Saturday 29 October 2016

Four Corners of the Same Room

I have a Smartphone, and like so many other Smartphone owners, it’s more than just a phone for me. One of my favourite things on it is my news apps, apps that stream me the latest news, and my favourite of these is the BBC news app. I have always valued the BBC news and to have it there on my phone is so great, they even let me group items by category, and then select the categories of interest to me. Of course one of these categories on my BBC news feed is the NHS.

Last Sunday (23/10/16) I was reading the BBC news feed on my phone when I was struck by something. All four stories, in the NHS news category, were linked. Not just linked because they were all related to the NHS, but linked because they were all, ultimately caused by the same problem.

They were:

The Royal National Orthopaedic Hospital (RNOH) in Stanmore, north London, has launched an appeal to raise £400,000 for its spinal injuries unit. They want to expand the unit by building six more beds and buying new rehabilitation equipment, and this is the only way to fund it. The Trust says they have to do this because there isn’t any government funding available.

Many years ago I worked at RNOH. It was a leading orthopaedic hospital, it performed surgery and treatments that weren’t available anywhere else, its spinal injuries unit was in high demand; but funding was never a problem. The Trust was highly regarded by the Department of Health and funded well to do its worked. This has gone and now they are begging online for funds for patient care. This refurbishment is for patient care, equipment and extra beds, it isn’t just funds to repaint the walls and buy “original art” to hang on them.

A sixteen year old woman, from Cornwall, with mental health problems was treated on a general medical ward for three months. She was a patient on a general medical ward, not even an adult mental health ward, because there were no beds for children/teenagers with mental problems in the whole county.

Teenagers with mental health problems are vulnerable enough but this young woman was nursed on a general medical ward, alongside patients with dementia and patients who were terminally ill. Also, the nursing staff would be skilled in general medicine, not medical health, they wouldn’t be able to meet her needs.

She is now receiving care in a dedicated mental health unit, but its 150 miles away from her home.

Hundreds of people took part in a march, on Sunday, in Barnstaple, Devon, against proposed cuts to the North Devon District Hospital. A leaked report has proposed cuts to stroke, maternity and neo-natal services.

These cuts are only proposals, these are not definite cuts to services, but they have already frightened the local community into action.

By 2021 NHS North East and Cumbria, which serves a population of over half a million (1), could be facing £1 billion deficit.

To cut back on expenditure they are proposing downgrading two Accident and Emergency units, and cuts to acute medicine and surgery services, maternity, orthopaedics, and paediatric services. These are severe cuts to core services provided by NHS North East and Cumbria, these are not fringe or under used services, these are some of the main healthcare services they provide.

And the thing that links these four stories is NHS funding, or the cuts to it.

The underfunding of the NHS has caused all four of these stories and the second story shows directly the effects on patient care these cuts are causing. It is very re-assuring seeing people marching in Barnstaple against proposed cuts to their local hospital’s services, but so far the majority of cuts have fallen on mental health and community services (2). These services are often hidden from public attention, and rarely generate much protest when they are cut; but when they are cut we see the hard effects they have on patient care (3).

NHS funding has not kept pace with rising costs and demand, demand is outstripping funding. In the last year there has been an increase in demand for almost all NHS services; Ambulance calls-outs were up 7% on the previous 12 months, A&E attendances were up 1.1%, Emergency admissions were up 2.7%, Diagnostic tests were up 5.8%, and Consultant-led treatments were up 5.1% (4); but two out of the eight targets for cancer treatment were missed (4) and the A&E target of 95% patients being treated within 4 hours was missed for the whole of last winter and even dropped below 90% (4), this dropped as low as 85.8% in June this year (5). The number of patients waiting longer than four hours in A&E, 181,535, has almost doubled in the past year, from 96,663 in June 2015 (5).

