Something has to give (and it’s not the Treasury)

As MD predicted (Eye last), the NHS England board responded bullishly to being given 40% of what every expert authority (apart from the Treasury) deemed necessary to keep the NHS upright for another year. Whilst Philip Hammond and Jeremy Hunt insist the extra money be used to get waiting times back on target, NHS England declared bluntly that ‘NHS Constitution waiting time standards will not be fully funded and met next year’.  NHS England also said that new advisory National Institute for Health and Care Excellence guidelines would only be implemented ‘if in future they are accompanied by a clear and agreed affordability and workforce assessment at the time they are drawn up’. So even if NICE says a new treatment is effective and good value for the NHS, it may only be provided in your area if the funding and staff are available. Pretty much what happens now.

The NHS probably could do more to reduce waste and variations in the quality of care, but it was the Conservative’s lethal Health and Social Care Act 2012 that has squandered billions on unnecessary reform, compulsory tender and transaction costs, substandard outsourcing and a fragmented system that struggles, in Nye Bevan’s vision, to ‘universalize the best.’ NHS England is at least being honest with the public about the harsh consequences of continued austerity, but many staff are worried that their hasty move to ‘accountable care systems’ in England is less about joining up care and more about outsourcing it en masse.

Performance problems in the NHS are not exclusively English. Wales has consistently failed to hit its targets for A&E waits, routine operations and cancer care. In 2012-13 it did not hit any of its monthly targets and in 2016-17 it was the same. The last time a target was achieved nationally was 2010. Northern Ireland cut its target for planned operations and care from 80% to 55% but has still not hit it. Scotland has a more ambitions 18-week target of referral to treatment of 90% but only 81.4% of patients hit that target in September 2017, the worst performance since 2011, and the number of people waiting more than the 12-week target for outpatient appointments, and for inpatient and day case treatment, has also increased.  But it’s the NHS in England that has seen the biggest deterioration. Last year, it missed every monthly waiting target. The problem is that a decade of near flat-line funding has coincided with a sharp rise in demand. A typical hospital will be dealing with 5000 new cases of cancer a year with the same number of oncologists. The number of A&E visits made each year across the UK has risen by 20% in four years to over 30 million, while the number of cancer cases has risen by more than a quarter to over 170,000. Staff increases have been tiny in comparison. Something has to give.

English trusts have already put bids in for a slice of Hammond’s £335 million ‘winter pressures fund’ but hospitals struggle to discharge patients due to the enduring crisis in social care. Despite a huge national drive to cut delayed transfers of care (formerly ‘bed blocking’), less than half the 2,400 beds targeted to be freed up for winter has been achieved, and the number of ‘bed days lost’ increased in the last quarter to 297,019. This does not bode well for winter, and neither does the crisis in care homes. More than half of care home places in some parts of England are in facilities rated as ‘inadequate’ or ‘requiring improvement’, according to a Which? analysis of Care Quality Commission (CQC) data. In Westminster alone, 69% of places aren’t up to standard.

Four Seasons, the UK’s second largest care home provider responsible for 17,000 residents, is £525 million in debt and struggling to cope with state funding cuts, the national living wage and staff shortages since the Brexit vote. A report by the Competition and Markets Authority has found that state funding for care home places is down by 8%. 75% of care home residents are Local Authority funded and on average they are paying 10% less than their actual costs. The average cost for a self-funder in 2016 was £846 per week (nearly £44,000 per year), while LAs on average paid £621 per week. This disparity has caused a deficit of £300 million, which will either be sorted by charging private payers more, refusing to take on state funded places, or closing care homes. Finally, research by Quality Watch calculated that care home residents in England had 40-50% more emergency admissions and A&E attendances than the general population aged 75 and over. So demand for care home places is up but care homes are in debt and closing, the lack of care home places is preventing the transfer patients out of hospital, and those that make it to a care home are far more likely to end up back in hospital. Hammond’s budget short-changed the NHS but made no mention of the crisis in social care. If the system can’t cope now how will it be in 2025, when the number of over 85s will have grown by 35% to 2 million?

