Failing Children (again and again)

Sir Al Aynsley-Green, Professor Emeritus of Child Health at University College London and former National Clinical Director for Children and Children’s Commissioner for England, has written to the Eye to expose the continued neglect of children in the NHS: ‘We have failed, are still failing and are likely to continue failing far too many children and young people through inadequate health services’.

‘Ten years ago, the Bristol Inquiry was cataclysmic in its condemnations (1), saying that children had been the ‘Cinderella’ service in the NHS for far too long. Lord Laming’s equally devastating conclusions followed from his Inquiry into child protection triggered by the murder of Victoria Climbie (2). Both uncovered the care of children being subordinated to the demands of adult services; lack of concern for vulnerable individuals; failure to protect children’s rights; quality of care less than it should be; failure of communication, effective planning and partnerships with professionals and parents, and lack of responsibility for children with ineffective leadership.’

‘Even before the financial crisis, the UK ranked bottom of the 21 richest countries for the well being of children. (3,4) Sir Michael Marmot’s recent review (5) on health inequalities documents highlighted (again) the impact of social disadvantage on longevity and morbidity, with so much adult ill health having its roots in childhood. Now we have Sir Ian Kennedy’s follow-up report on children’s health services commissioned by Labour in 2009 (6).’

‘He has exposed yet again that although there are patches of excellence, health services for many children and young people are still highly unsatisfactory, because of ongoing failure to give them political priority in the NHS coupled with cultural barriers between services that prevent professionals working together. He highlights again the imperative for effective leadership, and is highly critical of the role and the lack of training of GPs in the care of children.’

‘As National Clinical Director for Children, I lead a taskforce to define standards of care for children, young people and maternity services through a National Service Framework; it was published in 2004 and defines evidence-based standards of care for every aspect of children’s health (7). Alas, the NSF’s orientation was changed by Labour from ‘must-dos’ with hypothecated money for implementation to nothing more than aspiration over ten years. Without incentive to change, there was little progress.’

‘The Coalition’s proposals for children’s services (8) are set in the context of GPs being given responsibility for commissioning, just as Kennedy has highlighted their lack of training and failure to deliver effective children’s health care. The proposals appear to shoe-horn children’s services into adult-centric ideological reforms rather than starting with the fundamental question of how they should best be structured. Children are our most precious resource and it is beyond belief that we have failed so dismally to protect their best interests for so long.’

Time for the Health Select Committee to investigate?

1 Kennedy I (2001) Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995.
2 The Victoria Climbie Inquiry(2003)
3 UNICEF (2007) An overview of child wellbeing in rich countries. Innocenti Report Card 7
4 OECD (2009) Doing better for children
5 Marmot M (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010.
6 Kennedy I (2010) Getting it right for children and young people. Overcoming cultural barriers in the NHS so as to meet their need.
7 National Service Framework for children, young people and maternity services (2004):
8 Achieving Equity and Excellence for Children. How liberating the NHS will help us meet the needs of children and young people.(2010)

Breast cancer centre can open its doors as battling charity worker beats NHS

A charity worker’s seven year long fight to open a centre to provide therapy for breast cancer survivors and their families will finally be won next week, despite a hospital trust’s bid to misappropriate almost £1M of the charity’s assets.

The Primrose Centre in Bromley, Kent will open its doors for the first time on November 11, bringing to an end veteran charity fundraiser Mary Spinks’ long struggle against the bureaucrats of the NHS and Department of Health.

Whilst Mary Spinks, 63, fought to provide a support service helping up to 80 people a week when fully operational, the NHS sought to appropriate the charity’s assets to help balance the books of Bromley’s ailing hospital trust.

The saga began in 2003 when the then Bromley Hospital NHS Trust sold redundant hospital land to a developer. The land included a former hospital chapel built in 1864 which Mary Spinks persuaded the developer to donate as the future home for the breast cancer centre.

A charitable foundation created by Mary Spinks under the umbrella of Bromley Hospitals NHS Trust Charitable Funds became the chapel owner and she began the task of raising the £600,000 needed to convert the building to its new use and help finance its operation.

