The Budget 2017: three and a half ways it will impact healthcare

If you’re more sensible and more interesting than me, you probably haven’t looked through the thrilling contribution to world literature that is the Spring 2017 Budget.

For those who might still be interested in what our Government plans to do to healthcare spending but don’t have the time or inclination to read all 68 pages of figures, here’s a quick summary of the three healthcare related bits.

(1) £2 billion more for social care

While the NHS is struggling at the moment, social care currently looks like a Curly-Wurly being stretched between two hungry toddlers. Given that, the extra £2bn pledged over three years by Philip Hammond is welcome.

However, it’s estimated social care will need £2.8bn by 2019-20 so unless some more money can be found, or radical new policy solutions are found, social care is likely to be struggling for a while.

(2) £100 million for new facilities in A&E

A&E is in a perpetual state of just about managing, with January 2017 the worst month on record for waiting times. 15% of people had to wait longer than 4 hours to be seen, while the government target is 5%. Whether or not new facilities will stop people waiting longer, having £100 million of new buildings is nicer than not having £100 million to spend on new buildings.

Luckily, the idea proposed by the chancellor – having facilities for GPs to work in A&E – is not mandatory. While in principal having GPs in A&E to help triage patients is not a terrible idea, we don’t currently have enough GPs to fill jobs in GP practices. Transferring some of them to A&E and further exacerbating a community shortage doesn’t seem like the smartest move.

(3) £325 million for locally proposed capital investments.

The Department of Health’s latest wheeze is to get local NHS organisations to restructure themselves using ‘Sustainability and Transformation Plans’. Essentially, this means the NHS has been divided into 44 areas each with it’s own plan for how to make local services address local needs.

While local solutions are great and I’ll advocate localism as a solution for most things, they do allow Jeremy Hunt to say ‘well it’s your own plan’ when something goes wrong, which is probably the main reason they exist. Whatever the motivations, there’s going to be £325 million for local teams to bid for to build new facilities.

However, part of the criteria to receive the money is whether ‘the local NHS area is playing its parts in raising proceeds from unused land to reinvest in local services’. So effectively the policy is ‘sell some of your land, we’ll give you some money’ – which is an interesting way to encourage local creativity.

(3.5) 850 PhDs in Science, Technology and Maths

Not strictly a healthcare related bit, but additional funding for science PhDs is always a welcome thing. Investing in science and engineering always results in future benefits, and the Government has frequently said how much it values scientific research, so its good to see them putting their money where their mouth is.

 

That’s your lot. Nothing too horrendous, but nothing that’s going to radically change health or social care. Though Phillip Hammond has repeatedly said he’s going to make autumn the time when big money changes are made, so perhaps we’ll some more exciting things then.

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Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

More people are waiting over 4 hours to be seen in A&E than ever before, according to government statistics. Only 84% of people were seen within 4 hours in October 2016, the worst performance ever recorded in October, and 5% worse than last year.

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12 hour waits in A&E tripled between September October in 2016  Credit: John Ferguson

Not only did A&E have its worse October on record, so did 999.  Only 69% of patients who stopped breathing, or had no pulse, had an ambulance arrive within the recommended 8 minutes. This number fell to 63% when other types of life-threatening calls are included (e.g. severe bleeds, strokes).

To top off a truly disastrous triad for the NHS as it approaches the annual ‘winter crisis’, delayed transfers of care took up more time than ever before. Patients spent over 200,000 days in hospital in October, not because they were ill, but because they couldn’t be moved out of hospital. Delayed transfers (horribly known as ‘bed blocking’) occur for  many reasons, the commonest being unable to find spaces in either care homes or other NHS facilities.

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 Delays in providing mobility equipment can delayed people going home, leaving them at risk to infections and other illnesses  Credit: Matt Sawyers

These three indicators (999 waits, A&E waits and delayed transfers) act as a proxy measure for the slack in the NHS. Good numbers in each mean patients are flowing in and out of hospital in a timely manner. Bad numbers mean the NHS is becoming increasingly bottlenecked, and pressure is building up with the system.

