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

Thursday, 22 September 2011

Designer Insulin

The BBC report on a BMJ article about analogue insulins, saying:

The NHS could have saved £625m over 10 years if the older types of insulin recommended in guidelines had been prescribed, claim UK researchers.
Apparently, if the NHS had used the current NICE guidelines fewer diabetics would have been prescribed analogue insulin and would be prescribed human insulin instead. Analogue insulin cost three times as much as the equivalent human insulin.

I take the cheaper human insulin. When I was prescribed analogue insulin there was very little consultation, very few checks, the doctor simply said that "it will be better for you". This happened twice (for my basal and short acting insulin). Each time I used it for two years, found that it wasn't "better for me" and went back to the human insulin. At this point there was no attempt from the doctor to find out why I had chosen to reject the analogue insulin, so I assume they really didn't mind one way or the other.

So basically I had had two years taking an insulin that neither I, nor the doctor thought was "better" for me. So basically I agree with the conclusion that it was a waste of money (and the large effort by me trying to get a good blood sugar).

Campaigning and Fixed Term Parliaments

It is now law that UK Parliaments must last exactly 5 years. Get out your diaries for the next 50 years and mark the first Thursday in May in 2015, 2020, 2025... to be the day of the General Election. Since we know when the election will be, MPs will be able to schedule their canvassing. It is likely that those MPs who have a small majority will want to canvas for the optimum amount of time before the election to ensure they get re-elected.

Since voters have a short memory it means that once an MP is elected s/he can safely ignore the electorate for the majority of the term as long as they are seen everywhere for roughly a year before the election (and hence voters will not remember that they've been ignored for four years). MPs are paid a salary of about £64k and they do not have to attend Parliament: they do not have to take part in committees nor debates. The only job performance evaluation is on election day, and since elections are more a case of a popularity contest for the candidate (and/or their party leader) their performance in Parliament is largely irrelevant.

Since an MP is the representative of a constituency s/he is expected to do constituency work, but how do you know whether their presence in the constituency is electioneering, or constituency work? This means that an MP can legitimately spend a year canvassing and will be paid to do it.

Love it or loath it, the old system kept MPs on their toes. They did not know when the election would be. Consequently the electioneering occurred during the few weeks between the Prime Minister calling the election and the election day. That is all the time we have to put up with canvassing politician! Under fixed term Parliaments we will have to put up with canvassing politicians for (most likely) eight months. It works like this. The MP will finish a Parliamentary session in July the year before the election and then have a long holiday until September. At that point the public will see politicians on the TV and hence your local MP will have to be seen. For MPs with small majorities this is the time that the electioneering will start.

Rather than spend their time in London, they will spend it in their constituency canvassing (the public pays for them to have a home there). Since they will only need to return to vote in the cases when the vote is tight, that means they will be able to canvas every day until the following May. This gives them 8 months (with one day a week off, that means 200 days). A constituency will be about 18,000 homes. It is easily possible for an MP to visit 18k/200 or 90 houses a day (more likely they will avoid the areas where they are unlikely to get any votes, or areas where they can rely on the vote, which will cut the canvassing down considerably).

All of this means that the incumbent has a huge advantage. They will be paid to canvas and they will have a constituency base paid for. This means they can make sure that they can target swing voters to ensure their re-election.

Other candidates do not have this advantage. If they do not live in the constituency they will have the cost and disruption of buying or renting a home in the constituency. If the candidates is employed they will have to ensure that they work near the constituency (or change job), and they will then have to do their canvassing after a full day's work. This will mean that a candidate will be restricted in the number of homes they could canvas. The only people able to match the canvassing ability of an incumbent MP is someone with an independent income that they can use to finance their campaign. In other words: wealthy people.

The effect of fixed term parliaments is that it will favour the incumbent, and the only people who could challenge a sitting MP is someone who has a pot of cash that they can afford to spend on their campaign. Consequently, the House of Commons will get less representative as the only people able to campaign are the very rich.

Labour have a huge task to gain a majority at the next election. I estimate that Labour would need something like a 12% swing - compare this with the 8.8% swing that Tony Blair got in 1997.

For Refounding Labour I submitted the following idea. The Labour party should select its candidates early, preferably two years before the election (we know when the election will be!) The candidate will then be paid by the Labour party a living wage. say £18,000. The candidate then has the money to secure (rent) accommodation in the constituency and will be able to work full time canvassing. Since this is a wage, it should ensure that people without an independent income will be attracted to stand as a candidate. This should raise the number of women and BAME candidates and make the use of all women lists unnecessary.

A paid candidate will have two years to be seen as being a community leader, getting involved in local issues and hopefully getting results. This raises the profile of Labour in the area (which will hopefully have an effect on local authority elections) and will actually benefit the area. The ultimate result, of course, is that the area will get a Labour MP. If the candidate is elected, they will be an MP with a salary of £64k. This means (and only if they become an MP) they could pay back the money they were paid (say £12k a year, this means the "loan" will be repaid in three years). But there is an important point: they only pay back this money if they become the MP. If the candidate is not successful, they will not have to pay back the money. Since being a candidate should be treated as being a job (performance managed by the local constituency party who will feedback to the central party) the candidate must work as a full time campaigner. Since the candidate knows that they will be paid for the canvassing (and only repay when they become an MP and are earning 3.5 times more) it will not be seen as being a financial drain to be a candidate. The result is that it is more likely that there will be candidates from all walks of life, not just those who have an independent income.

The big issue is if a candidate fails to be elected. I suggest that existing Labour MPs pay for those paid candidates who are not successful. The 240 or so current Labour MPs standing for re-election at the 2015 election will have the advantage of being the incumbent, and so will be a paid canvasser as explained above. This means that there is no need to pay them a candidate's wage. To get a majority of 300 at the next election Labour would need approximately 60 more seats, so it makes sense to target the 100-most marginal constituencies. The money for these 100 candidates would amount to £3.6m and this could be raised by a 7% levy on all the Labour MPs from this point until the 2015 election (assuming MP salary of £64k, 3.5 years to the election). After the next election all MPs could then pay a levy of 4.3% every year (the 60 new MPs would pay this for this after paying off their candidate wage) which would fund 100 waged campaigners for the last two years of the parliament and this could be split between campaigners supporting the 50 Labour MPs with the smallest majority and the 50 target marginal seats.

Monday, 19 September 2011

Private Patient Income Cap

NHS hospitals treat private patients. When Parliament were discussing the bill to create Foundation Trusts there was a rebellion from Labour MPs and so the Labour government agreed to place a cap on how much private income an NHS acute hospital can receive from private income (Private Patient Income or PPI). This cap was arbitrary: FTs were limited to the percentage of their income that came from private work in 2003.

