Babylon or Bust

Perhaps the biggest crisis facing the NHS is the shortage of GPs. In 2016, 92 practices closed (including 34 mergers), and many patients now have to wait three weeks for a routine appointment. Health Secretary Jeremy Hunt promised 5000 more GPs by 2020, but in the 3 months to December 2016, there was a drop in full time GP numbers of 445. Numbers of GPs in training were up by just 147 in 2016. NHS England is now desperately trying to import GPs from countries that need them even more than we do, and train 1000 physician associates – who are currently unregulated – to take on GP work. Hunt’s other big hope is to use technology to take the pressure off GP practices.

Telephone triage, where all patients are screened on the phone by GPs to determine if they need a face to face consultation should – according to NHS England –  result in 20 per cent less A&E usage and cost savings of £100,000 per practice. However, when the scheme was tested in a proper trial published in the BMJ, it found that almost half of the patients who had a phone conversation still had to be seen in person, there was only a 2% drop in A&E attendances and this was dwarfed by rising costs from extra numbers being admitted to hospital (around £12,000 extra per 10,000 patients). Phone consultations worked well for simple problems but many patients had highly complex needs.

Undeterred, Hunt has announced ‘a decade of patient power’ by launching an NHS app which will (by the end of 2018) allow everyone in England to read their medical records 24 hours a day (some sadly will), book a GP appointment, order repeat prescriptions, check symptoms, encourage self-treatment or be ‘signposted’ to the best place to go for help. Quite how an App will succeed in cutting workload and costs when GP telephone triage and the NHS 111 phone triage has failed remains to be seen. The bottom line is that all new technology has to be rigorously tested not shamelessly promoted.

NHS 111 in North London has a contract with Babylon to use its Artificial Intelligence software in an App which doubtless it hopes will take the pressure of its call handlers and the rest of the NHS. Hunt even promoted it in a recent speech. Babylon was founded by Ali Parsa (who resigned as CEO of Circle after it withdrew its contract to run Hinchingbrooke hospital) and provides private GP services by video link and has corporate contracts with Bupa, Sky, and Boots. Earlier this year the Advertising Standards Authority told Babylon to stop saying on its website that it had the “world’s best doctors” and the “world’s most advanced AI [artificial intelligence]” after a complaint from GP Dr Margaret McCartney. Today, it just claims to use ‘the best doctors’ with no supporting evidence.

The website also claims that “An independent study tested the app’s symptom checker against nurses and junior doctors. It found that the app gave safe advice 100% of the time, whereas doctors gave safe advice 98% of the time, and nurses gave safe advice 97% of the time. It also found that the app is more accurate than doctors or nurses, sending patients to the most appropriate place for their treatment more often than either doctors or nurses. This means that the app not only gives safe advice, but also saves patients from spending time in Accident and Emergency or at their GP’s surgery when this isn’t necessary.” But as McCartney observed in the BMJ: ‘This study was not “independent”: it had six authors; five are current or past Babylon employees while the sixth is Parsa. The study is not indexed in PubMed and was not a real-life trial of how humans use the app but a simulation using actors and invented scenarios. I would not regard it as a trial. It omits essential details about the clinical scenarios tested.’ And it hasn’t been properly peer reviewed.

Babylon claims that its partnership with NHS 111 is an independent pilot programme set up to evaluate the technology, but McCartney has been asking since March for details of the pilot study, how they would assess any harms from the scheme and what proof they have that it is ‘100% safe’.

Parsa, meanwhile, has asked “Why couldn’t Babylon be a patient’s NHS GP?” His medical director (and GP) Mobasher Butt wrote in the BMJ. ‘Our AI app has reduced same day GP consultations by 40% by appropriately providing reliable healthcare information, self-management advice and pharmacy support. As a result, we have been able to keep waiting times for our list of hundreds of thousands of patients in the UK at a matter of hours rather than days or weeks. And 93% of users give four or five star ratings.’ Alas Dr Butt gave no references. Patient satisfaction is no substitute for proper scientific evaluation. Before Babylon replaces NHS GPs, we need robust proof that it works. Babylon’s claim to be 100% safe and have the world’s best doctors and AI are unsubstantiated drivel.