Hammond’s Trap

Chancellor Philip Hammond had to give the NHS some extra funding to fulfil the government’s pledge of a year on year real terms increase in health funding per head of the population. Predictably, he promised just 40% of what just about every expert authority calculated was necessary for the service to remain upright. He then compounded the pressure by demanding that the extra £1.6 billion for next year must resurrect the long-lapsed targets for waiting for non-urgent operations (18 weeks) and in emergency departments (4 hours). He knows the NHS hasn’t got a hope in hell of doing this, so the strategy must simply be to set up NHS England CEO Simon Stevens as the fall guy for failure.

Stevens incurred the wrath of Hammond and Theresa May by firing a very public pre-budget broadside at a conference in November when he warned that the NHS waiting list was heading for 5 million by 2021, that the government may be forced to “publicly, legally abolish patients’ national waiting times guarantees” and that it would become “increasingly hard to expand mental health services or improve cancer care.” By ordering Stevens to get waiting times back on track with 40% of what he asked for is Hammond’s attempt to put the NHS boss back in his box.

He is unlikely to succeed. Stevens is fiercely political. He had a constructive relationship with David Cameron and George Osborne which allowed him to make the absurd pledge that the NHS could make £22 billion of savings with just £8 billion of extra investment, hoping that this was just a starting position and he could secure extra funding in time. His relationship with May and Hammond is much frostier, and not helped by the government’s persistent misrepresentations about how much new money the NHS has already received (Eyes passim). So Stevens has decided to play hardball, cleverly citing the duty of candour which health secretary Jeremy Hunt introduced in direct response to the Mid Staffordshire disaster, which places a statutory obligation on all NHS staff to be honest, open and transparent if patients have been harmed or are at risk of harm from failures in care and underfunding. If all NHS managers and staff follow suit, it’ll be a very interesting winter.

Stevens also knows he has the experts on his side. The Care Quality Commission, the Health Select Committee, the Audit office, the NHS Confederation, the BMA, NHS Improvement, the Royal Colleges, the Patients’ Association and the Institute for Fiscal Studies have all warned that current funding levels are harming patient care. Independent experts at the Nuffield Trust, the Health Foundation and the King’s Fund together concluded that the NHS will need an extra £4 billion a year just to keep it functioning safely. As Stevens pointed out; ‘There is nothing out of the ordinary about needing such a sum. It would be a return to the average increases of the first 63 years of the NHS’s history, as against the exceptional choking back of funding growth of the past seven years. On the current budget, far from growing the number of nurses and frontline staff, in many parts of the country next year NHS hospitals and other services are more likely to be retrenching and retreating.” By offering 40% of what the best analysis says is necessary, and as a one off, Hammond and May know patients will continue to suffer. Stevens is being lined up for blame, but he will not go quietly.

Meanwhile, health secretary Jeremy Hunt buzzes around like a hyperactive stick insect, picking more unnecessary fights on twitter (scientist Steven Hawking, actor Ralph Little, 55,000 junior doctors, anyone who wants to come and have a go if they think they’re hard enough). His faith that technological innovation and management consultancy will lead the NHS out of the swamp seems undimmed despite evidence to the contrary. Commissioners in London have ditched a planned pilot of Babylon Health’s primary care symptom checker app (Eyes passim) after patients in a test used it to game the system and jump the queue to see a GP, rather than its intended aim of reducing the need to see a GP. The initial excitement about Care B’n’B – a scheme where the NHS rents out the spare room in your house to get patients out of hospital – has died down until the risks of poor care, abuse, and lack of regulation were properly considered. It may resurface in time. MD has recently stayed in a B&B in Australia, without realising it was next to a hospital. One guest was tube feeding with extensive oropharyngeal cancer, another with severe heart failure wore a portable defibrillator and the fridge was full of soup, juice and prescription-only drugs. It worked because patients and carers took full responsibility for their treatment, and what they took from the fridge. The nearby hospital has sensed an opportunity and is now planning a hotel for patients and carers. It’s hoping to make money in room charges and save money by freeing up its beds. But who will be blamed if it goes wrong?