When a trust is authorised as an FT it must agree not to exceed this cap. If it does, then the FT is in breach of its authorisation and can be de-authorised and return to being an NHS Trust. Mental health FTs are covered by different rules: the Health Act 2009 says that the proportion of income derived from private patients is capped to the greater of either the private income in 2003, or 1.5%. For example, in 2010/11 two FTs were in breach of their PPI cap: Basildon and Thurrock University Hospitals NHS Foundation Trust and Liverpool Women's NHS Foundation Trust. Monitor has agreed an action plan with these trusts.

So what is "private patient income"? This does not necessarily mean private patients because it includes services. So if an FT provides some pathology services to a private hospital that income counts as part of the PPI. In addition, according to Monitor's compliance rules, FTs can form partnerships with the private sector companies, and this has resulted in several FTs creating Private Patient Units (PPUs). An example of this is The Christie in Manchester which provides The Christie Clinic in partnership with HCA International. HCA (the parent company) is the largest for-profit healthcare company in the US. It also has the dubious distinction of paying the largest fraud settlement in US history when, in 2002, it paid more than $2 billion in civil law suits.

In 2010/11 FTs generated £252m income from private patients, from a total income of £26,867m (ie 1.1% up from 1.0% in 2009/10; figures from Monitor). This implies that FTs generate very little from private patients. However, there are some anomalies that bump up the PPI from FTs:

The Royal Marsden 30.7%
Royal Brompton and Harefield 14.4%
Moorfields Eye Hospital 13.7%
University College London Hospitals   6.6%
Papworth Hospital  6.1%
Guy's & St Thomas'  3.0%

The Health Bill that is just about to go to the House of Lords abolishes NHS Trusts, so the threat of d-authorisation will be pointless: all NHS Trusts will have to become FTs. The Bill also revokes the PPI cap. This means that Foundation Trusts will be no limit to how much income the trust will be able to generate from private patients.

So who are the private patients? Some patients will be foreigners travelling to the UK although as I have pointed out before, Deloitte does not mention the UK as a destination for US healthcare tourism. Moorfields Eye Hospital even has a hospital in Dubai. Approximately 20% of all healthcare spend in the UK is on private treatments so clearly there are people who prefer to pay for treatment that they could get on the NHS.

The supporters of the Bill say that private patients will bring in more money into FTs and this will provide a subsidy to NHS patients. However, PPI is unlikely to make a difference in most trusts because the income will be low. the downside of private patients is that it reinforces a two-tier NHS. A private patient will not want to be on an NHS waiting list, nor wait in a queue in a waiting room, nor have the same accommodation as an NHS patient. If they had money to give away and still wanted to be treated the same as an NHS patient, they would simply make a charity donation to the hospital. No, private patients want to get something for their money and that something is to jump queues and get better accommodation.

The following is a tweet from Dave West from HSJ, reporting from the Lib Dem conference.

What this says is that Shirley Williams is suggesting that the PPI cap should not be removed, instead it should be altered. She is suggesting that the arbitrary cap set at the level of PPI a trust generated in 2003 should be changed so that a trust cannot generate more than 50% of its income from PPI.

This is a typical pointless Lib Dem fudge. This PPI cap will have no effect on the majority of FTs. In 2010/11 FTs income was £27bn it is extremely unlikely that there is £13bn cash sloshing around in patients' pockets to pay for private treatment in NHS hospitals, so the 50% cap will only affect a few hospitals, and most likely the six listed above. Is it likely that The Royal Marsden will increase its PPI from 30.6% to 49.9%? There's very little chance of that. So the proposed amendment will have little effect at all.

I have never rated Baroness Williams as being capable of making the Health Bill better, and this suggestion reinforces my opinion. The Baroness could suggest an arbitrary cap of, for example, 30% (or maybe even lower, say 10%). This would give a clear indication that NHS Foundation Trusts should concentrate on NHS work. A lower cap, forcing the few outliers to divest themselves of some of their private patients, will give a clear signal. Setting the PPI cap at 50% basically says that the Baroness likes the idea of a two tier system where the same hospital treats patients differently depending on whether they are able to pay.

The Baroness could even suggest something cleverer and still stick to Lib Dem principles of equity. For example, the PPI cap could be in two parts: treating patients and providing services (for example pathology). The PPI on patient income could be set low (say 5% or 10%) to give a clear message that the NHS is about equity, and restrict the formation of a two-tier system; but the services PPI could be set high to encourage FTs to generate income from private hospitals other than from patients. The rules will have to be strict that services for NHS patients take precedence. If the intention is for NHS hospitals to be innovative, then they should use patent laws and licence private hospitals (but not NHS hospitals, there should be some benefits to be "in the NHS family") to use the techniques they developed and this income could come under the "services PPI".

Andy Cowper at Health Policy Insight reports Simon Hughes interviewed by Andrew Neil on BBC2's Daily Politics saying that 
"there's a lot of work still to do on the Bill ... it's by no means over ... there are three of four significant things still to be done ... we need to absolutely tie down that private work in any NHS hospital cannot become the dominant activity or the driver"
(my emphasis). This is the 50% PPI cap being trailed. If a hospital does less private work than 50% of its income, then it cannot be "dominant", right?

Friday, 16 September 2011

Corrigan's dumbing down of patients to close hospitals

Paul Corrigan writes today in a pamphlet for the right wing think tank Reform that the hospital is dead. Corrigan is one of the architects of the Blairite NHS Planwith the underlying aim to privatise the NHS and so it is fitting that his pamphlet is published by the pro-market think tank Reform.

Corrigan's thesis is that about 70% of NHS funds are spent on patients with long term conditions and that hospitals are not designed to deal with those conditions. Hospitals fix illnesses and do not manage long term conditions. Or so he thinks. He then gives some free market mumbo jumbo to say that primary care is not good at long term conditions either:
The funding structure of the NHS has been constructed so that the GP practices do not get rewarded for providing efficient, preventative services to the patients. Rather, the payments are received by the hospitals as the patients become sicker. Consequently, in this type of healthcare system, there is a larger incentive to admit patients rather than to avoid admissions.
Corrigan clearly thinks the entire NHS top-to-bottom is not fit for purpose.

If a GP needs to have a financial incentive to treat his/her patients properly then s/he is a poor GP and should not be in the job. The incentive for the GP is to achieve a patient who can manage their condition effectively; just that. The same could be said of hospitals, but remember, the payment by results system that Corrigan criticises was introduced by the team he was a part of. Is he saying that he was wrong? I do not see a mea culpa in the pamphlet.

