Tag: Rationing

NHS is being ‘protected’ from those who need protecting most by rationing treatment based on eugenic ‘guidelines’

NHS Bevan

 

The National Health Service (NHS) was born on 5 July 1948. It was the first time anywhere in the world that completely free healthcare provision was made available on the basis of citizenship rather than the payment of fees or insurance.

The NHS was founded on the principle of universal healthcare. It upheld the most fundamental principles of human rights: that each life has equal worth, and that we all have a right to life.

In 1946, the new Labour government passed the National Health Service Act. The model they used was based on one used in Tredegar in the 1930s, which was like an early, local version of the NHS. However, the new Minister for Health, Aneurin Bevan, who was MP for Tredegar, had to overcome opposition to the NHS. For example:

  • The British Medical Association (BMA), who feared that doctors employed by the NHS would lose income.
  • Many local authorities and voluntary bodies, which ran hospitals, also objected as they feared they would lose control over them.
  • Winston Churchill and many Conservative MPs thought that the cost of the NHS would be “too great.”

There are now four times fewer beds within the NHS than there were originally. That is despite increasing demand.

The Conservatives know the cost of everything and the value of absolutely nothing.

Tory governments have always been misers with public funds that are for funding public services. They prefer to hand our money out to millionaires.

However, the most fundamental role of government is to keep citizens safe. Without doing that, they have no legitimacy or authority. They have no point.

The role of public services is to protect and support the public who pay for them. As the coronavirus epidemic in the UK peaks over the coming weeks, many of our most vulnerable citizens face being cruelly let down by a government that has failed to ensure our public services are fit for purpose, particularly the NHS. 

Chronic underfunding over the last decade has left us with treatment rationing and situations in medical settings where patients are left for hours on end on trolleys in corridors without adequate care. That was happening long before the coronavirus did the epizootic shuffle through a couple of species to settle, often catastrophically,  in humans.

The government are transmitting irrational adverts asking the public to ‘protect the NHS.’ Yet it is the government that has failed in that endeavour. And systematically failed the British public. The NHS has ceased to be fit for purpose. Not because of any lacking on the part of its hard working front line staff, but because of chronic underfunding.

I’m sure NHS staff appreciate rainbows, applause and a mention from the Queen. I’m also sure they’d appreciate protective gear, extensive coronavirus testing kits, more standard ICU equipment and government funding much more.

This government have pathologised the notion of social safety nets, civilised support, and inverted the purpose of public services with an insidious neoliberal narrative.

It’s absurd, perverse and obscene.

This perverse rhetoric of ‘protecting’ a public service from ‘overuse’ has been with us for over a decade. It’s a way of normalising the dismantling of the services we have paid for.

Imagine the public needing to use a public service… makes you wonder what the Conservatives think they are actually for, if not serving the public. 

Of course, within the neoliberal framework, perverse profit incentives overshadow quality of service and delivery. It’s all about ‘efficiency’ and not quality. Public services have become cash cows: privatisation and profit. Another effect of market fundamentalism is the increasing conditionality of services, and in healthcare settings, the progressive rationing of treatments and cost cutting. 

However, that hasn’t worked out very well to date. It’s become a way of making individuals responsible for being ill and needing healthcare, and for the chronic lack of funding the government are responsible for; an inadequacy which is now being thrown into sharp relief.

The whole point of the NHS was to protect citizens, providing a universal healthcare service to all, ‘from the cradle to the grave’, regardless of someone’s circumstances. It was never intended to treat only the healthiest citizens, while leaving those who are elderly, frail or have expensive ‘underlying conditions’ to simply die.

Rationing treatment for covid-19

Rationing healthcare increased over the last few years, it has become the norm. Now, it has become very clear that treatment for covid-19 is going to be rationed. We have moved a long way from universal health care. 

The National Institute for Health and Care Excellence (NICE) have already introduced guidelines for establishing treatment ‘ceilings’, based on who they think is likeliest to survive covid-19. However, we have no way of knowing in advance of treatment if someone actually will survive.

Formal guidance says GPs should “proactively complete DNAR (do not resuscitate) forms, in advance of a worsening spread of coronavirus.”

People over 80 years old, and high risk groups are now being contacted about signing the “do not attempt to resuscitate” forms. This approach is firmly embedded in coronavirus planning and provision amid concerns over a lack of intensive care beds during the worsening coronavirus crisis.

Multiple GPs have said they are talking to patients who are older or in very high risk groups about signing “do not attempt to resuscitate” forms in case these patients were to go on to contract the virus. Some practices have also sent out letters to patients requesting they complete the forms, it is understood.

One leader of a primary care network, who asked not to be named, said: “Those in the severe at-risk group and those over 80 are being told they won’t necessarily be admitted to hospital if they catch coronavirus.”

Guidance issued by the Royal College of General Practitioners last week also touched on the issue, saying: “Proactively complete ReSPECT/ DNAR forms and prescribe anticipatory medications in advance of a worsening spread of disease.”

End of life conversations cover prescribing palliative pain relief, so patients aren’t left without the ‘appropriate’ medicines.

It’s understood these conversations are also being had with people living in nursing and care homes.

Jonathan Leach, a practising GP who helped draft the guidance, told Health Service Journal (HSJ) We have a huge role as a college [on this] as we see the volume and type of patients we should be sending into hospital and those we shouldn’t be.”

Type of patient? I wonder if I will be the type of patient that doctors will decide to treat? Or will I simply be left to die at home, because I have comorbid conditions? 

Leach continued: “If covid-19 gets into a care home because residents are mostly vulnerable, we will see a significantly greater number over a shorter period who need this type of [palliative] care. So, part of coping with that is thinking ahead [about having these conversations].”

I always thought that covid-19 gets into any place simply because of its contagion quality, not because of a particular demographic – it doesn’t have any special preferences towards care home residents because they are vulnerable. Vulnerability doesn’t invite more coronavirus infections. That’s why the prime minister, the health and social care secretary and other non-vulnerable ‘clever’ people among the government have also been infected recently. 