Winter is Coming

Does the NHS have enough beds to cope with the pressures of winter? Simon Stevens, the chief executive of NHS England says the NHS has ‘six to eight weeks to prepare’ and that the flu season could be bad given the H3 strain outbreaks in the antipodes that are heading our way. Simon says there are up to 3,000 NHS beds that could be freed if social care had the capacity to take patients that no longer need to be in hospital (so-called Delayed Transfers of Care DTOC). And yet NHS Improvement has warned that £1 billion extra investment in social care has failed to reduce DTOCs, and council leaders have written to Jeremy Hunt to say their DTOC targets are ‘undeliverable’.

This seasonal crisis comes on top of the everyday crisis of finding beds for patients in the NHS. The 2014 OECD league tables show that the UK, at 2.8 beds per 1000 people, has amongst the lowest for the number of hospital beds relative to population size, with England pretty much at the bottom. In the last decade, more than one quarter of hospital beds have been closed, with 37,000 fewer general and acute beds now than in 2006/7. Long stay NHS beds fell off the NHS under Margaret Thatcher, and with care homes closing every week due to debt and poor care, there simply isn’t the capacity in hospital or the community to cope with the demands of an ageing population. The UK’s hospitals are already among the fullest in the OECD, with occupancy above 90% and knock on effects for safety.

Stevens fails to mention that the situation may well get worse with the bed closures planned in the 44 Sustainability and Transformation Partnerships (STPs). Many of these have yet to be fully published and publically scrutinised, despite strong campaigning from groups like 38 Degrees, which makes a mockery of the government’s previous ‘no decision about me without me’ pledge. Jeremy Corbyn claims that STPs will cut a third of hospital beds, based on a sample of STPs brave enough to put figures on their plans. In Derbyshire, 535 of 1,771 beds will be cut by 2020-21 (30%). West, North and East Cumbria plans to reduce beds in cottage hospitals from 133 to 104, with beds at Cumberland Infirmary and West Cumberland Hospital going from 600 to 500 (an 18% cut).

A survey of England’s Clinical Commissioning Group chairs and accountable officers by the Health Service Journal last October was more revealing. Of the service changes planned or likely under STPs, 52% were closing or downgrading community hospitals, 46% predicted a further reduction in inpatient beds, 31% panned closures or downgrading of a full A&E service, 30% were planning closing an urgent care centre, 23% planned reductions in staff in acute services, 23% were stopping inpatient paediatrics in 1 or more hospitals and 21% were planning stopping consultant led maternity services in 1 or more hospitals. If these changes are a rational centralisation of expertise into bigger centres with better outcomes, fine. But the suspicion is that many changes are being enforced to make £22 billion savings rather than improve the quality of care, which is why the plans need full scrutiny.

Many of the same CCG leaders weren’t confident their STPs would deliver, citing lack of funding, political opposition, staff opposition, public opposition and inability to control the demand for NHS services as likely barriers. The theory that some hospital admissions could be prevented by better care in the community is sound, but it requires substantial investment in community services. Cutting hospital beds further to fund that investment is likely to backfire. Many patients who require hospital care are too sick to be treated in the community. Analysis of the spike in deaths in 2015 published in the British Journal of Healthcare Management suggested that a rise in various infectious agents, both viral and bacterial, was a more likely trigger for death than austerity. Some patients will have died anyway, but lack of capacity in the NHS means that far too many are getting poor quality care, particularly towards the end of life. Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, has analysed the section 28 reports of the chief coroner, who is obliged to report on deaths where there is a risk of other deaths occurring in similar circumstances. The reports suggest a significant decline in ambulance safety over recent years, particularly due to slow handovers in overcrowded A&Es preventing treatment and tying up the ambulance crew. There were also 48 warnings about the ability of ambulance services to handle the volume of calls and respond appropriately. Simon Stevens is right to warn of the perils of the seasonal H3 flu strain. But the strain on an overfull NHS and social care system is year-round, and patients and staff are harmed each day

Hunt v Hawking

Why did health secretary Jeremy Hunt choose to have a public spat with Professor Stephen Hawking about statistical analysis and the future of the NHS? Accusing Hawking of spreading ‘pernicious falsehoods’ was a high-risk strategy, but Hunt has an ego, is proud of his record as health secretary and took the bait. Hawking suggested the NHS is heading towards a US-style insurance system, run by private companies, citing the increasing involvement of the private sector in the NHS as evidence for this. Hunt argued the government has no plans to introduce an insurance system and the private sector currently takes only 7.7% of the NHS budget. But as former Tory prime minister John Major during the Brexit debate; ‘Michael Gove wanted to privatise the NHS, Boris Johnson wished to charge people for health services and Ian Duncan Smith advocated moving to a social insurance system. The NHS is about as safe with them as a pet hamster would be with a hungry python.’