Corrigan argues that up to 40 hospitals will have to close in the next few years because he says that the care of long term conditions should be moved to "the community". This is the buzzword at the moment, yet no one seems able to say where this "community" is nor where the funding comes from to make the move. While there may be savings in moving care to "the community" (I do not know if this is the case) it certainly involves investment to make the move.

For example, a GP doctorpreneur in my area has decided that his new company is "the community" where treatment must be moved to, and he has decided to set up a primary care clinic. The clinic will replace his own GP clinic (so far, so good) and a community hospital which is run by the local hospital and is out of his control (so is unlikely to close). The new clinic will cost £10m with neither the doctorpreneur nor the local PCT (nor, indeed, anyone else) with any clue where the money will come from. The local hospital has an annual budget of £170m (which includes community health services) with an annual capital budget far smaller than £10m, and a long list of more important things to spend the money on. I will leave it up to the reader to think where the funding will come from and who, in the future, will control healthcare in that community in the future. (Hint: it will not be the NHS, nor anything the community controls.)

Corrigan also puts a lot of confidence in telehealth.

Telehealth ensures remotes delivery of care to patients, usually with long term conditions, in their own homes. The use of telecommunications and other computer-based systems make remote medical care possible. ... Telehealth is primarily used for diagnosis but has also been regularly used in monitoring various conditions related to the conditions of the patients. Recorded data or real-time images are used for clinical inspection which may be required for prevention, diagnosis, or treatment of a disease.
This is all very good as long as the the telehealth makes a difference. I am not sure it will. The problem is that it involves putting expensive kit in people's home, or more likely, expecting them to pay for it. Is this a good use of resources? Will it give better care to the more affluent and better educated and put the less well off and less well educated at a disadvantage and increase health inequalities?

Corrigan uses the example of one long term condition - diabetes - to support his thesis. I have some knowledge in the area since I have had type 1 diabetes for 35 years. Diabetics use blood glucose meters (Corrigan calls them glucometers) that cost about £25 and use test strips that cost about 50p each. The strips are available on prescription but the patient usually buys the meter, or more often, gets the meter free from the manufacturer on the Gillette razor blade theory (they give away the handles because they make a big profit on the blades, you just have to make the customer choose to use the blades). Currently diabetics use the most complex computer in the world to interpret the results from the glucose meter: their own brain. They record these results and then periodically use an equally complex, but slightly more expensive computer: their clinician's (GP or diabetologist) brain. The second computer is actually used for reassurance, and to make periodic changes, there is no need for the clinician to be consulted more often than three or four times a year (if that often) since it is the first computer (them!) that does most of the work.

Both of these computers (the patient and the clinician) needs to be trained and occasionally re-trained. But once a patient understands how to treat their condition, they can - and should - be allowed to manage it themselves. The patient is far better to be able to manage their care, for the simple reason that the patient has all the data at the exact time the blood glucose test is made, and the clinician doesn't. Diabetes is a balance between insulin injections (and or other drugs), carbohydrate and exercise. There are other factors too, like general wellbeing (a cold will raise blood sugar) and other factors which I know affects my blood sugar that no one can explain (the change from spring to summer lowers my blood sugar, and the change from summer to autumn raises it, yet I do not eat differently nor take different amounts of exercise; when my father died, for six months afterwards I needed 25% less insulin, yet I ate and exercised the same).

A patient with a long term condition has expert knowledge, the clinician reinforces, but must not replace this knowledge. Corrigan disagrees:

However, many hospitals and clinicians recognise this and have started to consider care beyond the hospital walls through the effective use of telehealth. At the Ulster Hospital in Dundonald, diabetes management was tackled by Dr Roy Harper in 2009. The aim was to empower patients to become better self-managers of their diabetes through education and self-management and to efficiently titrate patients just starting on insulin to achieve optimal blood sugar control. Patients were trained to use the monitors including their glucometer and all readings are transmitted. Nurses carry out a triaging process and escalate patients according to protocols designed with the specialist nursing team. Virtual clinics are held to review patients who require extra support or a change in medication. The team is able to review real time data without the need for a hospital visit by the patient or a home visit by a community nurse.
What Corrigan is suggesting is dis-empowering patients. Rather than the patient manageing their own condition by using their expert knowledge of how much they have eaten, how much exercise they have taken and how well they feel to interpret their glucose reading and to determine their insulin dose, he is suggesting that the responsibility should go to a remote nurse who only has a fraction of the information: the blood sugar readings. This is day-to-day monitoring that dumbs-down the most important part: the patient.

Corrigan touches on the actual solution to managing long term conditions: "education and self-management".  This is the vital part: diabetics need to have periodic intensive education under clinical supervision so that they can experience getting their management wrong as well as how to get it right. This is something that should be done in a clinical setting - in a hospital - and not at home. Once educated the patient then needs minimal monitoring by a doctor. However, long term checks - like HbA1c, retina monitoring, and checks on the feet - are things that must be carried out and interpreted by a clinician and cannot be done by the patient. I would also say that periodically - perhaps every ten years - a diabetic's computer need a reboot. They should go through the whole process of re-training all over again as if they were newly diagnosed. This is not just to teach them to manage their condition according to the more up to date methods (and get them out of bad habits) but also to ensure that the newer drugs they are using are used effectively and not merely as a replacement for the older drugs they were used to. Again, this has to be done under clinical supervision in a hospital.

Corrigan is not advocating this type of care - a form of co-production with their care team - instead he is advocating that the patient becomes completely subservient and dis-empowered and that the doctorpreneur "in the community" has the control.

Nope, sorry, I do not agree. I far more prefer to see a diabetic consultant to ensure that my computer - my brain -is up to date, and monitoring that I am unable to do, by my GP.

Wednesday, 14 September 2011


Here's some figures, it's fun to compare and to try to interpret them.

First up, the British Attitudes Survey. Every year they publish results of a survey question asking what party the respondent most identifies with. Here are the results from the 2010 survey showing how the value has changed over the last 25 years:

For the last date (2008) the results are:

Cons 32%
Lab 26%
LD 9%
Other 6%
None 25%

These suggest that the country is quite Conservative, about a third of people "identify with" the Tories. The interesting figure is "None", that is, the people who do not want to vote and are not interested. Look at how this figure has grown since about 1994: over the last two decades people have got more turned off from politics. If I was running a political party it would be these people I would target.

