Myth Busting

“Demand for NHS services shows no signs of abating. With hospital finances increasingly weak, growing pressures on staffing, and the goal of moving care out of hospitals and into the community proving elusive, the NHS is heading for a funding crisis this year or next.” So reported the Nuffield Trust last month, with mental health services particularly hard hit. And may hospitals are now on ‘black alert’ and turning ambulances away in the summer So can anything achieve the quick and massive efficiency savings necessary to get the NHS out of financial meltdown?

No, is the simple answer- not that you’d realise it as the government and NHS England furiously try to paper over the cracks in the run up to an election. Many of the ideas doing the rounds make sense – investing in prevention, encouraging healthier lifestyles, moving care closer to home and better support for people with long term conditions. They could make the service better, but there is little evidence they will save it a lot of money. The average age of a GP patient is 75, and a hospital patient over 80, and as people live longer they simply need more care. Most people who go into care homes have had numerous failed attempts to stay at home (despite big cuts in social care funding) and only go in as a last resort. People in care homes tend to be very dependent, disabled, demented, frail and unwell. It’s a fantasy to think we could ever close all the care homes, and yet NHS England chief executive Simon Stevens told a recent Age UK conference that nursing homes could become redundant during his lifetime if only we invested in “new technologies.”

The idea that new technologies will save the NHS a popular recurring myth, especially amongst companies who manufacture them, and the many MPs and Lords who have shares or other vested interests in them. We clearly need to use electronic records, telehealth and telecare better but the Cochrane reviews and the Department of Health’s own Whole System Demonstrator trial (WSD) have thus far shown very limited evidence for their clinical and cost effectiveness.

WSD benefits were over-claimed by senior government officials before trials were published with NHS England’s Jim Easton (now of Care UK) saying: “Now we know telehealth works, there is no excuse or not rolling it out at pace”. Also, DH director of innovation Miles Ayling has penned pieces in the Health Service Journal next to sponsored pull-outs for telecare and plugging new technologies. Such enthusiasm despite the fact that the Connecting for Health NHS IT disaster cost an estimated £12 billion (more than the cost of all primary care), with many hospitals squandering large amounts on useless IT systems. How will new technologies be better this time round? Where’s the evidence?

Likewise, giving very frail, dependent patients their own health and social care budget is politically appealing and opens up the NHS to the private market, but there is as yet no evidence it will keep them out of hospital. Sweden and Holland – very ‘age-friendly’ countries with good integrated care – still need care homes. Another NHS myth is that there are too many hospital beds. In fact, we have lost around one-third of our acute beds since 1979; lost them faster than nearly all OECD countries; and have fewer beds per head of the population than nearly all. Urgent admissions have risen year on year during this downsizing and NHS hospitals are run very “hot” and close to capacity.

All four NHS countries have full hospitals, and the market in England is neither the cause nor the solution. In the NHS, it’s still doctors rather than finance directors who admit patients, and none would hospitalise a patient unnecessarily to make money for their trust. Far more likely is that patients are sent home when they need to be in hospital because there are no beds. Slashing hospital bed numbers further would be a very dangerous game, even if better community support existed (it doesn’t – social care and general practice are woefully underfunded). NHS England claims emergency admission of someone with frailty or long term conditions can become a ‘never’ event, but if you have a hip fracture, acute stroke, heart attack, severe sepsis etc, hospital is the only place to be if you want active treatment. The issue is patients stay too long after because there is nowhere for them to go. As people age, the demand for excellent care homes and hospital care will increase, and we need to get real about funding it, not obsess with market solutions of no proven benefit other than they make money for MPs, Lords and the former business associates of those now running NHS England.

Shop till you drop?

Is giving patients with chronic diseases their own health budget to buy the care they need a good idea? It’s certainly got Simon Stevens, NHS England’s new Chief Executive, very excited. Personal budgets for social care have been around for some years, and Stevens believes ‘north of five million patients’ will have a combined personal health and social care budget by 2018. £5 billion will be taken out of the NHS pot and handed directly to patients. What could go wrong?

Very few politicians will dare argue against such a grand scheme to ‘trust the people’, and if the people decide to buy all their healthcare from private providers rather than the NHS, it’ll be the cleverest Trojan horse to get private providers a slice of the NHS cake yet invented. That makes it even less likely that many in either House will kick up a fuss. Around 200 honourable members in the Lords and Commons voted through the Health and Social Care Act knowing the private health companies they have an interest in could benefit. None had the ethics or insight to abstain.