The Private Cancer Lottery Part 2

If you have private health insurance and need treatment, should you accept a cash bung to use the NHS? Most insurers offer this, typically £7,500 in the case of a life-threatening cancer. This makes sense in cases where the NHS has access to treatment or expertise that would result in a better outcome, but the motive of the insurers is simply to save money. A standard course of radiotherapy might cost £15,000, with similar fees for surgery, and the new chemotherapy drugs average £75,000 a year . So insurers can save millions by bribing desperately ill patients to switch to state funded care.

Private insurance varies enormously in cost, depending on your age and the level of cover you want to pay for. If you’ve had it for many years, you will likely have paid far more than and lump sum being offered. If you’re in a company scheme, you might be tempted take the cash. But generally, private patients now go to the back of the NHS queue when they switch sides. The days when a consultant you’ve initially seen privately could bump you up the NHS waiting list are largely gone. So by offering you cash when you’re desperate, insurance companies know you may wait longer and get a worse outcome (although private hospitals are far from risk free – see Eye last).

Many patients opt to go private not just for speed of treatment and choice of consultant, but in the hope they’ll get access to, say, new technologies and cancer drugs that have yet to be approved by NICE and aren’t available on the NHS. This is worth it if they turn out to work, but there is always the temptation in private medicine for doctors to over-test and over-treat because they have a financial incentive to do so. And doctors are not helped by regulators who approve new cancer drugs on flimsy evidence. The British Medical Journal reported two studies recently. The first found that between 2008 and 2012 the US Food and Drug Administration approved uses for 36 cancer drugs without evidence of survival or improved quality of life. Only five were shown later to improve survival compared with existing treatments or placebo after a median of 4.4 years on the market.

In cancer drugs approved by the European Medicines Agency between 2009 and 2013, 57% (39 out of 68) had no supporting evidence of better survival or quality of life when they entered the market. After a median of 5.9 years on the market, just six drugs had been shown to improve survival or quality of life. And even when drugs do improve survival the benefits are often marginal. In the above study, of the 23 drugs that improved survival, 11 (48%) failed to meet the modest definition of “clinically meaningful benefit” set by the European Society of Medical Oncology. In another study, the median improvement in survival among patients treated with 71 drugs for solid tumours was just 2.1 months. And, says the BMJ editorial, ‘these small benefits of cancer drugs typically occur in trials conducted in unrepresentative patient populations—patients who are younger and with less comorbidity than average clinical populations When a marginal drug advantage is applied to a real-world population, a small benefit may vanish entirely because of the fine balance between risks and benefits typical of these agents.’ And the average cost is £75,000 a year.

Many cancer drug studies use surrogate outcomes, such as tumour shrinkage, hoping this will be shown to correlate with better survival at a later date. For patients who are terminally ill, have few other treatment options and don’t have time to wait for more research, then experimenting with unproven drugs may be worth it, particularly as part of an ongoing trial. But as one cancer specialist told MD; ‘Basically, we burn or poison patients to treat their cancer, and often both. In all the enthusiasm surrounding the newest cancer drugs and radiotherapy techniques, we have to remember these treatments cost loads, have very unpleasant side effects and can do far more harm than good.’

A plastic surgeon told me of a 96 year-old patient he was asked to see, who had developed a huge pressure sore largely because of the aggressive radiotherapy and chemotherapy he had received for metastatic cancer. ‘I just thought how unkind and unwise we have become.’ Private healthcare my offer you more treatment options than the NHS, but these rarely include palliative care. The temptation with cancer may be to be ‘treated to death’ rather than to be allowed to die gently. As one consultant told my step father; ‘Do you know why they put rivets in coffins? To stop the oncologists trying one last dose of chemotherapy.’ He opted for palliative care.