In 2005, Hunt co-authored a policy pamphlet with Gove, Douglas Carswell and others which proposed a universal insurance system for the NHS and stated; ‘Our ambition should be to break down the barriers between private and public provision, in effect denationalising the provision of health care in Britain.’ Hunt’s current position is that the NHS will remain ‘a single-payer system’, funded from general taxation, and by his definition would remain a public service even if all its services were privately provided. However, private provision transfers significant power and funds to profit-seeking shareholders and to many (including MD), that constitutes privatisation of the NHS.

Simon Stevens, the current NHS England chief is credited with accelerating competition and private outsourcing under Tony Blair, later boosted by Andrew Lansley’s health act, but the NHS is now having to live with the disastrous consequences. A report by the Centre for Health and Public Interest has found that in the last 6 years, companies that run PFI contracts for the NHS have made pretax profits of £831 million that could have been spent on patient care. In the next 5 years, £973 million of NHS funds will go to PFI companies. And up to £4.5 billion been squandered on setting up, administering and regulating a rolling program of competitive tendering in the NHS since 2012.

Hunt and Stevens stand no chance of making their planned £22 billion of austerity savings by 2021 by fragmented competition. Instead, the English NHS is trying to move to ‘place based planning’ where local services merge, rather than compete, in the form of 44 Sustainability and Transformation Partnerships (Eyes passim). Each STP is expected to make its share of eye-watering savings, and some will try to become Accountable Care Organizations. As Hawking pointed out in The Guardian: ‘An ACO is a variant of a type of US system called a health maintenance organisation in which all services are provided in a network of hospitals and clinics all run by the HMO company. It is reasonable to expect the powerful US HMO companies such as Kaiser Permanente and UnitedHealth will be bidding for the huge contracts to run these ACOs.’ Hunt trumpeted Kaiser as a model for future NHS care at the Commons health select committee in May 2016. The NHS could run its ACOs but Lansely’s Health Act may force it to put them out to international tender to Kaiser etc.

Other cunning plans to balance the NHS books include selling off its ‘redundant’ land and building assets to property developers on the cheap (see the Naylor Review), encouraging the NHS to take on more private work and further discouraging GPs from referring patients to hospital. Referral management centres started under Labour but are escalating such that all referrals will be triaged weekly by clinical peer review. A third of these centres are currently run by private companies, the rest by the NHS at a total cost of £57 million since April l 2013. Some patients may not need referral, but others who need hospital treatment may be refused or delayed.

Hawking also criticised Hunt’s cherry picking of weekend mortality statistics based on a single paper in the BMJ. Hunt’s defence was ‘that to decide that one piece of research is the most credible is not cherry picking, it is doing what you have to do when researchers disagree.’ Bollocks. What you do is a systematic review of all the existing studies, not choose the one you like the results of. Orthopaedic registrar Ben Dean discovered the updated study originated from a request by Simon Stevens in a ‘7 day services meeting’ involving senior NHS England members and Deloitte. So perhaps not quite as independent as Hunt claims. Before the paper had been properly peer reviewed and published, NHS England was using it to justify changes to junior doctors’ contracts, and this bad science subterfuge was one reason the conflict turned so sour. People may die at weekends because of chance, because they are sicker than those admitted during the week, or for lack of care. The deaths could be avoidable or non-avoidable. If research shows more services are needed, it will probably need extra staff, rather than shifting around the existing staff who can barely cover weekday shifts. The NHS could well be safer at the weekend but Hunt’s alienation of a generation of junior doctors is unlikely to help.