By September 2007 the work was completed thanks to donations from local and national firms, charitable foundations such as Caron Keating Foundation and Pink Ribbon Foundation and members of the public, local golf clubs, together with help from companies including Marks & Spencer, Phillips and Fired Earth. It only remained to transfer the assets from the foundation run under the umbrella of the hospital charitable funds to the independent charity, the Primrose Centre.

And then came the bombshell. The hospital boss of 2003 had moved on and one of a succession of temporary chief executives claimed both the building and the charity’s funds belonged to the hospital.

“I couldn’t believe what I was hearing: it flew in the face of what we had agreed with the former chief executive,” said Mary Spinks who has raised more than £2M for various health charities since 1985.

“At the same meeting I was told the planned breast screening within the building would not happen as the NHS locally had surplus property it could use, and also the local PCT would not fund the service.”

For three years, the hospital trust, NHS London and the Department of Health stonewalled Mary Spinks’ attempts to restore ownership of the former hospital chapel to the charity.

“Throughout that time all I got was weasel words and promises: I was told it was a technical accounting problem; I was assured that the trust, and later NHS London and the Department of Health were working to try to resolve things in the charity’s favour. In fact, when I got email correspondence released under the Freedom of Information Act, it revealed their efforts were focussed on preventing the transfer of assets to the charity. One email said ‘it would make a desirable dwelling, corporate HQ or some other NHS use’,” said Mrs Spinks.

By July 2008, the hospital was generously offering to lease the former chapel – refurbished with £500,000 raised by the charity – back to the charity for £40,000 a year!

Former health minister Lord Hunt appealed in vain for the intervention of the then Secretary of State for Health, Alan Johnson. The trustees took a petition on behalf of the charity to No. 10 Downing Street and asked Sarah Brown to help, but to no avail.

Then in October 2009 the pro bono efforts of lawyers Weil, Gotshal & Manges paid off with the granting of a judicial review.

“The part played over three years by the law firm Weil Gotshal & Manges, Richard Drabble QC and the barrister Helen Galley on a pro bono basis cannot be praised enough,” said Mrs Spinks.

The High Court urged a negotiated settlement, but frustration followed as dates for meetings were agreed then cancelled by the NHS side. An April 2010 meeting finally resulted in a proposal from the NHS in June 2010, just four days before the parties were due back before the High Court for a judicial review hearing.

The proposal saw the NHS cave in and grudgingly hand over the former chapel, but it took until 26 September and the threat of further court action to get hold of £184,000 of the charity’s cash, which was being withheld by Bromley Hospital’s new bosses, the South London Healthcare NHS Trust.

After 30 years raising money for charities as well as sitting on bodies such as the Asthma Research Council, National Asthma Campaign Mary Spinks knows a thing or two about the principles underpinning the Big Society – and she’s got a message for David Cameron.

“Backing the Big Society can damage your health. I can’t begin to explain how stressful and distressing the experience has been. The actions of those involved at times stooped to the lowest level. I was so fortunate having the support of the two other trustees and Henry my husband who helped me through three horrid years convincing me the end would be worthwhile. David Cameron needs to sort out the NHS and Department of Health bureaucrats so that people like me can do our bit without the risk of intolerable behaviour by others along the way.”

Ends

Note to editors:
The centre’s mission is to provide survivors of breast cancer with support, including a variety of therapies and to help families of sufferers, especially children, with specialist counselling.

Any breast cancer sufferer or survivor or family member is welcome to contact the centre once it opens on November 11. Initially the centre will provide support for up to 18 people a day and will be open three days a week, rising to five days a week.

The centre will serve Greater London, Kent, Surrey and Sussex

Further information:
Mary Spinks can be contacted on 07860 649860
Jonathan Wood of Weil, Gotshal & Manges:0207 903 1000

www.primrosecentre.org.uk Tel: 01689 880218

Release issued by:
Bob Schofield 07873 148066

Good to see the HSJ picking up my story. And the comments are interesting too. Is it legal? Is it ethical? What happens if the money still runs out? What would Bevan do?