Given that all of these indicators typically worsen over the winter, it seems unlikely we’ll be seeing any improvements in the data in the upcoming months. In all likelihood, we’ll see the most pressurised winter in the NHS since records began. Maintaining quality of care in such an environment will be a Herculean task.

 

Parliament ‘sceptical’ about NHS England’s ability to deliver on mental health targets

An influential committee of MPs released a damning report today into the state of Britain’s mental health system. They found that only 1 in 4 people could access the mental health services they needed.

The cross-party Public Account Committee, in charge of making sure the Government spends money efficiently, said pressure on NHS budgets would make the Department of Health’s new mental health standards ‘difficult to achieve’ without taking money away from other services.

The Department of Health has pledged £1bn over 5 years to improve mental health provision but this is not ring-fenced. With the current financial pressures across the NHS, it will be tempting for NHS managers to use that money to plug short-term holes rather than invest in long-term  mental health provision.

Specific problems cited in the report include:

  • A lack of counselling in some schools meaning many miss the chance to have their symptoms identified early  – half of those who experience mental health problems do so before the age of 14 
  • Variability in the provision of services – in some areas 99% of people are seen in 6 weeks, in others it is just 7%
  • Lack of access to mental health care for current and former prisoners – 9/10 prisoners have a mental health problem, 7/10 have two or more

The Public Account Committee recommended, among other things, that the Department of Health and NHS England did the following:

  1. Figure out how much money they needed to pay for its mental health program, and which areas of spending they prioritised
  2. Join up services across government to improve continuity of care for those with mental health needs e.g. housing, social care
  3. Work out how many extra nurses and additional staff they would require to roll out their programs

Why these things were not done prior to rolling out new nationwide standards is not recorded. However, they do show a continuation of the Department of Health’s remarkably lax approach to planning ahead and gathering evidence, as shown by this argument from their lawyer in yesterday’s court case regarding junior doctor contracts.

 

Jeremy Hunt meets with media execs 7 times in 3 months – but doesn’t find time to see the BMA

Jeremy Hunt had meetings with 7 senior media figures between January and March this year, a period that includes 4 days of industrial action by junior doctors.

Jeremy Hunt, the UK Secretary of State for Health and Dr. Mark Davies, Director of Clinical and Public Assurance at the Health & Social Care Information Centre, visited the Kaiser Permanente Center for Total Health for a tour, given by Bernadette Loftus, MD, Mid-Atlantic Permanente Medical Group, Kim Horn, President, Kaiser Permanente, Mid-Atlantic States, and Phil Fasano, Chief Information Officer
UK Secretary of State for Health Jeremy Hunt and Dr. Mark Davies visit the Center for Total Health. Credit: Ted Eytan

These included James Kirkup, Executive Political Editor at the  Telegraph; Hugh Pym, the BBC’s Health Editor and Alastair McLellan, Editor of the Health Service Journal, the trade magazine popular among NHS management.

These meetings follow on from eight meetings he had with media figures between October and December last year, including with the editors of the Sun, Daily Mail and the Telegraph. Hunt met both Amol Rajan, Editor of the Independent, and Tony Hall, Director-General of the BBC, twice in a six month period.

During this period, Hunt has met a grand total of zero times with the Junior Doctor Committee of the BMA, though junior ministers have met with the BMA to negotiate the new contract. Hunt has also met with other sections of the BMA including the Chair of the General Practice Committee, Chaand Nagpaul.

The full list of media figures Hunt met with from October 2015 to March 2016 is as follows:

  1. Fraser Nelson, Editor, The Spectator, October 2015
  2. Amol Rajan, Editor, The Independent, October 2015 and January 2016
  3. Tony Gallagher, Editor, Sun, 27th October 2015
  4. The BBC News editorial team, November 2015
  5. The Daily Telegraph editorial team, November 2015
  6. Tony Hall, Director-General of the BBC, November 2015 and January 2016
  7. The Mail on Sunday editorial team, November 2015
  8. The Daily Mail editorial team, December 2015
  9. Janine Gibson, Editor-in-Chief, Buzzfeed, January 2016
  10. Jim Waterson, Political Editor, Buzzfeed, January 2016
  11. James Kirkup, Executive Political Editor, The Telegraph, February 2016
  12. Alastair McLellan, Editor, Health Service Journal, March 2016
  13. Paul Goodman, Editor of Conservative Home, March 2016
  14. Hugh Pym, Health Editor, BBC, March 2016
  15. Fiona Godlee, Editor, British Medical Journal, March 2016.