If the NHS can really make £22 billion more savings without harming staff and patients, Hunt and Stevens will deserve their place in history. MD’s money is on the NHS struggling along in heavy debt, cutting services, increasing waits and mopping up the crisis in social care that Theresa May is now too frightened to address. Merging health and social care into a single ‘care’ system makes sense but is fiendishly hard to do if one is tax-funded, the other is means-tested and the division is grossly unfair. For many, Nye Bevan’s promise of state funded ‘cradle to grave care’ has long since vanished.

Chris Day, Round 3

In 2014, Dr Chris Day was a junior doctor working on the Intensive Care Unit at Queen Elizabeth hospital in Woolwich, which at night routinely did not adhere to national staffing levels, putting patients at risk and placing huge stresses on the competent and dedicated staff. Day made a protected disclosure detailing these concerns on the night of 10 January 2014, but the Trust and Health Education (HEE) decided not to act on them, terminating his contract with what Day believes were false allegations and stalling his progress to consultant. HEE is an executive non-departmental public body, sponsored by the Department of Health, which – with local Deaneries – recruits doctors in training, supplying them to various Trusts, monitoring and appraising them. Like many whistleblowers, Day was forced down an employment tribunal route. His legal team argued that HEE should be held accountable for any detriment he has suffered under employment and whistleblowing law. HEE contended that “even if the facts alleged by Dr Day were true, HEE could not be liable in law for any acts causing him detriment.” In taking the case to court in 2015, Day discovered that the government was arguing 54,000 junior doctors out of whistleblowing protection. Day lost round 1

Seasoned whistleblowers argue that the existing protection is barely worth having anyway. As Dr Minh Alexander explains ‘The current UK whistleblowing law, the Public Interest Disclosure Act (PIDA), pays little attention to whistleblowers’ disclosures and does not compel employers to investigate them.  In a safety critical sector like the NHS, this puts lives at risk. NHS policy does not provide any failsafe for investigation of individual whistleblowers’ concerns where employers fail to conduct or commission local investigations properly, or at all. NHS regulators rarely use their discretionary powers to conduct wider investigations even when there are clusters of whistleblowers. And the law provides only a post detriment right to claim compensation. What is needed is pre-detriment protection from the point of disclosure.’

Health Secretary Jeremy Hunt claims to have made progress in appointing ‘freedom to speak up guardians’ to every trust and a national guardian to oversee them, but Dr Alexander is scathing. ‘These guardians have no defined responsibilities under the Act other than to receive disclosures and to publish relatively superficial data about them. Many are under the line management of the trust or government departments and there is a conflict of interest if whistleblowers raise concerns that relate to failure of government policy or performance, such as the consequences of the current cuts in the NHS. Whistleblowers frequently perceive that regulators close ranks to suppress their concerns. The National Freedom To Speak Up Guardian’s office has been established without any of the necessary powers to properly protect whistleblowers and is subordinate to the CQC.  It will not review cases until all processes are concluded, including Employment Tribunal claims. By the time the National Guardian may deign to review a case, the whistleblower would likely be hung out to dry, in poor health, broke, de-skilled, unemployable and blacklisted.’

Whistleblowers also rarely succeed in the courts (Eyes passim), but Dr Day is to be commended for his persistence. In May 2017, the Court of Appeal found that Hunt and the HEE’s arguments to deprive junior doctors of statutory whistleblowing protection were legally flawed. Day is now going back to an Employment Tribunal to bring a case against HEE and the trust. This could take years to complete. In July, 3 years after Day first raised concerns about intensive care at QEH, an independent review detailed a complete lack of medical leadership, low consultant staffing levels and inadequate clinical governance. There were 19 patients to each consultant, escalation of deteriorating patients was ineffective and there was a poor culture of incident reporting. Had Hunt and the NHS listened to Day’s concerns in 2014, this may have been prevented. So why has Hunt and the DH spent millions trying to shut Day up, rather than hear his story? In 2013 South London Healthcare Trust, which ran QEH, was crippled with a terrible PFI deal, forced into a bankruptcy regime by the Trust Special Administrator with savage cuts to services and widespread staff demoralisation that made recruitment very hard. The government’s actions may well have precipitated the crisis in QEH ICU. Unsurprising Hunt wants to delay Day as long as possible. Meanwhile, even the GMC has spotted the wider consequences of the case, reporting that English doctors in training don’t feel protected by HEE to speak up and are ‘less secure about raising concerns for fear of suffering detriment to their career.’ Hunt’s pretence that the NHS now encourages and listens to whistleblowers simply doesn’t stack up.