PCT halts funding for over 30 procedures to ‘remain sustainable’
26 October, 2010 | By Steve Ford

A Midlands primary care trust has halted funding for a raft of routine procedures, including cataract removal and hip replacements, in order to remain financially viable over the winter.

Until now PCTs have largely made small scale attempts to cut back on actual services offered, for example NHS Warrington ceased funding most IVF treatment last month. However, NHS Warwickshire has written to provider organisation chief executives outlining two lists of non life threatening procedures that it says will either no longer be funded permanently or temporarily – following discussion with its clinical executive committee.

The list of nine permanently banned procedures includes acupuncture, epidurals for back pain and oral vaccination against hay fever. The second list – of more than 20 procedures halted until the end of the financial year – includes new IVF treatment cycles, all routine elective orthopaedic operations, and secondary care back pain management.

All of the procedures in this second list can be accelerated, however, if the patient’s GP concludes the treatment should go ahead immediately, and this view is supported after review by a second GP, who has a specialist in the relevant clinical area.

The PCT has also banned consultants from referring cases to each other from 1 November, as part of moves to reduce the number of assessments and reviews taking place in secondary care that could otherwise be done in primary care. The only exceptions are cancer referrals and accident and emergency to fracture clinics referrals.

In his letter NHS Warwickshire chief executive Paul Jennings said there had been a “continual and significant increases in the demand” for acute services in the area, which had not been slowed by measures such as extending the range of services available in the community.
He said: “With winter now fast approaching we do not see any indications that this situation will improve in the short term.
“We must take urgent and immediate action to ensure that the health system in Warwickshire is sustainable both financially and operationally.”

Mr Jennings also expressed disappointment that a previous policy of defining 14 procedures as low priority and allowing providers to decide which were “sufficiently exceptional” to go ahead had failed to have sufficient impact, leading to the stricter measures.
He said: “Activity in these procedures has continued to grow overall despite these policies and so, we are no longer confident that the criteria laid out within those policies are being rigorously applied. We are therefore changing this process.”

Mr Jennings acknowledged to chief executives that the measures were “not ideal” and would be difficult to implement.
“However, I am sure that you will agree with me that the current situation cannot continue,” he said.
A spokesman for NHS Warwickshire claimed the move had the support of the majority of local GPs.

Readers’ comments (12)

Ian Bowns | 26-Oct-2010 10:18 am

This is an act of desperation. The real key to this specific problem lies in supporting patients’ decision making with information and counselling, which can reduce net costs. The wider issues can be addressed: Grand Junction Colorado has an efficient healthcare system, with low costs and high quality ratings. They describe seven features: leadership by primary care; payment system involving risk-sharing by physicians across sectors; equalisation of physician payments across patient types; regionalisation of specialised services; restrictions on supply of high-cost care; payment of primary care doctors for hospital visits; and good end of life care. All interesting in an NHS context. See http://www.nejm.org/doi/pdf/10.1056/NEJMp1008450

?

Anonymous | 26-Oct-2010 10:27 am

One significant gap in the NHS across all sectors today: Generally speaking, risk management is feared rather than embraced, hence we have a risk-averse culture that spans clinicians and managers, and NHS organisations. Sadly, it’s considered as important as training and development of staff. Both are major areas of continuous investment in US healthcare, because HMOs and hospitals know they are two enablers that will always yield better performance and efficiency in a targeted manner.

Anonymous | 26-Oct-2010 2:02 pm

and a marvellous piece of the dreaded postcode lottery. Not only is IVF straight to the top of the list again, but live in Warwickshire and you should move to Birmingham to get that new hip…

Richard Russell | 26-Oct-2010 2:35 pm

If a GP says that a hip replacement is needed and refers the patient but the commissioner says they will not fund it where does the legal right of a patient to be treated within 18 weeks fit?

The only way this will save money is if the GP does not make the referral in the first place but the commissioner has sent the letter to the hospital rather than the GPs.

If I needed a hip replacement and it was going to take more than 18 weeks to be treated then the courts have said that I can go wherever reasonable (including anywhere in Europe) to have my treatment carried out within 18 weeks and the commissioner legally has to pay all of the costs.

So the solution is that PCT actually needs to get the GPs to stop referring.