Now have a look at the results from the 2010 General Election:

% MPs% Vote
Cons 47%32%
Lab 40%35%
LD 9%22%
Other 5%10%

In terms of the number of MPs, Other and Liberal Democrats are similar to the BAS scores, but look at the value for the Tories and Labour. Since we do not have a "none-of-the-above" option on ballot papers it looks like the people who have no affiliation have given equal weights to Tories and Labour (bumping the Tory 32% "identity" to a value of 47% of MPs). Of course, individuals vote rather than select MPs, and the share of the vote shows the Tories at the BAS level and Labour, and in particular, Lib Dems, getting a boost from the lack of a "none-of-the-above" option.

I know that the number of MPs reflects the oddities of the first-past-the-post voting system, but even so-called "proportional" systems produce odd results. The election before the 2010 General Election was the 2009 Euro-elections. The results were:

% MEPs% Vote
Cons 37%28%
Lab 19%16%
LD 16%14%
Other 28%42%

The Euro-elections are based on the d'Hondt party list system where there are 11 regions (plus Northern Ireland) and each region returns between 4 and 10 MEPs with each party getting a proportion of MEPs according to the proportion of the popular vote the party gets in the region (Northern Ireland is an exception because it uses STV). The results above are for mainland UK (excluding NI). The Tory percentage of MEPs is 5% more than the BAS value and the Labour number of MEPs is 7% less than BAS. The LD number of MEPs is 7% more than BAS.

The large "Other" value is due to UKIP and BNP votes which are significant in Euro-elections, but not in other elections.

Now look at the political affiliations in the House of Lords, here compared with the BAS score:

% LordsBAS
Cons 28%32%
Lab 31%26%
LD 12%9%
Other 4%6%
None 23%25%

The House of Lords is unusual in that it has a "none-of-the-above" component that call themselves crossbenchers (I have listed these in the None row). It is interesting that within a few %age points the three main parties have Lords equivalent to their BAS score. But significantly, the Other and None figures are similar to the BAS scores.

Does this mean that the House of Lords is more representative of the population than elected bodies?

Sunday, 11 September 2011

Simon Jenkins is wrong about everything

There is a general aphorism that "Simon Jenkins is wrong about everything". On Friday he was a guest on BBC Radio 4 Any Questions. When the inevitable NHS reforms question came up he gave a characteristically ill informed answer (43m 45s). He said:

The NHS has been re-organised countless times in the last 20 years and every time  it has proved unsatisfactory. ... the reason is that when it has been re-organised it has been re-centralised.
Well, yes, there have been countless re-organisations, but he has not been paying attention if he thinks each organisation has been centralising. The creation of SHAs and PCTs localised decision making. The original twenty SHAs were devolved responsibilities from the Department of Health and similarly the 300 original PCTs received some responsibilities that had been central. The new Bill does the opposite, it takes the work of the current ten SHAs and centralises it into the four regional arms of the National Commissioning Board and these regional arms will take a quarter of the commissioning that is currently done by PCTs. The current Bill is a centralising bill.

Jenkins continues:

the health systems that appear to work are where the government pays but does not organise, ... for instance Denmark. There the counties run the hospitals ... in effect the counties run the health service.
He is five years out of date and even five years ago he was wrong. Denmark used to have 14 counties and with a population of 5.5m that means an average of 400k per county. The median size of PCTs in the UK is 290K, so our system is more localised than the Danish county system. However, in 2007 the system was re-organised replacing the 14 counties with five regions and so each region covers about a million people. Compare that with the 290k that our PCTs, before the reforms, cover. I suspect that Jenkins was getting confused between Danish counties and English counties, so to give the comparison: our PCTs are more or less a third the size of an English county (there are 150 PCTs and 50 counties or metropolitan areas). Under Lansley's plans public health (vaccination, action against smoking, obesity, teen pregnancy etc, will be carried out by English counties, this is yet another centralisation).

As a consequence of Lansley's disastrous mishandling of the system, the PCTs are coalescing into "clusters" each of which is roughly the size of the Danish regions (about a million people). So for a brief time we will look something like the Danish system, that is until the 300 or so Clinical Commissioning Groups take over. International studies show that smaller commissioning groups are financially unsustainable and are unable to commission effectively. Civitas, for example, present evidence that commissioning groups should cover populations no less than 300k (close to the size of PCTs); the BMA give a higher figure of 500k for the smallest size of an effective commissioning group.

However, it is interesting to compare the Danish system with the NHS. There is a fabulous facility called the European Health Observatory provided by WHO and the following uses facts from their health system profile of the Danish system.

Denmark is much smaller than England at 5.5m (about the population of Scotland which would have been a better comparison for Jenkins to make). OECD says that the Danes pay about a third more than us for their healthcare (UK: 9.8% GDP, $3287; Denmark: 11.5% GDP, $4348). EHO say that most of this money is "earmarked proportional taxation" at the national level which is then redistributed to the five regions via block grants based on social and demographic indicators. This is very similar to England where parliament (the Chancellor) determines how much the NHS will get and the money is then distributed to PCTs using block grants based on population size, demographics and deprivation levels (the contribution for deprivation levels is being cut by the current government).

In 2007 there was a reform that changed control from the 14 counties to five regions. So that means the control of local healthcare is for a body that covers about 1 million people.
Median population covered by a PCT is 164K, so about half a Danish county or one eighth a Danish region. Hence PCTs provide a more localised service. Would it make any difference if local healthcare in England was coordinated through county bodies rather than PCTs? 

In Denmark, GPs are private practice (not employed by the state) paid by capitation (a fixed amount per registered patient) and fee-for-service (for example, paid a fee per vaccination) - much like UK. Regions control the number and location of GPs. In England this work - the commissioning of GPs - is carried out by PCTs, but under Lansley's reform it will be centralised and carried out by the new quango the National Commissioning Board through its "regional arms" (four of them, covering between 10m and 15m people). In Denmark, GP's fees and working conditions are negotiated centrally - just like us. Access to primary care is free-at-the-point-of-use, just like the NHS. There is an option (about 2% of patients) to use any private GPs for an extra payment and such patients do not need to get a GP referral to see a specialist (much like private healthcare in the UK). Private healthcare in Denmark is not regulated.

Danish hospitals are owned and run by the regions, in England we moved to a system where the government owned NHS hospitals became NHS trusts, and in the late 90s NHS trusts became accountable to the local Strategic Health Authority. There were twenty SHAs, each covering about 2.5m people (compare this to Denmark where each region covers about 1.4m). SHAs were re-organised in 2006, so there are now ten (covering about 5m each). However, about half of hospitals are Foundation Trusts which means that they are autonomous and are not accountable to the SHA: the SHA does not "run" them. So compare the Danish centralised system where a central organisation (region) runs the hospitals to Foundation Trusts where they run themselves. (Again, Jenkins is wrong.)