Dr Leach called discussing DNARs with people who are not at the end of life but are older or in a high-risk group a “grey area”. He added these decisions “need to be done on a case-by-case basis” but it was “more humane” to do it in advance.

How can leaving someone to die because of deliberately inflicted government funding cuts, based on an artificially constructed ‘type’, be “more humane”? Leach should have met my grandmother, who, in her 90s was probably fitter and more active than he is. Yet she would have conformed to his ‘type’ of patient to be considered for a eugenics by laissez faire approach, based on just her age alone.

Recent guidance issued to hospitals said palliative care conversations with a patient’s family may have to take place remotely, and skilled palliative care teams may not have the capacity to undertake all conversations themselves.

A spokeswoman for the British Medical Association, which also co-drafted the GP work prioritisation document, said: “Considering, and where possible making, specific anticipatory decisions about whether or not to attempt CPR is part of high-quality care for any person who might be approaching the end of life or who might be at risk of cardiorespiratory arrest.”

That decision – choosing who is and who is not going to be given CPR-  isn’t ‘care’, high quality or otherwise. 

The National Institute for Health and Care Excellence’s (NICE) role more generally is to improve outcomes for people using the NHS and other public health and social care services.

Yet the NICE guidelines concerning treatment provision for covid-19 are founded on a distinctly eugenic rationale: ensuring the ‘survival of the fittest’ only. 

The guidance for the NHS on which coronavirus patients should receive intensive care treatment has heightened fears among disability campaigners that many disabled people will be refused life-saving treatment if they are admitted to hospital.

The guidance, which originates from NICE, says that all adult covid-19 patients should be assessed for “frailty” when admitted to hospital, and that “comorbidities and underlying health conditions should be ‘taken into account’.”

In other words, those who need it most will be the most likely to be denied treatment, based on a fundamentally discriminatory scoring system.

The guidance is in gross violation of the Equality Act, as it will result in discriminatory health care provision and violate the fundamental universal right to life, on the basis of protected characteristics; in particular, those of age and disability. 

The guideline says: “the risks and benefits and likely outcomes should be discussed with patients, carers or advocates and families using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.

“For patients with confirmed COVID-19, the guideline says decisions about admission to critical care should be made on the basis of medical benefit, taking into account the likelihood that the person will recover to an outcome that is acceptable to them and within a period of time consistent with the diagnosis.”

The Clinical Frailty Scale: NICE’s cold, callous categories of ‘types’ – ‘they’ and ‘these people’: 

Clinical-Failty-Scale
Profound discrimination and human rights violations are deeply embedded in the NICE covid-19 treatment guidelines. The NHS are offering a limited treatment plan, in advance, for those of us considered ‘frail’.

It’s worth noting that China didn’t leave elderly people or those with comorbid conditions to die without trying to save them. In fact some were saved through the sheer persistence of doctors. 

Young and healthy people also die of covid-19. We have no way of knowing in advance if someone will respond to treatment, unless we try it. Ismail Mohamed Abdulwahab is the youngest person in the UK, to date, at just 13 years old, to die of covid-19, without his family around him in hospital. And Luca Di Nicola, who was just 19 was also healthy previously. Neither had underlying conditions.

Even when doctors are reasonably sure someone will die, sometimes they don’t

In 2017, I had flu. Within just four days of the start of my symptoms, I ended up with advanced pneumonia and was in septic shock when I arrived at A&E. My prognosis was very poor. At one point I was having chemicals pumped into me to try and raise my blood pressure from off the floor. In the end a doctor decided to try a ‘last resort’ vasopressor (to raise blood pressure and prevent organ failure) called methylene blue, which is injected very slowly (it’s called a ‘slow injection’), because the chemical is dangerous if it accumulates in one spot.

Septic shock happens when a person’s blood pressure drops so low that organs are starved of oxygen, leading to sequential organ failure. If it can’t be remedied quickly, people die because of injured organs. It’s one of the key causes of death in people who are critically ill with covid-19.

But in my case, it worked. OK, so it turned my urine green for days, but here I am, still.

However, if I become critically ill with covid-19, my comorbid conditions will mean I am most likely going to be among those who reach a ‘ceiling’ of treatment, if the NHS is overwhelmed. One of the key reasons people die of covid-19 is because it causes severe pneumonia and sepsis. Deciding who may survive those conditions is difficult in advance of treatment. Yet the NICE guidelines show very clearly that those decisions have already been made. 

Eugenics in practice

A GP practice in Wales sent out a letter which recommended patients with serious illnesses complete “do not resuscitate” forms in case their health deteriorated after contracting coronavirus. Llynfi surgery, in Maesteg near Port Talbot, wrote to a “small number” of patients on Friday to ask them to complete a “DNACPR” – do not attempt cardiopulmonary resuscitation – form to ensure that emergency services would not be called if they contracted covid-19 and their health deteriorated.

do not rescusitate

The letter says: “This is a very difficult letter for the practice to write to you,” stating that people with illnesses such as incurable cancer, motor neurone disease and pulmonary fibrosis were at a much greater risk from the virus.

I have pulmonary fibrosis. I have to say the letter is probably rather more difficult to receive and read than it was to write. 

“We would therefore like to complete a DNACPR form for you which we can share … which will mean that in the event of a sudden deterioration in your condition because [of] Covid infection or disease progression the emergency services will not be called and resuscitation attempts to restart your heart or breathing will not be attempted,” it continued.

“Completing a DNACPR will have several benefits,” the letter continues.
“1/ your GP and more importantly your friends and family will know not to call 999.

 2/ scarce ambulance resources can be targeted to the young and fit who have a greater   chance.”

“The risk of transmitting the virus to friends, family and emergency responders from CPR … is very high. By having a DNACPR form in place you protect your family … [and] emergency responders from this additional risk.”

The letter said that in an “ideal situation” doctors would have had this conversation in person with vulnerable patients but had written to them instead “due to fears they are carrying the virus and were asymptomatic”.

“We will not abandon you,” it said. “But we need to be frank and realistic.”

But the letter makes it very clear that some people’s lives are valued rather more than others. Abandoning those people considered ‘frail’ is exactly what the guidance issued by the Royal College of General Practitioners and NICE outline and this GP surgery are intending to put that into practice. 