Previous attempts to find out the content of these meetings were unsuccessful, with the Department of Health refusing to release details under the ‘development of public policy’ clause allowed under the Freedom of Information (FoI) Act. The BBC declined to release details of the meetings under the exemption granted to it to protect its journalism operations.

Yorkshire and Humber School of Radiology to be ran by a radiographer; a bottle of red with lunch blamed

In very specific, but very silly news, The Yorkshire and Humber School of Radiology and Health Education England have chosen a non-radiologist, supposedly Dr Anne-Marie Culpan, as its head. She has no experience of radiology and isn’t medically qualified. She is in fact, a highly capable academic radiographer who has a PhD and is a senior lecturer in breast imaging at the University of Leeds. So no slouch, but definitely not a radiologist – a fact so concerning to the Royal College of Radiologists (RCR) that they are trying to urgently meet with the school to ‘explore how the damage caused by this ill-informed and ill-conceived decision can be limited’.

Now I don’t seriously believe the interview panel didn’t know the difference between the two, but according to the RCR, there was no radiologist on the interview panel, and an experienced and qualified radiologist did apply for the job, so it’s in play. For those unaware, here’s a simple guide that works for most situations –  radiographers use the scanners to do the test; radiologists look at the images to see what’s wrong.


As Anthony points out in the comments, the line between radiography and radiology can get a bit blurry. Some radiographers give radiotherapy treatments; others report on the results of tests in the same way as radiologists. The description above is not to be conclusive.


Now for why this appointment was exceedingly dumb.

  1. Head of Schools are responsible for delivering the training set out by the Royal College of Radiologists. Anne-Marie Culpan cannot even be a full member of this college as she is not a radiologist, leaving her outside of the loop when discussing clinical training.
  2. They are responsible for pastoral and training support of all radiologists in the Yorkshire and Humber area, including those in higher specialty training. Anne-Marie Culpan has not done even foundational medical training, leaving a question open about how much understanding and empathy she will have with complicated training problems.
  3. Anne-Marie Culpan would be responsible for any concerns raised about doctors. While I generally don’t hold much of a candle to the argument that only doctors can pass judgement on other doctors, I quite like those in senior positions to understand what the juniors should and should not be doing. It’d be extremely inappropriate for a radiologist to be in charge of supervising radiographers in training, it is no different the other way around.
  4. I do not know much about Dr Culpan, but her academic and radiographic work seems to have been very focused on breast imaging.  It seems hard to visualise how someone will go from being a very specialist research and teacher in one sub-speciality of a profession, to supervising 125 trainees going through generalist and sub-specialty training in a totally different profession.

While just one appointment, it does seem to part of a trend that doctors aren’t quite necessary under the people running the NHS. To expect a radiographer to understand what its like to be a radiologist and do so well enough to train consultants in that area is a ridiculous idea. It’s the equivalent of having a doctor train nurses or pharmacists, or in the non-medical world, a mainstream school teacher trying to train special school teachers. Let’s hope Health Education England don’t try such a dumb appointment again.

A Look at Our New Health Ministers

Under our new PM’s cabinet, everyone in the medical community was very happy to see Jeremy Hunt return in his role as Secretary of State for Health. After all he’s done the impossible and united every health professional and student around one issue, namely the feeling that Jeremy Hunt has no really business being in charge of the NHS.

While our dear leader may not have changed, his underlings have. So say farewell to Ben Gummer (Hunt’s chief lackey), Jane Ellison, George Freeman and Alistair Burt. In come Phillip Dunne, Fiona Blackwood and David Mowat.