There was a reform in Denmark 1993 to allow patients to be treated anywhere in the country (5-10% of patients take this option). The NHS had a similar reform in 2006, initially to cover specific private facilities (Independent Sector Treatment Centres) but tightened when Andy Burnham became the Secretary of State (to make the NHS the "preferred provider"). In Denmark private hospitals are less than 1% of provision. The Danes have co-payments for dentistry, physiotherapy, spectacles and pharmaceuticals. In the UK we call these "NHS charges", so in other words, the Danish system is very similar to the NHS.

One of the most significant thing about the Danish system is that there was very little change until 1970 when there were reforms to create the current system. There were some changes in 1993 to give patient choice (not significant, and largely used by the affluent and better educated, ie not equitable) and then again in 2007 when the system was re-organised from county based (14) to region based (5).

Frankly Simon Jenkins did not know what he was talking about. The Danish system has more similarities to the system we had in the 1980s before the Internal Market was introduced than to what the current government is proposing. The aphorism "Simon Jenkins is wrong about everything" is yet again upheld.

Saturday, 10 September 2011

The nonsense that is "cutting admin"

Are there too many managers in the NHS? I don't know, and I have never seen one iota of evidence to suggest that there are too many. The reason why the Conservatives went into the 2010 election saying that they would "cut administration by a third" is simply a gut feeling from Lansley. A political gut feeling. Lansley sensed that the Daily Mail brigade had decided that there was too much administration and as an election ploy he made his pledge to them.

The problem is that the majority of the "administration" that the these armchair auditors were complaining about was in hospitals, and Lansley cannot do a thing about administration in Foundation Trust hospitals because FTs are autonomous and are not run by the Department of Health. The only part of the health service that Lansley could change was Strategic Health Authorities and Primary Care Trusts, and so to meet his gut feeling, one third cut he had no option other than to sack the lot of them by abolishing the organisations. That is a big upheaval based on no evidence at all. (PCTs could well be over-managed, but we have no evidence of this, and no evidence if it is as high, or as low as one third too many. It could even be that PCTs are under-managed.)

All of that is politics and should have been pointed out at the election or afterwards, but it wasn't.

So now the civil servants in the Department of Health are implementing the policy. Government departments have to provide an Impact Assessment document indicating the effects of the policy. The government have just produced an IA for the Health and Social Care (Recommitted) Bill and over the next few days I'll post (or tweet) some items from it. My initial reading is that it is not a dispassionate, neutral civil servant document, instead it is a political document and could easily have come straight out of Conservative HQ. It justifies the policy rather than assessing the impact of the policy. (However, I have yet to read it in detail.)

Let's start with the original IA that was produced when the Bill was first published in January. Here is one example (and there are plenty more in that document) that indicates that this document is largely useless and highly political. The following figures have been updated in the more recent IA but I am giving them to illustrate another point (so if you want the more recent figures - I hesitate to use the term "more accurate" - then you should read the more recent version).

To be able to "cut administration by a third" the civil servants first have to determine how much administration there is. Table A1 says that PCT commissioning costs are £3.59bn (the document also notes that SHAs do very little commissioning so the majority of costs come from PCTs).

The following is Table A2 from the IA document that lists the "savings" that will be made (click on it to see it full size). You can see the £3.59bn in the top left hand corner, and below that the £353m commissioning costs from SHAs. These are "real terms figures" but the table assumes that the same amount of commissioning will be needed over the next ten years (bizarre, because as everyone keeps telling us, there are increasing demands due to the ageing population and new treatments, so it is not a good assumption to make that the amount of commissioning will remain the same for ten years).

The "Real commissioning budget" line takes the idea that administration must be cut by one third by 2014/15, so the figure of £2.63bn in the 2014/15 column is two thirds £3.59bn. The years between ramp down to this level.

What I expected from an IA document was the proof that "administration" could be cut by one third. I expected to see international comparisons, comparisons with the NHS in the past, comparisons with other services that commission services (like, for example, social care). I wanted some figures that said "if we run NHS commissioning like these other guys do, we will save this amount of money". There was no such statement. Instead, we get a table that says "if we cut administration funding by one third the costs of administration will fall to two thirds". Pathetic.

The huge damage that is being wrought on the NHS at the moment is being justified with pathetic documents like this. In the future people will ask "how did you allow this to happen to the NHS?" They will also ask "and on such flimsy proof?".

Thursday, 8 September 2011


Read this:
  1. the removal of all references to promoting competition whether directly or indirectly. 
  2. any duty to promote choice being made subsidiary to duties to promote fair access, equality of outcomes, and integrated services. 
  3. the removal of the facility for transferring NHS assets, including land, to third party providers. 
  4. retaining the cap on Private Patient Income by NHS Foundation trusts. 
  5. the restoration of the duty of the Secretary of State to provide or secure the provision of, healthcare services, and the reinstatement of the power of the Secretary of State to delegate his functions to NHS commissioners and to direct them as necessary. 
  6. the retention of the ability of the local authority overview and scrutiny function to refer significant services changes to the Secretary of State for adjudication. 
  7. providing that Health and Well-being Boards (HWBs) have a majority of elected members and are able refer unresolved disputes with local commissioners to the Secretary of State rather than to a national qango. 
  8. the explicit prohibition of the wholesale outsourcing of commissioning work to private companies. 
  9. guaranteeing that commissioning groups are fully co-terminous with social services local authorities, except where HWBs and local authorities agree otherwise, and are funded solely on the basis of the health needs of the population. 
  10. the removal of the power to pay financial incentives to practitioners as a means of influencing their referral behaviour. 
  11. rejection of any personal health budget scheme which allow users to spend NHS funds on private health insurance or as a top up towards private health care or to buy services or treatments judged too ineffective or inefficient for the NHS to buy. 
  12. the inclusion of a duty on all NHS bodies, when arranging with non-NHS bodies to provide services, to avoid any risk of essential NHS services (including teaching and research) being destabilised in an unplanned way through loss of income or case-load 
  13. ensuring Directors of Public Health remain independent sources of expert advice.
Is this Labour's key objections to the Health and Social Care Bill? No. This is the objection from the Social Liberal Democrats Forum (Dr Evan Harris' group).

I tried to find a succinct list from Labour giving their opposition to the Bill, but I couldn't find one.
Labour could be re-elected at the next election on a huge majority if it exposed Lansley's Bill and then campaigned against it. We hear so little from Labour that we do not know if they want the Bill or not. We do not know if Labour wants to be re-elected.