The GP surgery said the letter originated from Cwm Taf Morgannwg University Health Board, which then clarified the recommendation that vulnerable patients complete DNACPR forms was “not a health board requirement.”

“A letter was recently sent out from Llynfi surgery to a small number of patients,” a spokesperson said. “This was not a health board communication.

“The surgery have been made aware that the letter has caused upset to some of the patients who received it. This was not their intent and they apologise for any distress caused. Staff at the surgery are speaking to those patients who received the letter to apologise directly and answer any concerns they may have.”

The letter went viral on social media and one person said a nurse practitioner had recently visited her father, who is receiving palliative care, to also request he sign a DNACPR form.

The NHS currently has 8,175 ventilators and has said it needs 30,000 more to deal with an expected peak of covid-19 patients, while the health service is reportedly attempting to increase its intensive care capacity sevenfold amid fears the full effect of the pandemic could be overwhelming.

There is a lack of personal protective equipment across the NHS despite renewed efforts to provide ambulance crews, GP surgeries and hospitals with the masks, visors, gloves and aprons that help prevent coronavirus transmission. At least three healthcare workers have already died from the virus.

Doctors in the UK must consult with patients or their families if they decide that resuscitation would not be effective or that complications would result in more pain. Families can seek a second opinion but apparently, the decision is ultimately a “medical judgment” to be made by a doctor.

Based on the damning guidelines issued by the Royal College of General Practitioners and NICE .

So the ‘collateral damage’ due to years of Tory governments systematically underfunding the NHS is an uncivilised denial of medical support for those who need it most, based on a distinctly eugenic logic.

It took just two months into a global pandemic to scrape away the thin veneer of civilised democracy, equality principles and our standard of universal human rights.

Once the coronavirus crisis subsides, we must never forget that those of us with ‘underlying’ medical conditions were considered expendable in order to ensure those who generally needed medical intervention the least got it at the expense of others, because of government priorities, which are never about ‘uniting and levelling up’.  

Universal health care was destroyed by the Conservative governments of the last decade, and has been replaced by calculated, cost-cutting eugenic practices based on a deeply ingrained antipathy towards groups with protected characteristics, but in particular, towards those citizens with any degree of frailty.

A doctor in Spain breaks down, as he describes how people over 65 years old with Covid-19 are being sedated and left to die, so that younger people may have priority for treatments and support, such as ventilators.

In the UK, NICE have drawn guidelines that set out who will get priority for treatment for the coronavirus. Not those most in need. Those most likely to survive anyway will have priority access to treatment. Elderly people and those who have underlying conditions will simply have isolation to protect them.

Universal health care and the universal right to life have become conditional. The  universal human rights that were fought hard for and earned are now a distant memory.

The Conservatives have systematically eroded both human rights and universal health care provision. The latter because of deliberate and chronic underfunding.

Scratch the surface of right-wing neoliberal ‘libertarianism’ and there lies a deeply embedded eugenic ideology.

The NICE guidelines have introduced the notion that our society requires triage, not as a last resort, but as a preemptive measure. It seems some people are considered too expensive to save. The NICE document separates human life into blunt categories. In one small group of boxes, there are people deemed to be worth saving. In the others, there are groups of people who, it has been decided, ought to be just left to die.  As cheaply as possible.

What is outlined in the NICE guidelines and clarified in the  and letter from the GP practice is not quite mass murder, but it is a sort of pre-planned, homicide by lack of funding, indifference and laissez faire.

The arguments presented for triage on the basis of ‘frailty’ are arguments from the eugenicist right wing. The fact that those who designed the guidelines think the elderly and the ill are acceptable losses is something we should remember long after the pandemic is over. This tells us the neoliberal obsession with ‘market forces’ was not about human potential or a flourishing society, nor was it about, productivity and abundance, but about something else.

For the high priests of ‘small government’ and market fundamentalism, citizens are expensive, especially if they need regular medical care. And the NHS should provide that care, because WE pay for it. The real drain on our health care is the increasing number of private company ‘providers’  who are draining vital funds into piles of private profits.

The UK will emerge from pandemic with its hierarchy still intact, and its elite shielded from the grim realities and disadvantages that ordinary people face. Those citizens who need things such as public services (perish the thought), well, they will continue to be regarded by the powers that be as ‘life unworthy of life’.

This is a government, lets not forget, that decided initially to run a dangerous, pseudoscientifc experiment on ‘herd immunity’ and ‘behavioural change’. That didn’t work of course. No-one knows if having covid-19 leads to immunity after recovery. Or for how long. Some viruses simply mutate. A good example is H3N2 strains of influenza. My entire family had it over Christmas in 1968. I was very young, and remember my mother said we had “Hong kong ‘flu”.

H3N2 evolved from H2N2 by antigenic shift and caused the Hong Kong Flu pandemic of 1968 and 1969 that killed an estimated one million people worldwide. In 2017, I got it again. It’s a particularly nasty strain that the ‘flu vaccination can’t protect people from, and has become increasingly resistant to antivirals such as Tamiflu. In the years that H3N2 circulates, more people are hospitalised with ‘flu complications. Partly because this virus simply changes itself to dodge defeat. The second time I got it, I ended up with pneumonia and in septic shock, as outlined earlier.

You’d think parasites like viruses would have evolved to find ways of not killing their hosts off. It’s hardly in their best interests after all.

It’s almost the epitome of neoliberal commodificationism and consumerism.

My point is, we simply don’t know if people who have covid-19 are immune afterwards. No-one does.

The NICE guidelines have introduced the notion that our society requires triage,  not as a last resort, but as a preemptive measure. It seems some people are considered of less worth than others, and too expensive to save. 

Now we know that our current government, with it’s apparent ease in sliding towards eugenic solutions, are never going to be the cure for all of our ills.

On a global scale, covid-19 has thrown the evils of neoliberal economic systems – especially embedded inequality, the systematic erosion of fundamental human rights and the fragility of democracy – into sharp relief.

And some governments’ indifference to the lives and deaths of populations.

