPDATE 23.00

Dr Clare Gerada tweeted the following at 21:36:


This puts another perspective on Hunt's cancer name & shame: cancer is rare and so the diagnosis rate of each GP is small. This means that it will be difficult for NHS Choices to come up with a criteria to use to determine when to give a "green" or a "red" flag. Going on this tweet, it seems that the cancer diagnosis rating flag will be a non-starter.

Thursday, 1 May 2014

Self-care "Payment by Results"

For forty years I have had regular doctors' appointments for my diabetes. This has been mostly with hospital doctors, but from about the mid 90s it was GP diabetic clinic appointments too. For the first thirty years they all had the same format: blood results, told to do better, given form for the next blood test, dismissed. Years after I had taken my last exam, every six months I would be given a test, fail it and then be chided for not trying harder. I would always leave those appointments angry. My blood tests were not bad, they were simply not perfect; and it wasn't that I was not taking responsibility for my condition, I was, I just had a busy life and sometimes I could not understand why I had high results or how to get them lower.

Then about ten years ago, for some reason, my diabetic appointments changed from a personal test of my responsibility to a conversation with my doctor. No longer were my non-perfect results treated as a personal failure, and entirely my responsibility. Now the doctor was interested in how I could be helped to understand my results and improve them. The doctor no longer looked down on me as a problem, but instead treated me as part of the solution. This is Shared Decision Making.

Today the right wing organisation, 2020Health have come up with an idea that the rate of tax I pay should depend on my blood sugar.
We propose ‘Payment by Results’, a financial reward for people who become active partners in their health, whereby if you e.g. keep your blood sugar levels down, quit smoking, keep weight off, take on more self-care there will be a tax rebate or an end of year bonus. This could be monitored by the GP, linked to QUOF or facilitated by electronic patient records.
(I have no idea what QUOF is. Are they referring to the Quality and Outcomes Framework that is usually initialised to QOF?)

So now, the very person who I hold in my deepest confidence - my GP - will be determining my tax bill. Does this make sense?

We know that type 2 diabetes is associated with deprivation, National Diabetes Audit 2009-10 says "Type 2 diabetes is strongly associated with age, ethnicity and social deprivation":
The prevalence of Type 2 diabetes rose from 3.18 per cent in the least deprived quintile (Q1) to 4.49 per cent in the most deprived quintile (Q5). Furthermore, the effect of deprivation on the prevalence of Type 2 diabetes is most pronounced in the 16 to 55 years age range (Table 2). In those aged 70 years and over, similar numbers of Q1 (12.1 per cent) and Q5 (14.8 per cent) have Type 2 diabetes, but under the age of 55 Type 2 diabetes is more than twice as common in Q5 (3.0 per cent) as Q1 (1.3 per cent). This may reflect lifestyle differences in exercise, diet and weight.
Because there are more type 2 diabetics in the most deprived areas, this means that the 2020Health's "Payment by Results" will be applied to the poor, who are least able to afford a healthcare plan that has a financial basis, rather than the rich. Further, after the debacle of the care.data programme, where Tim Kelsey will be selling your GP medical records to insurance companies, we now have an equally abhorrent idea that your "electronic patient records" will be made available to HMRC. When will these right wingers realise that our confidential medical records should remain confidential?

Finally, it is worth quoting Dr Phil Hammond's reaction to this report:


Tuesday, 29 April 2014

Real Personalisation Will Never Happen

I really get sick of a small minority of people with vested commercial interests saying that personal healthcare budgets (PHBs) delivers "personalisation". I am sick of it because they don't seem to understand what personalisation is. Such people insist that by turning patients into consumers will personalise their care. It won't, it just turns them into consumers with the responsibilities and worries that come with spending budgets carefully.

Let me give you an example of where we need personalisation, where PHBs will not deliver this personalisation, and a subject which commissioners obsessed with their version of "personalisation" have shown no interest. Prescription medications.

I have three long term conditions and so I take seven different drugs. Since one of those drugs is not available in the dose I take, I take three pills of it. That means I take five pills in the morning, two before I go to bed (the other medication I take is two types of insulin). That is a small number of pills compared to many elderly people. I am middle aged, with relatively good eyesight (OK I have diabetic retinopathy, so that increases my count of long term conditions to four). I have good co-ordination and memory. Yet I still forget to take medication. Sometimes I get to the end of the fortnight and realise that there is one pill left over in the blister pack, so clearly I had missed that pill sometime during the last 14 days, with no idea when.

My pharmacist knows what drugs I take, it's on my prescription script and she attaches a label telling me when to take them. Instead of me having blister packs for seven drugs, why not blister packs for the seven days in the week? Half of the strip for morning, half for evening. It's Tuesday, so I take the strip that is marked (IN BIG BOLD LETTERS) Tuesday. I do not have to go hunting for the right blister pack for the right drug, because that has been done by the pharmacist already.

That strip of pills can only be used by me, because no one else has my combination of long term conditions requiring exactly those doses. This is real personalisation and it will never happen.