However a patient presents at a GP in pain needing a hip replacement and they refuse to refer them then isn’t the GP opening themselves up to a reasonable amount of clinical governance risk. For example GP agrees that a patient needs a hip replacement, refuses to refer, patient then has an accident directly linked to their bad hip, GP liable?

Will be interesting to see how this works in practice…

Anonymous | 26-Oct-2010 2:56 pm

Arent commissioners supposed to give notice ?? As a provider can i mreject emergency cases because i am not making money from them ?? Its anarchy is this what Secretary of State wants ?? Will he intervene or is down to localism I wait with interest

Anonymous | 26-Oct-2010 3:05 pm

What is even more interesting is how this story has been reported locally……. more spin than on a top! The PCT claiming that this is to ease “winter pressures” on secondary care or even better in another local paper to allow the joints more time to “heal themselves”!! Rather than being really honest and informing the people of the truth …..they have over spent- Staff employed by PCT’s have always historically had higher pay bands than their conterparts in the secondary care sector and have people in post that no one knows what they do….. and please dont contact them after 2pm on a Friday because they have all gone home!

Seems to me that the only thing that they can do is persuade the Warwickshire population not to go to their GP, if they suffer from a condition that may require one of the procedures that have been stopped. Job done! Lets see how that one pans out or even more radically they could look closer to home and hold a mirror up to themselves.

Anonymous | 26-Oct-2010 3:11 pm

The investigation should begin over serious finacial mis-management at NHS Warwickshire over a number of years and why now local patients are having to pay the price for that. This is one place where you can say GP Commissioning, bring it on as it could not be any worse for the population of Warwickshire. Local GP’s should beging to have serious conversations with the SHA and DH about why they should potentailly inherit the deficit of a failing organisation and how they can have their budgets be-based as a result.

Anonymous | 26-Oct-2010 3:14 pm

As for the comment re: notice, that does not seem to bother the PCT. When is a contract not a contact…. ? when signed by NHS Warwickshire obviously.

Anonymous | 26-Oct-2010 3:37 pm

We need to get real. Most PCT’s are having trouble meeting the ever growing demand for health care and are having to make huge savings which often falls on the hospitals who cannot get paid on an activity x price any longer. If you think its getting bad wait until next year. Cutting costs is important but unless we cut demand we will see more headlines like this. Can we afford to offer free, health to people who self harm, perpetual DNA’s and nice to have treatments. In the private sector you have to look at all sides of the P & L, and make substantial changes and not just fiddle around the edges.

Unsuitable or offensive?

Anonymous | 26-Oct-2010 3:42 pm

Stopping elective orthopaedics will not save the full cost of those operations. Orthopods will be under-utilised and theatres will stand empty, incurring cost. A proportion of the patients who would have been treated electively will then end up in A&E for a more expensive operation having deteriorated. This is entirely contrary to QIPP. What happened to “local leaders of the NHS” ?

Unsuitable or offensive?

Bob Neilans | 26-Oct-2010 3:50 pm

Agree fully with Anon 3.42PM – If these elective procedures aren’t enough to prevent the PCT overspending, what is next to be stopped? And of course, because of the funding structure of the NHS we will end up with expensive real estate, equipment and professionals idle. Delaying I can understand, but stopping?

Unsuitable or offensive?

Piushkumar Patel | 26-Oct-2010 4:37 pm

Is no one prepared to stand up and say that we have moved too far away from the NHS envisioned by Beverige and Bevan? We (and this now means myself as a GP commissioner) need to have an honest conversation with the public about what we can and can’t afford. IVF is the most emotive issue, but ultimately it does not fit with the founding principles of the NHS, which were essentially to allow all to work by making sure that they were fit enough. In the (near) future, I will have to say to my patients that they can’t have certain procedures on the NHS. I look forward to it. The NHS has expanded it’s remit into areas of elective care where it simply should not be.

Explicit rationing in the NHS is no bad thing. When he was shadow health secretary, I made Andrew Lansley stand on stage at the NICE conference and say: ‘There is and has to be rationing in the NHS.’ He’s now hoping GP Consortia will do it for him, but NHS Warwickshire is ahead of the game, announcing a list of treatment restictions ‘to manage demand in the acute sector.’ However, there’s no mention of any patient consultation in drawing up this list. Whatever happened to no decision about me without me?