We must never forget this; the government believe that one life is worth less than another – some lives can so easily be regarded as expendable.

 


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Cash for Care: nudging doctors to ration healthcare provision

Image result for NHS rationing treatment

Today, while everyone is being distracted by the continuing resignations from Theresa May’s disintegrating government, the Conservatives are openly talking among themselves (again) about charging for NHS services. So much for the government’s continued reassurances and promises about UK healthcare continuing to remain ‘free at the point of access.’  

The NHS has never been safe in  Conservatives hands.

Last week I wrote an article about the stealthy creep of rationing of treatments in the NHS, and how gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith. 

One important point I didn’t raise in the article was about how the marketisation of the NHS has given rise to ‘perverse incentives’, which violate the very principles on which the national health service was founded. Neoliberal policies have shifted priorities to developing profitable ‘care markets’ making ‘efficiency’ savings and containing costs, rather than delivering universal health care.

Another shift in emphasis is the “behavioural turn”. It’s politically convenient to claim that people’s behaviours are a major determinant of their health. Some illnesses are undoubtedly related to lifestyle – type two diabetes, for example. But it is difficult to blame individual’s behaviours for type one diabetes, which is an autoimmune disease, and these may happen to people who lead very healthy lifestyles, as well as those who don’t. This ‘behavioural turn’ shifts emphasis from the impact of structural conditions – such as rising inequality and poverty – on public health. It also provides a political justification narrative for cuts to healthcare and welfare provision. (See also The NHS is to hire 300 employment coaches to find patients jobs to “keep them out of hospital”. )

Behavioural economists have claimed that ‘nudge’ presents an effective way to ‘change behaviours’ within the NHS and ‘improve outcomes’ at lower cost than traditional policy tools. Back in 2015, the Nudge Unit were looking for “many potentially fruitful areas in which to use behavioural insight to improve health and health-service efficiency, either by retrofitting existing processes or by designing completely new services most effectively.” ‘Fruitful’ as in lucrative for the part-privatised company, but not so lucrative for the NHS.

Behavioural economists are working for the government and public sector to “harness [public] behaviours to shift and reduce patterns of demand in many public services.” The problem is that human needs arising from illness are not quite the same thing as human behaviours and roles, yet the government are increasingly conflating the two. (See discussion on Talcott Parsons and the ‘sick role’ in this article, for example, along with that on ‘work is a health outcome’.)

Public services are associated with fundamental human rights, which in turn are based on notions of fundamental human need. Addressing basic human needs is fundamental to survival.

As Abraham Maslow concluded, motivation for behaviours is is closely related to fulfilling our basic needs, because if they are not met, then people will simply strive to make up the deficit as a priority. This undermines aspiration and human potential. Fulfilment of psychosocial needs will become a motive for behaviour only as long as basic physiological needs ‘below’ it have been satisfied. Health is a fundamental human need. To paraphrase Maslow, we don’t live by bread alone, unless there is no bread.

Public services are an essential part of developed democracies, they ensure all citizens can meet their basic needs, and therefore, the provision promotes wider social and economic wellbeing and progress.

Image result for maslow's hierarchy

Maslow’s hierarchy of human needs

The Nudge Unit had already run a trial in Nottingham, which provided feedback to doctors of the cost of a commonly used discretionary lab test. This prompt retained clinical freedom, and did not ask doctors to order fewer tests – but the number of
tests fell by a third.

anttibiotic resistance

In 2016 the UK government set a target to half ‘inappropriate’ antibiotic prescribing by 2020. The Nudge Unit set out to “improve prescribing in line with government ambitions”. 

Behavioural economists from the Unit claimed that by informing doctors that they are prescribing more antibiotics relative to 80 per cent of their peers, they are reducing the number of ‘unnecessary’ prescriptions by 3.3 per cent (more than 73,000 prescriptions) – helping to address what the Chief Medical Officer has identified as perhaps the greatest medical threat of our age – antibiotic resistance. 

Between 2014 and 2015, the Behavioural Insights Team sent letters to 800 GP practices, telling them that other practices were recommending the use of antibiotics in fewer cases. (There is no evidence presented to determine if this was actually true, and judging by the template letter, it’s highly unlikely that it was true.)

The nudge method employed is called ‘social norming’, which operate as a kind of community enforcement, as norms are unwritten rules that define ‘appropriate’ behaviours for social groups. We tend to conform to the expectations of others. Changing perceptions of norms alters people’s expectations and behaviour.

Understanding norms provides a key to understanding social influence in general and conformity in particular. The Conservatives have traditionally placed a significant emphasis on social conformity.

There are ‘hotspots’ where more antibiotics are prescribed. However, the fact that these places tend to be some of the most deprived areas of the country strongly hints that there are underlying socioeconomic factors at play that cannot be solved with a nudge or prod. Research indicates that community socioeconomic variables may play a significant role in sepsis-attributable mortality, for example.

Social problems such as poverty and inequalities in health arise because of unequal distributions of wealth and power, therefore these problems require solutions involving  addressing socioeconomic inequality. As it is, the government is unprepared to spend public funds on public services to redistribute resources. 

The behavioural study did not include any consideration of socioeconomic variables on rates or severity of infection, or types of infection. 

The idea that ‘changing the prescribing habits in hospitals’ and GP surgeries will impact on antibiotic resistance is based on an assumption that doctors over prescribe antibiotics in the first place. There is no evidence that this is the case, and it’s very worrying that anyone would think that targeting doctors with behaviourally-based remedies will address antibiotic resistance and assure us, at the same time, that antibiotics are actually prescribed when appropriate, and tailored, ensuring the safety and wellbeing of the patient, rather than being prescribed according to arbitrary percentage norms distributed by behavioural economists.

The trials did not include sufficient data regarding clinical detail or diagnostic uncertainty that might justify antibiotic prescribing in individual cases.

One of the nudge unit team’s key aims is to design policies which reduce costs. They say: “The solution to the problem of AMR is not just to produce new and better drugs – that takes time, and a great deal of money. We must also reduce our use of antibiotics when they are not needed. Sadly, it seems that they are used unnecessarily twenty percent of the time in the UK”.