The Private Lottery

MD recently met a group of NHS oncologists, most of whom did private work and most of whom had private health insurance. The private work allowed them to supplement their NHS income and practice the standard of medicine they’d want for their friends and family (longer consultations, quicker access to treatment). And their private health insurance allowed them to get the care they’d want for themselves and their family. As one put it; ‘NHS waits are increasing and for some cancers, that dramatically reduces the effectiveness of treatment and your likely survival.’

Private health insurance, and self-pay for private care, is on the increase for those who can afford it, or whose employers wish to pay. With nearly 4 million people on the NHS waiting list after 7 years of flat-line funding, private insurers and providers are eyeing a big opportunity that will only get bigger with any drop in national income and loss of EU health workers accompanying Brexit. The Conservatives lifted the cap on the amount of private work NHS hospitals can do, to allow them to reinvest profits in NHS services. But as one Oxford consultant put it; ‘The local private services offer taxis to and from treatment. If you’ve got cancer, the extra stress of taking an hour to park at an NHS hospital and worrying about a fine if the clinic overruns shouldn’t be underestimated.’

The private sector has the extra assurance of knowing it can use the NHS as a safety net. A recent report by the Centre for Health and the Public Interest (CHPI) based on an extensive review of 177 CQC reports into English private hospitals has estimated that in the last three years, the NHS has picked up a bill of £250 million for sorting out complications that happened in private hospitals. Some argue that going private takes the strain off the NHS, and that these complications can also happen under NHS care. But transferring patients between hospitals carries its own safety risks and staffing levels in some private hospitals are still scandalously low. Many private providers also resist full scrutiny and make it hard for patients and the CQC to compare safety and quality with the NHS, even though many private hospitals treat NHS patients under contract.

The CHPI report – ‘No safety without liability: reforming private hospitals in England after the Ian Paterson scandal’ – makes 5 excellent recommendations. 1. Private hospitals should directly employ the surgeons and other consultants who work in their hospitals, rather than subcontracting the work out and having less control over rogue surgeons like Paterson, who was jailed for 20 years for grossly negligent breast cancer treatment.  2. Private hospitals will not be truly safe unless they have adequate facilities to deal with situations where a patient’s life becomes endangered following an operation, ending the hazardous transfer of patients to NHS hospitals. 3. Private hospitals must end the reliance on a single junior doctor (a Resident Medical Officer) working extreme shift patterns to provide post-operative care for patients. 4 Private hospitals should be required to adhere to the same patient safety reporting requirements as NHS hospitals in order to enhance the possibility of detecting any risk of harm to patients. 5 The legislation governing private hospitals should be amended to make clear that all those who are registered with the CQC should be fully liable for all the services which are provided within them, including the actions of surgeons and other healthcare professionals.

The inquiry into Paterson will doubtless be interminably protracted, so well done the CHPI for nailing the legislative and operational changes that need to happen now. The current situation is summed up by one of Spire’s legal representatives wrote to one of Paterson’s patients; the private hospital is ‘under no obligation to provide competent surgeons to perform breast surgery at the hospital.’ Private providers argue that it is the job of the NHS and GMC to ensure consultants who play for both sides are competent. But as a CQC inspection reporting to Kent Institute for Medical Services found; ‘The very large number of consultants with practising privileges posed a risk that they would see patients and provide treatment in an unfamiliar environment where they were not used to the equipment and did not know the local policies.’ And as one insurer told me; ‘There are still consultants  who play the system, overcharging and over investigating.  In some cases they claim to have removed, say, a  breast when the breast is still there. We repeatedly warn them but a few just carry on overcharging.’

There is some excellent private treatment available if you happen to know who the best, most ethical  NHS consultants are who also practice privately, and do so in well-staffed, familiar surroundings. But it tends only to be local doctors who have that local knowledge. Everyone else is currently in the dark.