All the talk at the moment is what this Lib Dem peer, or that Lib Dem peer will attempt to amend when the Bill reaches the Lords. Why aren't we hearing the same thing about Labour peers? Is it because the labour working peers are all Blair's chums who couldn't care less?

Labour is the party of the NHS. But if Labour does not raise its game on opposing the Health and Social Care Bill it will lose this title; or worse, it may get the name of the party who failed to raise a finger to protect the NHS.

Meanwhile, if you are a Lib Dem go to the conference and vote for Dr Charles West's motion. If you are Labour then campaign that these 13 points form Labour's objection to the Bill. If you are Conservative then you should be ashamed of your party.

(Updated to get the name of SLF right.)

Wednesday, 7 September 2011

Over to the Lords

So now the Lib Dems have voted. Four brave souls - who clearly value the NHS more than their chance to become a minister - voted against the Bill: Andrew George, Julian Huppert, Greg Mulholland and Adrian Sanders. Ten others could not get off their arses to oppose the bill and took the typical Lib Dem sitting-on-the-fence position of abstaining.

The strategy, so I am informed by Dr Evan Harris, is for the Lords to make the Bill better.

I have a lot of respect for the Lords. My brother is an academic and is an advisor to a Lords Select Committee and as part of this he regularly gives well attended lectures in Westminster. He tells me that the Lords show more enthusiasm for the subject than his soon-to-be-£9k-fee-paying-thanks-to-LibDems students do! I have written that I think this aspect of the Lords - mostly non-political experts - is unique and important and should be preserved. I have suggested that there are ways to remove political patronage that will make it more democratic and keep the experts in the Chamber.

However, the Lib Dem manifesto from last year says:

Liberal Democrats will: Replace the House of Lords with a fully-elected second chamber with considerably fewer members than the current House.
So, they want to create a clone of the House of Commons where all but 14 Lib Dems chose to sign the end of the NHS as we know it. Remember that there is only one scientist in the House of Commons, and that is Dr Julian Huppert, the Lib Dem rebel. There is a smattering of doctors, including Sarah Wollaston who told us there were serious accountability issues in the Bill, yet she still voted for it! The bullying by the political parties (which Wollaston has also written about) clearly keeps the MPs in check.

The chamber that Dr Harris wants to be the saviour of the NHS will be savaged by his party leader's plan to "reform" the Lords. Clegg's bill will reduce the membership of the upper house from 789 to 300, 80% of which would be elected by STV. This will mean that there would be space only for 60.5 experts [300 is about half of 650, so at the current rate of one scientist per 650 elected MPs, that would suggest about half an elected "lord" in the new chamber], a number that would be easily outvoted by the whipped politicians.

Harris puts a lot of confidence in Shirley Williams. I am not sure why. Yes, once she belatedly realised that there was an issue she has opposed the Health Bill, but I have never read anything from her that illustrates that she really understands the dangers. I agree with Roy Lilley, Lord Owen will make the most significant changes and he is likely to destroy any government argument. Harris, showing his political colours, prefers Williams to Owen because, well, Owen is now a crossbencher (not a member of a political party) and is exactly the sort of expert that Clegg wants removed from the House.

Friday, 2 September 2011

Personal Healthcare Budgets

One of the best features of the NHS is that you know that whatever unforeseen healthcare issue you have, you will always get treatment according to clinical need. Anyone who waters down this basic principle of the NHS does not deserve to hold public office.

Enter the concept of personal budgets for healthcare. I will write more about this subject but here are some initial thoughts. The first point to make is that all the major political parties are in favour of personal budgets. This would imply that the majority of people are in favour of them, and that there is a universal demand for them. But stop anyone in the street and ask them about NHS personal budget and you'll find that they either have not heard about them, or they are against them. If you get a positive response for personal budget, it will be usually followed up with the hope that it will result in more money spent on them. The sad truth is that there is no more money, and that in the future the money spent on healthcare will decrease, not increase.

What are personal budgets? The idea is that through a personal budget patients will be offered more choice and control over their care. However, at the moment the policy makers are very careful to say that they will be offered only be patients with long term conditions. Policy makers are also careful to say that they will be only offered to patients with "stable and predictable conditions". The combination of these two restrict their application to a limited number of perfect patients. Finally, policy makers are extremely careful to say that no one will ever be denied treatment as a result of having a personal budget. Life is never perfect, but let us assume the best case for patients.

If no one will be denied care, this implies that the situation we have at the moment - where care is according to need - will be the baseline, that is, the minimum spend. Politicians are acutely aware that they must not be seen to be introducing rationing. It would be political suicide for a politician to be seen to be introducing any policy that require patients to pay for top-up for NHS care. This means that when personal budgets are introduced they must be more than what the patient would otherwise receive through their existing NHS care.

Patients will not be simply handed a pot of cash to spend however they like. Instead, they will be handed a limited list of approved treatments (or providers) or patients will be asked to have a treatment or provider approved before they will be able to spend the money from their budget. This requires the work of an administrator, advisor or advocate and it will be in addition to anny administrators currently used. Further, since this will be devolved down to the patient level, rather than across a large number of patients, it will not benefit from economies of scale. The administrative costs of personal budgets will be more than not having personal budgets.

To make the budget more personal, a patient must be given access to the budget. Whatever access the patient is given, it is unlikely to be actual cash, otherwise the patient would be able to spend the budget on something other than healthcare (for example, heating bills). Instead, the personal budget is likely to be in some other form of currency: for example vouchers. The conversion of these other currencies will have a cost.

When you add all of this together, personal budgets will cost more for the same treatment than not having personal budgets. The only way that personal budgets can be made popular for those that will receive them, is if they will result in more spent on those patients. However, there is a fixed overall healthcare budget so if more money is spent on patients with personal healthcare budgets, this means spending less on those without them. I object to any policy that results in taking money from one patient to give to another if there is no clinical benefit for both patients.

Further, I dislike quoting Liam Bryne but "I'm afraid to tell you there's no money left" is apposite. Any policy, in the foreseeable future, that involves spending more will be rejected by the Treasury, so therefore every government policy must result in spending less. Since personal budgets involve spending more on administration, they mean spending less on healthcare, and any temporary rise in spending on healthcare designed to make personal budgets popular will ultimately result in bigger cuts in the future.

I can never support personal budgets.

Thursday, 1 September 2011


I was first diagnosed with diabetes in 1976, in those days it was called juvenile diabetes or sometimes insulin-dependent diabetes, now it is called type 1 diabetes (because these days type 2 can occur in children, and insulin is sometimes used to treat type 2 diabetes). My diabetes was monitored by a six monthly appointment with a consultant paediatrician at the local hospital. My memories are of gleaming polished floors and patrician (and all male) consultants. The hospital was build before WWII with 70's extensions, and the paediatrics department was in the old part. Perhaps it was my age, but the enduring impression is of doctors whose opinions you could not question, not quite the consultant barking orders at you (like Sir Lancelot Spratt) but certainly everything he said was followed to the letter.