The various Nudge Unit reports on behavioural strategies that target doctors don’t mention any follow-up research to ensure that the reduction in antibiotic prescriptions did not correlate with an increase in the severity of infections or poor outcomes for patients. In fact one report highlighted that those who were admitted to hospital because their condition deteriorated were excluded from the trial, as they no longer met the inclusion criteria. That effectively means that any adverse consequences for patients who were not given antibiotic treatment was not reported. And that matters.

The authors say “We as the authors debated at length as to whether we should emphasise the fact that 80% of the prescriptions are being used in necessary cases.” 

There is no indication of how ‘necessary cases’ are determined, and more to the point, who determines what is a ‘necessary case’ for antibiotic treatment. Furthermore, the report uses some troubling language, for example, doctors prescribing antibiotics ‘above average’ were referred to more than once as the “worst offenders.” However, as I’ve already touched on, patients needs may well vary depending on a range of variables, such as the socioeconomic conditions of their community, and of course, complex individual comorbidities, which may not be mentioned in full when doctors write up the account for the prescription.

Sepsis, which may arise from any kind of infection is notoriously difficult to diagnose. It is insidious and can advance very rapidly.  It’s even more difficult to determine when a patient has other conditions. For example, sepsis can arise when someone has flu. That happened to me, when I had developed pneumonia without realising that I had. It’s standard practice for paramedics to administer a broad spectrum antibiotic and intravenous fluids to treat suspected sepsis and septic shock. This can often save lives. Sepsis kills and disables millions and requires early suspicion and antibiotic treatment for survival.

Once the causative agent for the infection is found, the IV antibiotics may then be tailored to treat it. The wait without any treatment until a firm diagnosis is potentially life-threatening. But the biochemical tests, such as CRP, and X-rays take time. 

Treatment guidelines call for the administration of broad-spectrum antibiotics within the first hour following suspicion of septic shock. Prompt antimicrobial therapy is important, as risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics. This time constraint does not allow the culture, identification, and testing for antibiotic sensitivity of the specific microorganism responsible for the infection. Therefore, combination antimicrobial therapy, which covers a wide range of potential causative organisms, is tied to better ‘outcomes’. 

In the trial, behavioural economists referred to medical notes, and if there is no diagnosis, the necessity of the prescription is then questioned. Knowledge of complex medical histories may also influence doctors’ decisions, and this may not have been mentioned on medical record. A cough and breathlessness is a common symptom influenza. However, a patient with a condition that compromises their immunity, or someone who needs immune suppressants, for example, is rather more at risk of developing bacterial pneumonia than others, and someone with COPD or asthma is also at increased risk.  

If a person dies because treatment was not given promptly in high suspicion cases of severe infection and sepsis, who is to be held accountable, especially in a political context where treatments are being rationed and prescriptions are being increasingly policed?

It’s also worth bearing in mind that massive doses of antibiotics are added to livestock feed as a preventative measure and to promote growth before the animals are slaughtered and enter the food chain. Using antibiotics during the production of meat has been heavily criticised by physicians and scientists, as well as animal activists. The pharmaceutical industry is making billions annually from antibiotics fed to livestock, which highlights the perverse incentives of the profit motive and potentially catastrophic impact on humans. It is estimated that between 70 – 80 percent of the total of antibiotics used around the world are used within the animal farming and food industry. No-one is nudging the culprits. 

The potential threat to human health resulting from inappropriate, profit seeking antibiotic use in food animals is significant, as pathogenic-resistant organisms propagated in these livestock are poised to enter the food supply and could be widely disseminated in food products.

Antibiotics used on farms can spill over into the surrounding environment, for instance through water run-off and slurry, according to a report from the UN’s environment body, last year, with the potential to create resistance to the drugs across a wide area.

In 2013, researchers showed that people who simply lived near pig farms or crop fields fertilized with pig manure are 30% more likely to become infected with methicillin-resistant Staphylococcus aureus bacteria.

Cash for care – rationing referrals to hospital consultants and diagnostic testing

It was announced in April this year that General Practitioners (GPs) across England will be able to “better manage” hospital referrals with a “digital traffic light system” developed by the Downing Street policy wonks. This nudge is designed to target the ‘referral behaviours’ of GPs.

GPs are being offered cash payments as an ‘incentive’ to not refer patients to hospitals – including cancer patients – according to an investigation by Pulse, a website for GPs. 

Furthermore, a leaked letter sent by NHS to England to Clinical Commissioning Groups (CCGs) and seen by Pulse magazine last year, asks that all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals.  

A “clinical peer review of all referrals from general practice by September 2017”, will be required, the letter said. 

To ‘incentivise’ the scheme, the letter said that there will be “significant additional funding” for commissioners that establish peer-led policing schemes. It added that it could reduce hospital referral rates by up to by 30 per cent. NHS England said that they want to introduce the “peer review scheme” whereby GPs check the referrals of one another to ensure they are ‘appropriate’. However, experts warn this increasingly Kafkaesque layer of bureaucracy could lead to more problems and possible conflict with patients’ safety and standard of care. 

In a trial of the nudge scheme, four NHS clinical commissioning groups (CCGs) have been using “profit share” initiatives to ration care, to help them ‘operate within their budgets’. Clinical Commissioning Groups hold the budget for the NHS locally and decide which services are provided for patients. 

Through this scheme, GPs are told they will receive up to half of the money that is saved by fewer patients going to hospitals for tests and treatments.

So to clarify, surgeries are being offered financial ‘incentives’ for not sending patients to hospital to save money, that is then reinvested in part to implement further rationing of healthcare. The move has been widely condemned as a “dereliction of duty” by the community of medical experts and professionals. Referrals to consultants often involve important diagnostic procedures, therefore there is often no way of knowing for sure in advance of the referral whether or not it is “warranted”.

The NHS has had ‘referral management centres’ in place for many years.  However, last year they were at the epicentre of a scandal when it was revealed that the use of these centres has increased 10-fold over recent years. Furthermore, the centres are privately run and extremely expensive to employ, diverting funds that could simply be spent on patient care.