Personal budgets in health have been piloted in England only on a small scale and the PHB website has lots of heart-warming stories of patients with chronic diseases and disabilities who have benefited by, say, getting the physiotherapy, nursing or counselling care they need, when they need it.

In social care, patients are allowed to employ their own carers and take them into the NHS. As one Eye reader wrote: ‘‘I have a degenerative neurological condition and I’m completely bedridden.  My diet is mostly fluid (I have a peg into my stomach) and I’m fortunate in that I receive Direct Payments from social services to fund my team of carers (that was a battle with social services… drove them potty but I knew what my rights were). My support workers always accompany me on admissions to hospital, otherwise I’d never receive the assistance I need as the wards are so understaffed. They are my advocates and they keep me safe and speak up for me in the NHS”

Stevens, and the government, believe that giving patients combined health and social care budgets will keep them healthier, happier and more independent in their homes and this will reduce hospital admissions, therefore compensating for the £5 billion that may be taken out of the NHS to pay for the scheme. It would be easy to set up a trial to prove this. Recruit a few thousand patients who are eligible for personal health budgets, split the group in half and randomly assigning them to either get a budget or not. Then follow them all up to see if the people with their own budgets have fewer hospital admissions. Sadly this has not yet been done. Research and reform rarely go arm in arm in the NHS. Enthusiastic ideology nearly always trumps evidence.

The experience in social care is that early adopters of the scheme get a healthy budget and do very well, to make it look a political success, but when you try to roll it out to millions it gets more problematic, particularly as budgets are then squeezed year on year. Also, new layers of bureaucracy – the ‘resource allocation system’ (RAS) – are invented to try to let people know the size of their budget upfront so they can make sensible decisions about how to spend it. This hasn’t worked well in social care and many clients on personal budgets now get either get exactly what they got before and often less, as all social care funding has been cut.

The patients who benefited most in social care opted for direct cash payments, rather than letting someone else manage their budget, and those considering the health budget should choose this option and get in there early – preferably before the election – and before the money is cut back. If people are given excellent advice and support on how best to make complex choices and spend the money, the system could work very well for some. But this support too costs money. And we could enter a world where the health and social care you get depends less on your needs and more on how good you are with the money. And what happens if you overspend?

Universal healthcare is being replaced by a market system on a very personal level, with no evidence base. There will be winners and losers, and you either opt for a budget or stick with an NHS that’s £5 billion poorer. Say yes, and two hundred happy Lords and MPs will be after your business.

Rate my as a doctor, but don’t blame me for a service in crisis

Health secretary Jeremy Hunt’s plan to name and shame GPs who fail to spot cancer by placing a red flag next to their practice on the NHS website has been rightly slammed. However, MD is strongly in favour of patients and relatives rating their NHS care, and encourages his to do so. There is good evidence that people who have a good experience of NHS care, and feel listened to and included in decisions about their care, get better results. Putting this information in the public domain provides important feedback to the NHS and individual staff, and guides patients where to go to find kind, competent care.

Publishing patient experience information in real time, as many hospitals are starting to do, is a good smoke alarm to step in and stop poor care before too much harm is done, and a great was of praising excellent care. Some sites such as Patient Opinion allow you to have a conversation with a willing GP practice or hospital and try and sort out problems. In some instances, this has happened commendably quickly. On the website MD uses, every word a patient or carer writes is published unedited. Doctors aren’t in the business of always giving patients what they want, and occasional patients are vexatious. But the overwhelming majority provide honest feedback on their experience of care and what could be done to improve it. If all the NHS did was listen and act on this feedback, it would improve the service far more than any political reform.

One problem with Hunt’s plan is that politicians and NHS bureaucrats are simply not trusted to provide accurate fair ratings in the same way patients are. Wrongly flagging up a practice as providing substandard cancer diagnosis could have serious psychological and legal consequences. And for the few doctors who are making fundamental errors that would fail your medical finals, a regulator should have stepped in to support and retrain them long before a red flag appears on a website.

The main reason MD gets such positive ratings in the care of young people with chronic fatigue syndrome, is that I have 90 minute consultations. Difficult diagnoses cannot be done in 10 minutes. GPs are under ridiculous pressure to manage demand and be competent in ridiculously short consultations, and patients are having to wait dangerously long times for specialist referrals, and increasingly having the referral refused. Young people with serious mental health problems are currently being denied access to the specialist care they need. Some Child and Adolescent Mental Health Services (CAMHS) are in meltdown, many staff have gone off sick and those that remain have to ‘choose’ between a child who has been self-harming for a year and a child who has been self-harming for a week. The latter may respond best to treatment, the former will be absolutely desperate. The one who doesn’t get seen gets bounced back to the GP, who has to pick up the pieces.