Nope, I’ve not heard of any of them either. Here’s a few titbits on each, as well as their voting record on major health bills.

 

Phillip Dunne (Minister of State for Care and Support; senior underling)

  • Voted against smoking bans
  • Didn’t vote on end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

Dunne owns a farm for which he drew £15, 793 from last year. Clearly that’s going well for him. His previous job as the Ministry for Defence Procurement has gone decidedly less so, to the point where problems with defence procurement make nearly every issue of Private Eye. The latest issue points out that the UK has spent $4bn on 9 patrol aircraft when the US managed to get 12 for $2bn. Let’s hope he doesn’t bring this kind of deal making to the cash-strapped Department of Health.

Additionally, Dunne went to Eton and Oxford so it’s good to see that underrepresented demographic get a chance in politics.

 

Nicola Blackwood (Undersecretary of State for Health Services)

  • Voted for smoking bans
  • Voted against end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

Blackwood has longtime experience as a patient in the NHS. Her childhood chronic fatigue syndrome meant she was home schooled for GCSEs and A-levels where she did well enough to go to Oxford. She has Ehlers-Danlos syndrome and postural tachycardia syndrome secondary so stays in regular contact with health professionals, which should help her ear close to the ground. Her fellow MPs thought well enough of her to elect her as Chair of the Commons Science and Technology Commitee in June 2015.

Less happily, she was part of the Tory rebellion in 2012 that killed off House of Lords reform. In  non-health matters, she voted against gay marriage and wants to repeal the ban on fox-hunting, so she’s not the most socially liberal MP out there.

 

David Mowat (Undersecretary of State for Public Health)

  • Voted for and against smoking bans
  • Has never voted on end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

The only non-Oxbridge minister in the DoH, Mowat is a chartered accountant by trade. This should help him get along with the head of the Care Quality Commission, Peter Wyman, who was a beancounter for PricewaterhouseCoopers until 2010.

Mowat rarely rebelled against his party but one of the only times he did was voting against making it clear that sex-selective abortion is illegal, which is an interesting position to hold to say the least.

Aside from this the most interesting fact about Mowat appears to be that he is one of 7 government ministers called David. Depressingly, there are more ministers called David than there are from ethnic minorities. Hooray for diversification.

 

 

 

 

 

Another nail in the coffin of NHS-funded homeopathy as Liverpool ceases funding

Another nail in the coffin of NHS-funded homeopathy as Liverpool ceases funding

Liverpool CCG has decided to decommission its homeopathic services after a public consultation found support for ending funding immediately. This is a swift about-face for the CCG after it approved spending on homeopathic services in February 2015.

The CCG opened a public consultation on homeopathy after a threat of legal challenge from The Good Thinking Society, a pro-science charity. 64% of Liverpool-based respondents indicated they wanted funding stopped, with 30% wanting the service continued. Michael Marshall, Liverpool resident and Project Director of the Good Thinking Society, welcomed the CCG’s decision: “This consultation shows overwhelmingly that the people of Liverpool believe limited NHS funds should be spent on treatments that are shown to actually work.”

The decommissioning of homeopathy in Liverpool continues the demise of homeopathy throughout the UK. Wirral CCG is the only area north of  Watford Gap currently funding homeopathy, and they are currently running a public consultation to determine whether to continue.

Homeopatic pharmacy, Varanasi Benares India
Homeopathy is a popular alternative to conventional medicine in many countries. However, there is no high-quality evidence to suggest it does what its advocates says it does.        Credit: Jorge Royan

In the South West, Bristol Homeopathic Hospital ceased funding homeopathic treatments in October 2015. The only remaining homeopathic hospital in England is in London, which receives funds from 17 CCGs. Limited information is available, but projections on what this totals range from £1.7-3m.

Elsewhere in the UK, Northern Ireland spends no NHS money on homeopathy and Wales spent £250 in 2014/15. In Scotland, 5 health boards funded homeopathy at a cost of approximately £1.9m in 2014/15, with the Glasgow Homeopathic Hospital accounting for the vast majority of this spend.