Moreover, those who were reviewing the referrals were also found to have varying levels of clinical knowledge, and so were not always able to correctly identify which referrals were ‘necessary’. They were also extremely inefficient as patients were forced to wait a long time for appointments. 

The Pulse investigation into referral incentive schemes being run by NHS clinical commissioning groups (CCGs) across England found some regions offering GPs as much as 50 per cent of any savings they can make. The “profit-share” arrangements mean practices stand to benefit financially by not sending patients for treatment or to see a specialist.

Hospitals are paid for operations and other activity, so by sending patients to cheaper services run by GP practices – such as diabetes and pulmonary clinics – or by keeping them out of hospital altogether, practices can increase the size of savings. GPs are not paid per procedure. Rather, they receive a single payment when each patient is registered with them. 

Currently, when doctors are referring patients for appointments with hospital consultants, the nudge – in the form of a “Capacity Alert System” – operates by displaying a red light next to hospitals with lengthy waiting times, and a green light next to those with more availability, on the system. 

The system underwent two trials in north-east and south-west London over the winter. During these pilots the number of referrals made to overburdened hospitals was reduced by 40%, while those made to hospitals with ‘spare capacity’ rose by 14%, according to NHS England. There was no comment made regarding the impacts of the scheme on patients’ health.

GP leaders have also said it is “insulting” to suggest doctors are sending patients to hospital arbitrarily, and raise significant conflicts of interest.

“Cash incentives based on how many referrals GPs make have no place in the NHS, and frankly, it is insulting to suggest otherwise,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs.

Of course, it’s important to take measures to ensure that GP referrals are appropriate and high-quality, but payments to reduce referrals would fly in the face of this, and erode the trust our patients have in us to do what is best for them and their health.” 

The NHS has been squeezed for increasingly drastic ‘efficiency savings’ in the past eight years. It’s absurd, however, that a huge amount of money is being spent on restricting access to healthcare, rather than on simply adequately funding healthcare provision.

Dr Peter Swinyard, chair of the Family Doctor Association, said the profit-share schemes were “bizarre”, adding: “From a patient perspective, it means GPs are paid to not look after them.

“It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.”

Meanwhile, NHS Barnsley CCG has identified a £1.4m funding pot to pay its practices if they achieve a reduction in referrals to specialties, including cardiology, pancreatic surgery, and trauma and orthopaedics.

The CCG said the 10 per cent target was “ambitious but achievable”.

Last year it was discovered that the NHS has to spend £1.5 billion in legal costs when patients don’t get what the standard of care expected and pay for from their healthcare providers. In 2015/16, there was a 27% increase in the number of claims and a 72% increase in legal cost, which amounted to £1.5 billion.  With the amount of money that the NHS is spending on legal costs for medical blunders, the NHS could have paid for the training of more than 6,000 doctors. Or eased the rationing of essential healthcare provision.

The purpose of the NHS has been grotesquely distorted: it was never intended to be a bureaucratic gatekeeping exercise that rations healthcare. The purpose of all public services is to provide a public service, not ration provision. Such is the irrationality of the government’s ‘market place’ and ‘profit over human need’ narrative. 

Dr Eric Watts, a consultant haematologist for the NHS, says that the British government couldn’t care less about the fall of the NHS. He said, “This is a triumph of secrecy and implacable lack of care about the NHS by a Government determined to watch it fail then fall.” 

One CCG told Pulse“Ensuring treatment is based on the best clinical evidence and improving historical variation in access is essential for us locally.

“Financially, it is an effective use of local resources which will improve patient experience and outcomes and increase investment in primary care in line with the Five Year Forward View commitments.” Those ‘commitments’ are the increasing implementation of cuts to healthcare provision and funding.

Cuts to care may well improve financial ‘management’ but it cannot be claimed that healthcare rationing “improves health outcomes” for patients. That flies in the face of rationality.

NHS England also said last year that funding will be available for CCGs to start “peer review schemes”, where GPs police each other – checking that their colleagues are referring ‘appropriately’, but it is not clear what it thinks about direct payments linked to cutting referrals.

The “Cash for Cuts” investigation, by GP publication Pulse, asked all 207 CCGs in England about their processes for cutting referrals. Of the 180 who responded, 24 per cent had some kind of incentive scheme aimed at lowering the numbers of referrals. 

This included payments for getting GPs to “peer review” each other’s referrals or other strategies. 

Dr Chaand Nagpaul, from the British Medical Association (BMA) has  also criticised the nudge scheme. He says “It’s a blunt instrument which is not sensitive to the needs of the patient and is delaying patient care. 

“It has become totally mechanistic. It’s either administrative or not necessary for the patient. It’s completely unacceptable. Performance seems to be related to blocking referrals rather than patient care.”

The CCGs have defended the schemes, saying that at the time they were pushed through, the NHS was struggling through the worst winter ever in its history and had not been able to hit target waiting times since 2015. The CCGs have said that the scheme is only to help reducing ‘unnecessary referrals’ and therefore improve outcomes for ‘genuine patients’, and not to reduce numbers overall. Who decides which patients are ‘genuine’, and on what criteria? 

Dr Dean Eggitt, who is the British Medical Association’s GP representative for Barnsley, Doncaster, Rotherham and Sheffield, also disagrees with the scheme. 

“The scheme is unsafe and needs to be reviewed urgently,” he said. 

The BMA’s GP committee have said that it had raised concerns nationally where CCGs have set an “arbitrary target” for reducing referrals. 

Before Christmas, Jeremy Hunt, the Health Secretary, announced that he wanted hospitals to find another £300m in savings on basic items like surgical gloves and bandages, and a long-awaited pay rise for nurses is contingent on staff boosting “productivity”.  

A Department of Health and Social Care spokesperson said: “Patients must never have their access to necessary care restricted  – we would expect local clinical commissioning groups and NHS England to intervene immediately if this were the case.” 

I’ve asked NHS England whether it would be reviewing cases where GPs stand to profit financially for not referring patients, along with others, but I have had no response at time of this publication. 