Westgate House
Market Street
Warwick
CV34 4DE

Tel: 01926 493491

Fax: 01926 495074
8th October 2010

Birmingham & West Birmingham NHST
Management Centre
Dudley Road
Birmingham
B18 7QH

Dear Chief Executive

As you know, throughout this year we have seen continual and significant increases in the demand
for acute services across Warwickshire. In response we have taken action to refresh treatment
policies, remind clinicians of their content and extend the range of services in the community. This
has not had a significant enough impact to reduce the capacity problems that your Trust asked for
our help with, nor will it have enough impact on our projected spend. With winter now fast
approaching we do not see any indications that this situation will improve in the short term. I know
that you will agree with me that this situation is not sustainable.

It is our responsibility to ensure that we deliver high quality care within the resources available and
this can only be achieved through working in true partnership. We must take urgent and immediate
action to ensure that the health system in Warwickshire is sustainable both financially and
operationally.

At the October meeting of NHS Warwickshire’s Board a proposal to manage the demand for acute
services was agreed. The proposal broadly addresses two areas: stopping or deferring
treatment/procedures for specific conditions that are not life-threatening; stopping all
assessments/reviews by secondary care clinicians that can be undertaken in primary care.

Stopping/deferring specific treatments/procedures:

As you know NHS Warwickshire has previously defined a range of treatments as Low Priority
Procedures, for which we have allowed providers to determine the cases that are sufficiently
exceptional as per the policy. Activity in these procedures has continued to grow overall despite
these policies and so, we are no longer confident that the criteria laid out within those policies are
being rigorously applied. We are therefore changing this process. We are also extending the list of
procedures within the LPP policy.

The following list of procedures will permanently not be funded for NHS treatment:

Chairman: Bryan Stoten Chief Executive: Paul Jennings

o
Acupuncture
o
Endoscopic thoracic sympathectomy
o
Facial hirsutism
o
Ganglion treatment
o
Botox therapy for hyperhidrosis
o
Oral Vaccine for seasonal rhinitis
o
Penile implants
o
Spinal epidural injections for chronic back pain
o
Therapeutic use of probiotics
The following list of procedures temporarily (until 1st April 2011) requires prior approval for NHS
funded treatment except in instances where the activity is cancer-related (Note: in many instances
we have defined thresholds for treatment against which we will assess the referral for prior
approval):

o
All other procedures included in the current LPP policy – see attached list
o
Cataracts (including prior approval for a second eye to be treated)
o
IVF/ICSI (except in cases where the treatment cycle has already commenced or
where the current age criteria will be exceeded if treatment is not commenced before
April 2011)
o
Bariatric Surgery
o
All routine elective orthopaedic procedures (to include inpatient, day case and
outpatient procedures)
o
All secondary care back pain management
o
All oral and orthodontic procedures in secondary care
No treatments in these areas should be carried out by providers without the prior approval of NHS
Warwickshire. Should providers undertake any of these treatments without prior approval, NHSW will
not fund that activity.

Reducing assessments/reviews in secondary care:

Our ability to manage outpatient demand is being hampered by a number of factors. These include
the range of points of entry to services, confusion over service pathways and the quality of the data
to enable us to identify the causes of activity growth. We are therefore introducing additional
measures with regard to non-GP referrals.

•
All consultant-to-consultant referrals should cease from 10th October 2010 and the referral be
redirected back to the patient’s GP for consideration with the exception of:
.
cancer referrals
.
A&E to fracture clinic referrals
•
The recorded source of the referral must be transparent for all outpatient referrals. As a
consequence we require providers to stop coding the source of referrals as “97 -other”. From
previous audits activity coded in this way often includes both GP referrals and Consultant to
Consultant referrals.
We will not pay for any consultant to consultant referrals from 1st November, we have assumed
that there will be some referrals in the system during October, but we would expect that no new
referrals will be made. Where the source of the referrals is 97 or has a default code (C999998)
the PCT will not pay for those attendances from 1st November.