You can support Dr Day’s case at www,crowdjustice.com/case/junior-doctors-round-3/

Pay up or die

Health Secretary Jeremy Hunt’s pledge of £1.3 billion to improve mental health services may repair some of the damage of the last five years but it’s unlikely to provide ‘parity of esteem and provision’ with physical health services. Indeed, it can be divisive and harmful to separate the two as they frequently occur together. Chronic physical illness can have profound psychological consequences, and those suffering severe mental illness are far more likely to die prematurely from physical illnesses (Eyes passim). What’s needed is the holistic care of properly funded GP and community services.

The Health and Social Care Act (2012) made it unlawful to discriminate between physical and mental health, but the NHS has always raided mental health budgets to prop up other, more high profile services. There are now 6,000 fewer mental health nurses and 170 fewer psychiatrists in England than there were in 2010. In 2016, a government report found mental health services can’t cope with demand. Suicide in England was rising following many years of decline, with 4,477 people killing themselves in an average year. There was a 10% increase in the number of people sectioned under the Mental Health Act. One in 10 children and adolescents had a diagnosable mental health problem, but the average wait for a specialist appointment was 21 weeks in 2014, and many appointments were cancelled at short notice due to staff shortages. A quarter of people with severe mental health problems were getting less support than they needed and were high risk for self-neglect and suicide.

The average maximum wait for a community mental health team appointment in 2016 was 30 weeks. Mental health wards were dangerously overfull and routinely in breach of safe staffing guidance, with patients – including children – shunted all over the country for specialist care. One in five women develop a mental health problem during the perinatal period but less than 15% of areas provided effective services for women and 40% provided no service at all. Despite this damning report, 57% of clinical commissioning groups cut their mental health budgets last year, and further services were cut.

Hunt’s belated cash injection is clearly welcome but the idea that an extra 21,000 specialist staff – including psychiatrists and psychiatric nurses – can be trained or recruited in four years is sheer fantasy. The government won most seats by promising to continue austerity, and so sustainable funding for mental health in the future will only come from savings elsewhere. Sustainability and Transformation Plans in England are simply a smokescreen for changes in NHS services at three levels. Specialist changes that improve the quality of care should be welcomed by all. The fact that so many people survived horrific events in Manchester and London is not just down to the excellence of the staff but also that major trauma services have been concentrated in centres of excellence. Improvements in stroke and cardiac care are other examples. The second level of closures and mergers are happening because some services just can’t be safely staffed 24 hours a day. Emergency and maternity departments will close overnight or for good because they can no longer provide safe care. And the third level of changes are simply to save money. Merging services will be inconvenient for those who have to travel further, and may sometimes be dangerous. But for money to be invested into community care, general practice and mental health, if first has to be sucked out of hospitals. And none of this gets anywhere near addressing the crises in social care and the collapse of care homes.

The alternative is to put more money into health and social care, but the electorate had a shit fit at Theresa May’s suggestion that people should use their homes as after-death collateral on social care costs, and the LibDems pledge to put a penny on income tax for NHS and social care also bombed. Brexit is likely to make the economy weaker in the short term and make recruitment and retention of EU staff much harder. 86,035 jobs in the English NHS were advertised in the first quarter of this year, and these vacancies don’t include general practice or the thousands of jobs that aren’t advertised because they simply can’t be filled. Add in the public sector pay cap, abolition of nursing bursaries and real terms cuts in the NHS budget over the next few years, and it’s hard to see how universal care can survive. On a brighter note, the NHS again topped the Commonwealth Fund analysis of the health services in 11 countries, coming top for process, access and equity but – bizarrely – tenth for outcomes. The NHS is a very fair system that isn’t very good at keeping people alive. After 7 years of austerity, increases in life expectancy have ground to a halt. Perhaps this is the secret strategy to take pressure off social care. Allow the poor to die from austerity and poor care, whilst anyone with assets is left to fund their own social care or rely on relatives to do the caring for them. It’s a plan, but perhaps not the plan Nye Bevan envisaged for an NHS approaching its seventieth year.