The NHS was founded on the principle of free and open access to healthcare provision for everyone. The nudge schemes I’ve outlined have introduced ‘perverse incentives’ that prompt GPs to ration health care. I have argued elsewhere on many occasions that nudge and the discipline of behavioural economics more generally is technocratic prop for a failing  political and socioeconomic system of organisation – neoliberalism. Rather than review the failures of increasing privatisation and ‘competition’, the government chose to deny them, applying increasingly irrational ‘solutions’ to the logical gaps in their ‘marketplace’ dogma. 

Yet it is blindingly clear that citizens needs and their human rights are being increasingly sidestepped by the absolute prioritisation of the private profit incentive. 

Nudge isn’t about ‘economics theory and practice adapting to human decision making’, as is widely claimed. It isn’t about remedying ‘cognitive biases’. It isn’t about people making ‘flawed decisions’.

It’s about holding citizens responsible for the problems created by a flawed socioeconomic model. It’s about a limited view of human behaviours and potential, because it frames the poorest citizens in an increasingly unequal society as ‘failed entrepreneurs’. Those members of the public who need to access public services are increasingly being portrayed as an economic ‘burden’. As such, nudge places limitations on and replaces genuine problem-solving approaches to public policy.

Nudge is about authoritarian governments using a technocratic prop to adapt human perceptions, behaviours and expectations, aligning them to accommodate inevitable  catastrophic social outcomes. These outcomes are symptomatic of the failings and lack of rational insights of wealthy and powerful neoliberal ideologues, who are determined to dismantle our public services. Without the consent of the majority of citizens. 

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The NHS was never safe in his hands. The company he keeps has made sure of that.

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Rationing and resource gatekeeping in the NHS is the consequence of privatisation

People march through London to mark 70 years of the NHS

People march through London yesterday to mark 70 years of the NHS.

Gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith. 

In the NHS, even the resource gatekeepers have gatekeepers, those receptionists standing sentry at the end of the telephone, and in general practices, who ration access to the GPs so assiduously we patients often get better before we’ve managed to arrange an appointment. Or ended up at an Accident and Emergency Department.

Only a service dedicated to keeping the public and service providers apart could have devised a system so utterly demeaning. It turns patients into supplicants and receptionists into bouncers who make decisions they are unlikely to be qualified to make, neither being roles to which any of us aspired.

Now, it has been decided that the NHS needs to scrap more medical procedures, including injections for back pain, surgery to help snorers and knee arthroscopies for arthritis, which form part of an initial list of 17 operations that will be discontinued completely or highly restricted by NHS England as many of these problems “get better without treatment.”

I can assure you that arthritis of the knee, or anywhere else for that matter, doesn’t tend to get better. Medical interventions can help patients with ‘managing’ the condition, however. 

Varicose vein surgery and tonsil removal also feature on the list of routine operations to be axed as part of NHS England’s drive to cease “outdated” and “ineffective” treatments.

The latest round of rationing is hoped to save £200m a year by reducing “risky” or “unnecessary” procedures. Patients are to be told they have a responsibility to the NHS not to request “useless treatment.”

However, complications from varicose veins, for example, include leg ulcers which require more costly specialist treatment to help them heal. 

Steve Powis, the medical director of NHS England, said: I’m confident there is more to be done”, adding that the list of 17 operations formed “the first stage” of rooting out futile treatments that are believed to cost taxpayers £2bn a year.

“We are also going to ask ‘Are there other procedures and treatments we should add to the list?’. Additions could include general anaesthetics for hip and shoulder dislocations and brain scans for patients with migraines.

Hip and shoulder dislocations are notoriously excruciating, as is the process of having the joint relocated, though the latter is short-lived. It’s particularly brutal to leave patients without pain relief, and especially children.

The reason why brain scans are often very important when people develop migraine symptoms is that they can determine whether the severe headaches are caused by something more serious, such as a subarachnoid haemorrhage (which happened to me) or a tumour (which happened to my mother). Sometimes ‘migraines’ are something else.
Powis added: “We have to spend taxpayers’ money wisely. Therefore, if we are spending money on procedures that are not effective, that is money we could spend on new treatments that are clinically effective and would provide benefits to patients. It’s absolutely correct that, in getting more efficient, one component of that is to make sure we are not undertaking unnecessary procedures.”

The rationing comes as the government prepares to raise taxes and ditch an increase to the personal income tax allowance to pay for NHS funding plans. According to proposals, £20.5bn of extra funding would be set aside for the health service by 2023. In a speech at the Royal Free hospital in London a fortnight ago, Theresa May said tax rises were inevitable.

However, there doesn’t seem to be any indication that this additional measure will ensure the public has value and adequate health care for their money. 

The prime minister said: “As a country, taxpayers will need to contribute a bit more.But we will do that in a fair and balanced way. And we want to listen to people about how we do that, and the chancellor will bring forward the full set of proposals before the spending review.”

Here are the 17 treatments NHS England may axe

Four procedures will only be offered at the request of a patient:

  • Snoring surgery
  • Dilation and curettage for heavy menstrual bleeding
  • Knee arthroscopies for osteoarthritis
  • Injections for non-specific back pain

A further 13 treatments will only be offered when certain conditions are met:

  • Breast reduction
  • Removal of benign skin lesions
  • Grommets for glue ear
  • Tonsillectomy
  • Haemorrhoid surgery
  • Hysterectomy for heavy menstrual bleeding
  • Removal of lesions on eyelids
  • Removal of bone spurs for shoulder pain
  • Carpal tunnel syndrome release
  • Dupuytren’s contracture release
  • Excision of small, non cancerous lumps on the wrist called ganglia
  • Trigger finger release
  • Varicose vein surgery

Some of these procedures do improve the quality of people’s lives. I’m wondering how this sits with the government’s drive to push people with disabilities and medical conditions into work.

Although it was announced recently that the NHS is to hire 300 employment coaches to find patients jobs to “keep them out of hospital.” It’s what the government probably calls the ‘two birds and one bullet’ approach.