Chairman: Bryan Stoten Chief Executive: Paul Jennings

Action for Acute Providers to take to support this plan:

In order to implement the above, with effect from Monday 11th October 2010 the following action
needs to be taken:

•
No patients to be offered TCI dates for surgery for the above categories with immediate
effect. In line with the acute Trust contract, patients should be offered TCI dates up to 3
weeks in advance so we would expect elective activity in these categories to have ceased by
the end of October 2010. NHS Warwickshire will therefore not pay for any activity in these
categories from November onwards unless Prior Approval has been given.
•
Providers should send NHS Warwickshire a copy of their Waiting List, by specialty, including
NHS number as at 8th October. This should be received at the PCT by 11th October.
•
Providers should produce a list of all existing patients (i.e. already referred) who might be
expected to be affected by the changes outlined in this letter and who either did not have a
TCI date as at 10th October 2010 or who have been given a TCI date after 31st October
2010. These patients should be referred through the PCT’s prior approval process for
consideration of funding. These patients will be clinically reviewed by the PCT to determine
whether their treatment should be approved by exception, in accordance with the process.
•
Where patients have been booked for a First Out-patient appointment, this appointment can
take place as planned, and if the consultant subsequently believes that a procedure is
necessary and meets the criteria, the patient details should be sent to the PCT for approval
through the Prior Approval Process.
•
Providers shall not accelerate activity in other specialties nor reduce waiting times. . If activity
is accelerated, the PCT will not pay for any activity above the planned forecast, at specialty
level, based on month 4 activity.
•
If a provider receives a new referral from a Warwickshire GP for one of the above treatments
it should come with a prior approval from the PCT. If it does not come with a prior approval
then the referral should be sent back to the GP.
Action for NHSW to take to support this plan:

•
The PCT will monitor the shape of provider waiting lists to ensure that activity is not being
accelerated in any specialties. If activity is accelerated, the PCT will not pay for any activity
above the planned forecast, at specialty level, based on month 4 activity.
•
The PCT will not issue providers with performance notices for breaching the maximum 18
week target for the remainder of this year’s contract.
•
The PCT has a Prior Approvals Panel which will consider all funding requests for patients
who either meet the thresholds for treatment or who may have individual circumstances that
make them exceptions to the policy. This panel will also review all patients on provider
waiting lists for treatment who have not been given a TCI date as at 10th October 2010.
•
The PCT will issue guidance to providers on the Prior Approval Process by Friday 15th
October 2010.
•
The PCT will inform all Warwickshire GP’s of the details of the above changes.
•
Warwickshire GP’s will be asked to submit all new referrals that could require one of the
above treatments through the Prior Approval Process.
Chairman: Bryan Stoten Chief Executive: Paul Jennings

•
The PCT will inform all acute providers where it is an Associate Commissioner of the above
changes and require them to institute the action above.
•
In conjunction with our main acute providers, the PCT will agree standard letters/information
for patients to inform patients and their carers of the nature of the changes being made and
the reasons behind these.
I know that implementing the above steps will be difficult for all of us and this is clearly not an ideal
situation. However, I am sure that you will agree with me that the current situation cannot continue. It
is vital that we take decisive action and move forwards in close partnership so that we can fulfil our
duty to the health economy to deliver a sustainable future.

Yours sincerely

Paul Jennings
Chief Executive

Co-ordinating Commissioners

Chairman: Bryan Stoten Chief Executive: Paul Jennings

LOW PRIORITY PROCEDURES

Arthroscopy for diagnostic examination of knee joint
Carpal Tunnel Syndrome
Circumcision
Dilatation and Curettage for menorrhagia (D&C)
Facet Joint injections for chronic low back pain
Gallstone surgery (if not symptomatic)
Grommets/myringotomy
Hysterectomy for menorrhagia
Inguinal hernia in adults (asymptomatic)
Spinal Fusion for disc problems
Tonsillectomy/adenontonsillectomy for recurrent tonsillitis
Trigger Finger release surgery
Varicose Vein surgery
All Aesthetic Procedures

Chairman: Bryan Stoten Chief Executive: Paul Jennings