The NHS, then and now

Health Secretary Jeremy Hunt was up to his usual cherry-picking tricks at the Tory conference, claiming that the brains behind the NHS was not Nye Bevan, but Conservative health minister Sir Henry Willink and his 1944 white paper. In fact, the idea for a state health service is usually credited to the social researcher and poverty campaigner Beatrice Webb in 1909. Lloyd George introduced state organised health insurance in 1911, but for workers only. Lord Dawson, President of the Royal College of Physicians, reported in 1920 that ‘the best means of maintaining health and curing disease should be made available to all citizens’ and it was William Beveridge who first proposed ‘cradle to grave care’ in his 1942 report. Willink’s contribution was important – garnering cross party support for a consensus that ‘everybody irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and Allied services available. The service should be comprehensive and free of charge and should promote good health rather than only the treatment of bad.’ But it was Bevan who fought the vested interests and made it happen in 1948. The Conservatives voted against the creation of the NHS 22 times, including in the third reading.

Bevan resigned from government in 1951, as a matter of principle over the introduction of prescription charges introduced to meet the demands both on the NHS and of the Korean war. Nothing, it seems, will tempt Jeremy Hunt to resign and five years in he is the NHS’s longest serving health secretary. His conference speech was full of praise for NHS staff and promised that they would get first refusal on any affordable housing built on NHS land that was sold off. Alas, the pressure on NHS finance directors to balance the books is so great it’s likely that any such ‘surplus’ land will be sold off in a hurry and on the cheap, rather than getting a proper market price for it. Hunt was ‘confident’ the 150,000 vital EU health and social care workers would be able to stay after Brexit but 18 months on could offer no guarantee.  Many are now leaving, and many more are no longer coming.

Hunt said that the ‘most important thing I have learned as Health Secretary’ is that turning around poor performance in the NHS ‘wasn’t about the staff, it was all about the leadership.’ It’s true that the NHS has some decidedly mediocre leaders alongside the great ones, and with an average tenure of 18 months the job of an NHS chief executive is hardly attractive. But Hunt also knows the NHS and social care system is falling off a cliff edge due to a lack of adequate staff numbers, and to suggest you can ‘lead’ your way out of the danger zone without more staff is laughable. Hunt knows this, but his belated decision to train more doctors, nurses, physician associates and nurse associates is too late.

The current state of play in the NHS makes grim reading. The CQC’s annual report found that more than a quarter of mental health trusts and almost a fifth of acute trusts previously rated “good” have got worse on re-inspection. There are 1.2 million older people with unmet care needs, and 90,000 vacancies in adult social care staffing. 2.5 million patients breached the 4-hour waiting time target, acute bed occupancy rates averaged 91.4% (85% is considered safe), and nursing home closures cut beds by 4,000. Over 2 million days were spent in hospitals by patients who didn’t want or need to be there, but had no alternative. Ambulances were stuck in queues in emergency departments resulting in 680,000 lost hours. Ambulance responses to life-threatening calls have risen by 22.5% over the past three years, and ambulance waiting time targets have not been met since 2015. The waiting list for consultant-led treatment has risen to 3.85 million – 25% higher than it was three years ago. 25,000 operations were cancelled last year in the NHS in England because of a lack of beds. And austerity has made it much harder for people to adopt healthier lifestyles and take the strain off the NHS.

A report by the Children’s Commissioner details ‘shockingly’ poor support from the NHS for children with mental health problems. 50% of local areas failed to meet standards on crisis care. Only 25% of the 210,145 children aged 5-17 with mental health issues received help last year. Vacancy rates for mental health nurses are 25% in London. There were 42,692 reported attacks on NHS mental health staff in 2016-17 in trusts who responded to an FOI, up from 33,620 in 2012-13. There are 1,000 fewer nurses and health visitors than a year ago. The number of GPs have fallen by 3% since September 2015. One in five practices report 2 or more vacancies, and waiting times for a routine GP appointment are commonly 3-4 weeks. None of this appeared in Hunt’s speech, so may not be on the radar of Brexit preoccupied chancellor Philip Hammond. But if he doesn’t get his cheque-book out on November 22, the chances of the NHS being ‘lead’ out of the crisis by Hunt are slim indeed.