A man with a birthday placard as thousands of people march to mark 70 years of the NHS

Yesterday, tens of thousands of people marched through London to mark the NHS’s 70th anniversary and demand an end to government cuts and further privatisation of the health service. Bearing placards reading “Cuts leave scars”, “For people not profit” and “Democracy or corporate power” demonstrators moved down Whitehall on Saturday afternoon to the chant of “Whose NHS? Our NHS”.

The protesters stopped outside Downing Street to demand Theresa May’s resignation en route to the stage where they were greeted by a choir singing “the NHS needs saving, don’t let them break it”. Shortly after, Jeremy Corbyn addressed the crowd – organisers said there were about 40,000 people present – demanding an end to privatisation, the closure of the internal market, for staff to no longer be subcontracted to private companies and for social care to be properly funded.

Corbyn said: “There have been huge attacks on our NHS over many years,” he said. “The Tories voted against the original legislation and have always sought to privatise it and continue an internal market.

“Paying money out to private health contractors, the profits of which could and sometimes do, end up in tax havens around the world.

“Think it through, you and I pay our taxes because we want a health service for everybody, I don’t pay my taxes for someone to rip off the public and squirrel the profits away.”

I absolutely agree. 

A brief history of the travailing NHS under Conservative governments

The government has failed to adequately fund the NHS since taking office as part of the coalition in 2010, and has overseen a decline in the once widely admired public health service, as a way to privatise it by stealth. 

The Tories have utilised a spin technique that carry Thatcher’s fingerprints – it’s called ‘don’t show your hand.’

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Jeremy Hunt and the Conservatives insist the NHS is ‘safe in our hands’

Chris Riddell 16.08.09

The direction of travel was set 25 years ago by the NHS review announced by Margaret Thatcher on the BBC Panorama programme in January 1988. The Conservatives have a poor track record with the NHS. Thatcher ushered in the NHS internal market, the mechanism that introduced what many in the health service still revile: competition.

Health authorities ceased to run hospitals but instead “purchased” care from hospitals who had to compete with others to provide it and became independent, self-governing trusts. The stated aim was to ‘increase efficiency’ and ‘eliminate waste’ through competition. Yet by the time John Major was prime minister, we saw the crisis deepen, with the postcode lottery and patients parked on hospital trolleys in hospital corridors for hours on end, waiting to see a worn out, overworked doctor.  

In order to assess the impact of Thatcher’s legacy on healthcare, it’s essential to appreciate that NHS market reforms began on her watch. Even the apparently relatively minor step of outsourcing hospital cleaning services was to cast a dark shadow over hospital care decades later. Putting cleaning services out to competitive tender meant that the job of cleaning wards went to the lowest bidder – often to companies that used casual, untrained staff, supplied by job centres. The contrast between the high quality of surgical treatment and the dirtiness of wards became notorious. The level of hospital-acquired infections grew steadily, including those caused by  ‘superbugs’  including MRSA. 

A study published by the Health Service Journal laid the blame for the rise of antibiotic resistant infections on poor hygiene standards; finding hospitals full of rubbish, uncollected left-over food in canteens and dirty linen strewn over bedroom floors. The impact outsourcing has had on cleaning services has been a constant source of tension since those early reforms. While trade unions and medical professionals have consistently argued against it, business leaders have always rejected any connection between outsourcing, infection rates, and declining standards.

Public sector outsourcing is central to the present government’s ideological strategy, despite the evidence that is now stacked against it being genuinely ‘competitive’. Since 2010, the number of large contracts awarded has increased by over 47% with tens of thousands of workers in various sectors – health, defence and IT – being transferred to corporate employers like Serco, Capita and G4S. The UK’s public sector has become the largest outsourcing market in the world, accounting for around 80% of all public sector contracting in Europe. These multinationals are not particularly interested in competition; they’re interested in profit and being in a monopoly position where they can dominate the market. Despite the wake of scandals that follows these companies, growth in the public sector outsourcing market shows no signs of slowing and the government shows no signs of learning from these events. 

Thatcher wanted to introduce even more radical changes – such as a shift to an insurance based healthcare model, with ‘health stamps’ for the poor – but in a busy decade, it seems that her battles with trade unions and left-wing Labour councils took priority.

It was under Thatcher’s administration that the climate of austerity began within the NHS. 

Then there was the Black Report into health inequalities, published in 1980 after a failed attempt by the  Conservatives to block its publication, noted that health inequalities in the UK were linked to socio-economic factors such as income, housing and conditions of work. The government rejected the report’s findings and recommendations.

Conservatives published a policy book called Direct Democracy in 2005. It claimed that the NHS was “no longer relevant”, and a system was proposed whereby patients were funded “either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice” – with the poor having their contributions “supplemented or paid for by the state”. The authors included the current health secretary Jeremy Hunt. 

Against a backdrop of austerity and public cuts, healthcare facilities are continuing to contract out their facilities management and clinical services. But, the practice remains deeply controversial and the consequences are becoming more visible. 

Thatcher’s competitive tendering was introduced for cleaning, catering and other ancillary non-medical services, and were extended by the Tories in the ’90s under the NHS and Community Care Act – the first piece of legislation to introduce an internal market into the provision of healthcare. This was followed by the Private Finance Initiative (PFIs) in 1992 under the Major government.  Lansley’s reforms – premised on ‘increasing the diversity of providers in the management of the NHS’ – represent only the culmination of this legacy.

A centrally funded health service has demonstrated its a major contribution to reducing health inequality, by permitting healthcare practitioners and policy makers to design services and deliver care based on need, not the profit incentive. An increasingly privatised NHS has simply led to rationing and inadequate healthcare.

The biggest single contribution to health inequality is social inequality, a problem that has deteriorated significantly in the wake of the Conservative agenda of combined economic austerity and welfare reform.

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Image courtesy of Robert Livingstone 

 

Related

The Coalition has deliberately financially trashed the NHS to justify its privatisation

Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper

Private bill to introduce further charges to patients for healthcare services is due for second reading today

Labour challenge government about ‘shocking’ rise in coroner warnings over NHS patient deaths

 


I don’t make any money from my work. I am disabled and don’t have any paid employment. But you can contribute by making a donation and help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.

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