Appointments took a couple of hours because other than the consultation with the paediatrician there was also a trip to the pathology department to have several tubes of blood taken which were then tested for the following appointment (later on, finger prick tests - or more accurately finger jabs because they cut a wide hole in my finger - were introduced so I would have one of those as well as having blood removed from my arm). After leaving the hospital there was always a trip to the cake shop to make up for the blood tests (remember, this was the 70s). Although I do remember it taking time to go between various appointments in the hospital (as well as the blood tests) I do not remember waiting long to be seen.

When I reached 16, I was moved to the adult diabetic clinic in the same hospital where I was seen by a diabetes consultant. The adult clinic that was held in outpatients which was in one of the 70s buildings. To a 16 year old the adult diabetes clinic was a shock. My impression was that diabetes was a condition of the elderly and I was somewhat weird that I had an old people's disease. There must have been teenagers (or even middle aged people) who attended that clinic, but I never saw them, it was the old people I saw.

One distinct memory is queuing up for disposable needles at the hospital pharmacy. I had a glass syringe and so-called reusable needles. However, these blunted quickly which caused scaring and fat to disappear from my injection sites (30 years on, I still have lumps in my thighs from using reusable needles). Part of the problem was the impure insulin. When I was first diagnosed I took bovine insulin and after a few years I moved to porcine insulin; the hospital also started prescribing disposable needles. My control was much better on the porcine insulin, but since this was around the time I started using disposable needles I don't know if the improvement was due to the needles or the insulin. However, one thing is for sure, disposable needles made injecting quite a lot less unpleasant. I could not get disposable needles from my community pharmacy because GPs were not allowed to prescribe them (I was told: because of the cost), so I had to wait for a hospital appointment to get them.

My memories of the hospital adult clinic was not of gleaming floors, instead it was of long waits in waiting rooms full of old, ill people. I distinctly remember peeling paint everywhere.

During this time I had the same GP. She had a very much "hands off" attitude and since (other than the diabetes) I was healthy I never saw her. She did, however, make one of the best recommendations I received soon after I was diagnosed: she gave my mother the address of another family with a child my age who had diabetes. We learned a lot more about living with diabetes from that family than we did from any of the clinicians we talked to. Since diabetes is 24x7 and you can never "cure" it, learning to live with the condition is vital.

When I went to university (and later, when I got a job in the city where I had studied), I went to the hospital diabetic clinic (conveniently at the university hospital). The clinic was only for people of my age: young adults, and discovered that I was not the only young person with the condition. The university hospital was newly built and modern. There was none of that light blue paint that seemed to be used everywhere in the hospital I attended when younger. Instead, there was light wood everywhere and they even had carpeted floors in the clinic. My appointments were always on time, this (and the location - I could get to the diabetic clinic from the university department where I studied via a short cut through the medical school) meant that I could attend the clinic without missing much lecture time. I do remember being seen more often than not by registrars - perhaps an attribute of a teaching hospital - who were mostly female and not much older than me. (Yes, I was a young man, I paid close attention to such things.) After graduating I got a job at the university, so again, it was convenient to take little more than an hour off to attend a clinic.

My treatment changed over this period. When I started at university I used disposable syringes (the needles were attached) and porcine insulin. After a couple of years I moved to human insulin and then after I graduated I changed to using a pen. The first insulin pens would deliver two units of insulin per click, since I had a big dose (around 20) it would mean clicking the pen multiple times making sure I remembered how many. On one occasion I went out to dinner with some work friends and just before the food appeared I went into the toilets to inject. I remember hearing the characteristic click-click-click of an insulin pen from the stall next door and was surprised to discover that it was the technician who worked for me in my lab. I had known him for two years and I didn't know he was diabetic, nor he know that I was.

Again, my GP had a "hands off" approach: the treatment of diabetes was the consultant's responsibility, although I did find that when I occasionally went to my GP he would point out that there was a connection between the condition I presented and my diabetes (usually the fact that my blood sugar was too high). My only contact was the regular request for prescriptions.

A decade later, married with a child, I moved house to follow my job. I registered with the local GP and at my first appointment I asked to be referred to the local hospital. "We don't refer patients to the hospital clinic: we have our own diabetic clinic". I had registered at a fundholding practice although I did not know what this meant. At the first diabetic clinic the doctor told me that he had just been on a course about diabetes. Was this supposed to reassure me by telling me how up-to-date his knowledge was? I don't know, but his next statement dismissed that reassurance: "... but since you've had diabetes for 17 years I think you know more about diabetes than me!" Oh dear.

The practice was a new build and close to my home. However, I worked half an hour's drive away (coincidentally, where I worked was a ten minute walk to the local hospital). Since diabetic clinics were during my working hours it meant that if I had a diabetic clinic I would have to take the morning off work. From memory, appointments were prompt, possibly because it was a new venture for the practice and they had given it more than enough resources. Since I did not see the doctor other than for my diabetes (at this point my control was much better due to the modern insulin I was taking) I do not know how long a patient would wait for a GP appointment.

To be fair to the doctor in the GP clinic, he did notice when there were changes in my eyes and he immediately referred me to the local hospital for laser treatment. This was like going back in time: the hospital was pre-war and some of it was Victorian. My memories are of long waits sitting on plastic chairs in corridors. The eye clinic did emergency work so often I would see someone lead in (or pushed in on a wheelchair) with bandaged eyes and then told my appointment would be delayed as they treated the emergency case. The clinic was just ten minutes walk from where I worked, but the long periods of time I spent waiting for appointments meant I would have to take an afternoon off work. Treatment during week days have a knock-on effect. I taught week long courses and it was not convenient for me to take a morning off halfway through the course, but if I was given an appointment for treatment I had no option, I had to attend on that particular day for fear of not being able to get an alternative date.

Then I changed jobs and moved house (now with another child). The town had two GP practices with surgeries 100m of each other. Both were modern buildings and since there was not much difference between them, we chose more or less at random. At my first GP clinic I told the GP that I wanted to be referred: this time I decided that I was not going to accept just the GP clinic. The GP said "that's fine, we will put you down as shared care".

So now I was seen by the local hospital clinic and the GP clinic. The contrast was marked. The hospital was largely pre-war and the outpatients was in a large 80s extension that had not been completed. The clinics were crowded, (mostly elderly people) and I never had an appointment on time. In those early days at some point during the afternoon a nurse would announce that the doctor had been called away to attend an emergency and so our appointments were delayed (a diabetic clinic for me was always a case of turn up at 2 and be seen after 5).