One of the reasons I stopped general practice is I just don’t find it safe. There is huge pressure not to refer because of the financial difficulties of the NHS, and an increasing number of referrals are refused. So to be publicly outed for not investigating sooner could lead to a huge increase in hospital referrals, and yet more refusals. One in three patients will at some stage get cancer, just as one in three will get diabetes, one in three will die with dementia and 1 in 4 currently have a mental health problem. There are all sorts of delays in the diagnoses of many of these diseases, but no evidence that blaming GPs on the brink of a breakdown will improve the care that patients get. On the IWGC website, the vast majority of ratings for NHS staff are very positive. Some staff dislike the idea of a commercial organisation collecting and publishing this information, others feel it is more likely to be accurate than letting the NHS do it, with its history of IT errors, gaming and cover-ups. I certainly wouldn’t trust any data Jeremy Hunt fed to the Daily Mail. For transparency and accountability to work in the NHS, staff have to believe in it.

Cardiac surgeons have put outcome data in the public domain for years. Surgeon Ben Bridgwater’s University Hospital of South Manchester web page shows his photo, his qualifications, his CV, his cardiac surgery and activity results, the national results for cardiac surgery, advice on how to interpret the graphs, what patients think about him, and how this patient experience information is measured. In specialties when there are clear outcomes and fair comparative measures, others should follow suit. General practice is murkier because it’s about managing uncertainty under pressure, and trying to have a sense of what might be the more serious diagnosis that needs urgent referral amongst the day’s 50 consultations. The NICE website publishes clear criteria about which symptoms and signs should qualify for an urgent two week cancer referral. The Macmillan website clearly describes suspected cancer symptoms. Diagnosis is an imperfect science, and 15% turn out not to be wrong. Patients should ask ‘What else could it be? How would I know? And what should I do if symptoms don’t improve or persist?’ If you get another opinion, you might be very surprised how different it is. And far more useful than waiting two years for a red flag to appear on the website.

Inquiring into the GMC

Jeremy Hunt has rightly ordered an inquiry into NHS whistleblowing, to be chaired by Robert Francis QC. He cannot hope to fulfil his promise of no more health service cover-ups without understanding why and how the numerous cover-ups in the past have happened. And this inquiry must reach every level of the NHS, to show how high up the chain the denial, incompetence, amnesia and wilful blindness has gone. MD has long since given up on the General Medical Council as having any meaningful role in calling doctors to account or protecting patients from avoidable harm. The Eye reported Dr David Elliman, a consultant paediatrician at Great Ormond Street to the GMC on September 30, 2011, alleging that he failed to act appropriately on whistleblowing concerns that might have prevented the death of Baby Peter Connelley. The GMC is still investigating. And the GMC is still pondering its initial decision not to hold an inquiry into the conduct of Dr Barbara Hakin, now deputy CEO of NHS England, in not responding appropriately to the patient safety concerns of whistleblower Gary Walker (Eyes passim). This referral is now two years old.

The overwhelming impression is that the GMC delays difficult cases so long in the hope complainants will withdraw their complaints. This is certainly the experience of Dr Peter Wilmshurst, the Godfather of NHS whistleblowers (see Shoot the Messenger ), who has dedicated his life to holding those who lie about the results of medical research to account. ‘I have two cases before the GMC and five that the GMC recently refused to act upon. The Assistant Registrar has audited the five cases and found that in 2, the GMC’s handling of the cases was materially flawed and in the remaining 3 it may have been materially flawed, but the GMC decided not to look further into those 3 cases. In those 5 cases, which the GMC will not reopen, the Assistant Registrar decided that the decisions of the Case Examiners (to dismiss the cases) was wrong and the wrong decisions were because of incorrect advice from the GMC’s expert, a medical qualified professor of law and medical ethics. The Assistant Registrar said that the GMC’s expert failed to consider some allegations in those cases, and with respect to allegations that he did consider the advice of the GMC’s expert was ambiguous and contradictory and the Assistant Registrar says that the GMC cannot understand some aspects of the advice from their own expert.’

‘With respect to the two ongoing cases, one follows complaints that I made in 2008 which the GMC has tried repeatedly to get out of dealing with. The latest stunt has been to threaten me with a High Court hearing unless I comply fully with the GMC’s disclosure requests. Initially the GMC’s lawyers asked me to disclose legally privileged court documents and had I done so I would have broken the law. The GMC’s lawyers must have known that they were asking me to break the law. I had to engage a lawyer to bat that off. Next they asked me to disclose the medical records of over 400 patients and witnesses in the case. The GMC has the right to those documents but does not have the right to ask me for them. I would be in trouble had I disclosed them.

I informed the GMC’s lawyers of the fact that they should have known that they are entitled to have the records but must apply though the relevant hospital medical records department for the documents. In the 15 months since I told the GMC this, they have made no attempt to get the records. I believe that again the GMC was wasting my time and attempting to get me to do something wrong. However the GMC subsequently asked me to disclose other documents, which I have been compelled to disclose. Those are over 6,000 documents, consisting of over 34,000 pages that I have spent many hundreds of hours copying and emailing to the GMC. Had I refused to do so the GMC threatened me with a High Court hearing and said that they would drop the charges against the dishonest doctor that I had reported. He has previously appeared before the GMC for other offences of dishonesty that were found proved.

GMC disclosures are not covered by the Legal Procedures Rules, which apply to maintaining confidentiality of disclosed documents in court proceedings. Those given disclosed documents by the GMC (i.e the charged doctor) can do what they wish with the disclosed documents and those documents that I disclosed include patient information, which will be given to a doctor that has a record of dishonesty and research misconduct. The GMC will give no reassurance about their confidentiality.

The other on-going case involves complaints from another and me about a medical member of the GMC Council. We specifically allege that the doctor silenced and detrimentally treated whistleblowers, including those who raised concerns about Mid-Staffs. I best say no more at this stage, except that once again the GMC is trying to bog me down with an unreasonable disclosure request.’

If someone as ethical, knowledgeable and determined at Wilmshurst struggles to get any form of timely accountability from the GMC, it shows how pointless and soul-destroying the exercise can be for patients and carers. A further kick in the teeth for Wilmshurst emerged when surgeon Anjan Kumar Banerjee was awarded an MBE in the Queen’s Birthday Honours List for ‘services to patient safety.’

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Wilmshurst reported Banerjee to the GMC twice. On the first occasion he was suspended from the Medical Register for falsifying medical research and on the second occasion he was erased from the Medical Register for “lack of probity” (he defrauded patients and medical insurers) and for “substandard medical practice”, which involved him performing inappropriate operations, particularly on private patients. Amongst the GMC’s determinations was that he lied to patients with cancer about the length of NHS waiting lists to induce them to go privately. He was struck off the Medical Register for 6 years, then allowed back on.

Banerjee was made a Fellow of the Royal College of Physicians in Edinburgh for the first time when he was awaiting his GMC hearing, at which time he was suspended from his hospital, under investigation by the police because of his financial misconduct and under investigation by the Royal College of Surgeons because of concerns about his clinical skill. Despite the fact that he is a surgeon and not a physician, he was re-elected to the RCP Edinburgh after returning to the Register. He has also been elected to Fellowships of the Royal College of Surgeons in Glasgow and Royal College of Surgeons in Edinburgh since going back on the Medical Register. The Royal College of Surgeon in England withdrew his Fellowship in England after the GMC adjudications, allegedly because they were so angry that he had presented false data during his Hunterian Professorship lecture (the most prestigious lectures of that College). Banerjee continues to claim the Master of Surgery qualification from the University of London even though the investigation by Professor Michael Farthing for the University showed that the data used for the thesis that was submitted for that degree was also false. Banerjee is now apparently also on the Board of Examiner for the Faculty of Pharmaceutical Medicine of the Royal College of Physicians.

As Wilmshurst puts it: ‘I am in favour of rehabilitation of offenders, but I found the speed of Banerjee’s rehabilitation surprising. If you add to this the fact that the GMC also found a professor guilty of serious professional misconduct for his involvement in research misconduct and he was then invited to  give a prestigious named lecture at the Royal College of Physicians in April this year,  and the fact that a gynaecologist was given a Silver Clinical Excellence Award by the Advisory Committee on Clinical Excellence Awards only 18 months after being placed on the Sex Offenders Register, I cannot help asking whether the rewards in medicine are going to the wrong doctors.’

NHS and Social Care need to be a single, joined up system. And the Ombudsman needs to own up, learn and apologize to the Titcombes.