Although the outpatients department was new it was still tatty: I guess it had not been repainted since I had been built. The older parts of the hospital were worse. The hospital was made up of several building of various ages and there was a long corridor (a covered walkway) between them. For years it seemed that the hospital had no money to replace broken ceiling panels, so occasionally when walking along that corridor you could see the pipes and wires that were the very guts of the hospital. The eye clinic I attended was in the old part and it was cramped with patients waiting on chairs along a narrow corridor. There was one positive memory: whenever I attended the diabetic or eye clinic I had to take my diary because after my appointment I could make the next appointment and was given a specific time and date. This meant that there was even a possibility of ensuring that the appointment would not be when I was away on holiday, although I rarely got the appointment within the three or six months that the consultant requested.

The GP diabetic clinic was very different. In those early days the GP made a double appointment at a time when they did not have a surgery. These were very relaxed and concentrated more on how I felt I was coping with living with diabetes rather than the obsession with numbers shown by the consultant at the hospital. Conveniently, if the hospital required a blood test I could have the blood taken at my GP rather than the hospital. At the hospital there were always long waits and I would have to pay for parking. The GP surgery was a short walk from where I lived and the queue for blood tests was always short.

During this time my treatment changed again: I was changed to analogue short acting insulin. This was a disaster. My control went haywire and I put on about 15Kg. Eventually my wife told me I had to change back to the human insulin. I did and my control returned, but I was still somewhat wary since I had changed my treatment without the consultant's permission. In fact, at the next appointment the consultant merely said "no one else seems to have had a problem" and that was it.

In the new millennium things changed. The hospital started to be better funded and it got a loan from the Department of Health so the outpatients department was completed and the whole hospital redecorated. There was a new A&E department and the eye clinic got a new waiting room, and had had contrasting paintwork and signs in letters large enough to read when your eyes are dilated. The hospital was no longer dilapidated.

Since that time I have never sat in a full waiting room and appointments are always prompt. It has been a decade since I last heard a nurse explain that appointments are delayed because of an emergency case. Yet during this time I have been an emergency case myself - I phoned the eye clinic having suffered a haemorrhage in my eye and was told to go immediately to the clinic where I was seen.

But there are other differences. Now I cannot book an appointment at the clinic, instead the appointment is sent to me. I guess this is in response to the 18 week target so that the hospital can change clinics quickly. However, it is a real pain because you cannot guarantee that the appointment letter will get to you before the appointment: one housebound neighbour got an appointment through the post two hours after the appointment time. If you need to change an appointment then you have to phone up and inevitably you get an appointment later than the original, extending the time between clinics. The hospital also seems to regard appointments as easily moveable and often I will get a letter saying that "due to unforeseen circumstances, your appointment has had to be changed". During the time my eyes were unstable (I was told they could haemorrhage at any time) the consultant said he wanted to see me every three months, but the appointment system never took this into account. On one occasion I had three letters changing the appointment, the final one giving me a date 14 months after my last appointment (I phoned, and was given a "cancellation", but the system should not allow an appointment to be made that contradicted the clinician's opinion by so much).

My treatment also changed. First, I was put on an ACE inhibitor by the hospital. Next my long acting (basal) insulin was changed to an analogue, and after using it for twoi years I changed it back to the human insulin, again, because my control had deteriorated on the analogue. In addition, my GP put me on statins, and at a later stage, a calcium channel blocker when my blood pressure had shown it was rising from the recommended value. The ACE inhibitor, calcium channel blocker and statins are all preventative medicines. My cholesterol and blood pressure have been normal for most of my life (sometimes, from their reaction, I used to think that this disappointed the clinicians) but latterly my test results have veered off the recommended range for a diabetic and so I was prescribed the medicines.

With the appointment system aside, the hospital has improved immensely over the last ten years. The GP clinic has gone in the opposite direction. First to go was the ability to have blood taken for a hospital clinic. I was told that since the GP paid for the phlebotomist they would only draw blood for the tests the GP ordered. This now meant that for the blood test for the hospital (to be done two weeks before an appointment) I would have to travel to the hospital. Since there was no co-ordination between the GP and hospital, I would sometimes have a blood test for both within a few weeks - they would not share the results.

Then the diabetic clinic changed to a single appointment during surgery time, so now I had longer waits because my diabetic appointment was treated like any other GP appointment. After a while the diabetic clinic changed again, this time it was the practice nurse took them, not a GP. I learned fairly early on not to ask questions, because if I did, the nurse would say "you should make an appointment and ask the doctor". This surprised me because the diabetic nurse at the hospital was very knowledgeable, she knew far more about living with diabetes (including the various insulin pens and blood testing kits) than the doctors. The GP practice nurse was there merely to measure me. 

This coincided with my GP (who ran the original clinics) taking time off for a lengthy illness, and then taking early retirement. However, when I went to another GP about a diabetes related issue he told me that none of the GPs were now specialised in diabetes telling me: "I really should do something about that". As I write this, the GP clinic still hasn't got a doctor who specialises in diabetes. Finally, at my last GP diabetes clinic, the practice nurse told me that they have lost a member of staff (I assume this means a cutback) and so rather than seeing me twice a year (to monitor my condition) they would see me once a year.

This tale has shown a progression of the treatment over time. Initially my diabetes was treated by a hospital consultant and both my GP and I never wanted to contradict what he said. Then during the fundholding period my GP wanted to do everything he could. After that I moved to split care and I found a level of assertiveness about my care. During this time my hospital care got better, but my GP care got worse. First my GP wanted to see me, then she was replace by a practice nurse, and now I am seeing the practice nurse less often, the next stage is surely me not being seen at all by my GP practice.

The government tell us that an important part of their "reforms" is self treatment. This is a nonsense. If you are a diabetic you cannot live without self treatment. It is a 24x7 condition and if you do not treat it, you die. The government implies that I, as a diabetic, am not treating my diabetes well enough, presumably because I am costing them too much. They do not understand that my incentive to have good control of my condition is to feel well. I do not even want to live longer, I just want to feel well, and because of that I am proactive in my own treatment. However, I know why the government wants to involve me more in "self treatment": they want to cut costs. The government does not have a measure of how well I feel, but they do have a measure of how much I cost them.

Self treatment is a natural end point in the relentless journey that is to "move care from hospitals to the community". The "community", ultimately, is the patient. The question is whether the move to self treatment will result in diabetics losing their control and costing the NHS more.