The annual conference of the NHS Confederation is where politicians of all sides present their big ideas for health and social care. In the one before an election, there is usually tedious point scoring but this year Jeremy Hunt, Andy Burnham and Norman Lamb all agreed that the service faces massive challenges, that health and social care need to be joined up as a single system and – having just gone through the biggest reforms in NHS history – it will require further massive reforms to do this.

When the NHS was founded in 1948, half the population died before the age of 65. Now, the average life expectancy is 80, with the rich living 15 years longer than the poor and having 20 more years of healthy living. Inequalities in health and truly staggering. One in three children born today will live to 100, but one in four boys born in Glasgow still won’t make it to 65. One in three people will get cancer, one in three will get diabetes and nearly everyone will get heart disease. Obesity appears unstoppable. Liver disease, kidney disease, musculoskeletal disease, depression and anxiety are all on the increase.  Mental illness currently costs the UK over £70 billion a year and one in three people over 65 will die with dementia. Many people with dementia live for many years, even if they haven’t been properly diagnosed and treated. Dementia alone already costs the economy more than cancer and heart disease put together. Some patients have three of more incurable diseases, and are on multiple medications the combined effects of which are unknown.

The NHS and social care system is crucially dependent on millions of  unpaid carers and the round-the-clock pressures and responsibilities they face are huge. If carers went on strike, the NHS and social care service would collapse overnight.  Already the NHS is unable to provide safe staffing levels and care around the clock. Staff recruitment and retention is critical in some areas and some specialties. Your ability to access care and the standard of care you get across the NHS is hugely variable as are the outcomes for just about every disease. Your chances of survival even depend on what day, and time of the day time of the day, you get sick.

Every other western country is facing similar problems and the NHS at least has the potential to properly coordinate care in one single, joined up system had it not been forced down the route of marketization.  Burnham has said Labour will repeal the competitive element of the Health and Social Care Bill, and make the NHS the preferred provider of services. Both he and Norman Lamb spoke of a single health and social care system with a single budget, with patients having ‘whole person care’ delivered by single team. Burnham believes this will be ‘a 10 year journey’.  Lamb wants immediate action now to legally oblige health and social care commissioners to pool their budgets. The theory is that elderly patients with high medical needs also have high social care needs, so there is currently a lot of duplication of effort, miscommunication and patients falling down the cracks between services.

Nobody is promising extra money, despite the ever increasing demand, and it’s likely the NHS may hit a wall before the election. Hunt is hoping to kickstart integration with ‘a better care fund’, which transfers £3.8 billion of existing NHS money to social care services in the hope that it will pay for itself by reducing emergency admissions. However, cuts in existing social services have been so savage it may only just keep social care afloat and not keep patients out of hospital. And it seems inconceivable the NHS could lose so much money without affecting patient care. Hunt has publicly promised an end to NHS cover-ups and to support whistleblowers and carers who speak up, which could come back to haunt him before the election were it not for the monstrous back log of unresolved tragedies still awaiting truth and reconciliation.

At Morecambe Bay, the role of the Parliamentary and Health Service Ombudsman (PHSO) has at least moved a step closer to proper scrutiny. The PHSO have been subject to wide spread criticism following the revelation that they refused to investigate the death of Joshua Titcombe in 2008(Eyes passim). The PHSO stated at the time that there would be ‘no worthwhile outcome’ in pursuing an investigation. Years later, in 2011, Joshua’s death was eventually subject to an inquest which revealed serious failures in his care and triggered a review by Monitor which found 119 serious risks to mothers and babies in the unit.

Information obtained under the Data Protection Act by Joshua’s father shows that the case advisor at the time had recommended an investigation but the former Ombudsman, Ann Abraham declined to investigate  following non documented meetings with Cynthia Bower, the former CEO of the Care Quality Commission (CQC), in months before the  last general election. Mr Titcombe wrote to request an internal review of these circumstances in July 2013 but the new Ombudsman, Dame Julie Mellor refused the request. The events at Morecambe Bay are now subject to an independent investigation led by Bill Kirkup, but the Ombudsman initially refused to participate in this process too. The Eye has learned that Mellor has now made a u-turn and agreed to ‘fully cooperate’ with Dr Kirkup’s investigation. But why have the PHSO gone to such lengths to avoid proper scrutiny of its actions at Morecambe Bay? All eyes are now on Dr Kirkup to provide the answer. Hopefully before May.