But there are is also increased demand and failed targets at the other end of hospital care. 6,105 patients’ discharge from hospital was delayed, when they were medically fit, in June this year, often because social care support was not available to support them at home, compared with 6,045 in May this year (5). The number of days lost to delayed transfers of care, people not being able to be discharged to social services care, was 171,298, the second highest recorded, below only the total of 171,452 in May 2016 (5).

Waiting list of patients awaiting elective treatments (Non-emergency treatment or planned operations) continues to grow, with an estimated 3.8 million patients waiting for treatment in June 2016; this is the highest level since December 2007 (6).

The NHS is facing more and more demands and yet the government’s reaction seems to be the opposite. Faced with this unprecedented rise in demand, the government’s reaction is to limit NHS funding, and to repeatedly demand efficiency savings. Nearly half (47 per cent) of NHS trusts are facing end-of-year deficits (6), and 23% of Commissioning Care Groups (CCG), the groups that commission NHS services, are also facing deficits this year (6). 40%of NHS trust finance directors and 61% of CCG finance leads are concerned about meeting the productivity targets they have been set for them by the Department of Health this year (6).

But how big are these deficits? What is there cost in pounds? NHS Trusts ended 2015/16 in deficit (£2.45 billion) for the second year in a row. Halfway through this year, the NHS reported a deficit of £1.6 billion, and predicted an end of year loss of £2.8 billion (7).

How did the NHS get into this mess? The press always makes much of “financial mismanagement”, as if a handful of accountants on NHS Trust boards caused these billion pound deficits. The truth is the government has caused this; they have withheld funds from the NHS as it faces year-on-year increase in demand for its services. Back in 2010, when the Conservatives got back into government, they set the increase in funding for the NHS. Between 2010 and 2021 the NHS will be given a 10% increase in funding (9). This isn’t a 10% increase each year; it is a 10% increase in funding over the eleven years between 2010 and 2021. This works out to 0.9% increase each year (8). This doesn’t take into account inflation, the rise in cost of healthcare (which is much higher than inflation) and the extremely high increase in demand. No wonder the NHS is so underfunded.

The Department of Health has said the NHS will receive extra funding this year, £4 billion (9), part of an extra £10 billion in funding by 2021. But the NHS is facing a £2.8 billion deficit by the end of the financial year (7), which will swallow up three-quarters of this £4 billion, leaving a little over one billion in extra funding. £1 billion maybe a lot of money to most of us, but the annual NHS budget is £117.229 billion a year (10), so this will work out at about 1% extra funding to support all the extra demands on the NHS. The Department of Health has made a lot of noise about this extra funding, but this is the same Department of Health who is demanding £22 billion of “efficiency” savings from the NHS by 2021 (2). “Efficiency” is now government code for cuts because all the efficiencies, of this scale, were found decades ago. The government gives a little with one hand and takes away a lot with the other.

But this £10 billion increase in funding has already been question. The Health Select Committee, the parliamentary committee of MPs that has oversight of the NHS, has been examining NHS financing and they have found that this £10 billion is an over estimation. The real increase in funding will be more like £4.5 billion (11), less than half of the £10 billion being claimed. They say this is due to all the extra funding demands being put on the NHS, such as severe cuts to social services budgets, which is causing delayed patient discharges. And it is the NHS who is funding the care of patients who cannot be safely discharged. Dr Sarah Wollaston (Tory MP), chair of Health Select Committee, has written to the chancellor saying it gives the "false impression that the NHS is awash with cash" (11).

People in Barnstaple marched out on their streets at the threat of cuts to their local hospital, but local NHS services are already being cut and stretched beyond their capacity. Why aren’t people marching on the streets of every city and town and village in this country? NHS services are being cut and scaled backed right across the country, but a piece at a time. They are being cut when empty jobs aren’t filled, when facilities aren’t being refurbished, when no new equipment isn’t being bought, when staff are expected to treat more and more patients with no extra resources.

Our NHS is being stolen away from us a piece at a time, why aren’t we rioting on the streets? Surely we don’t all believe Jeremy Hunt’s lie that the NHS is safe in his hands?

Drew Payne

Thursday 27 October 2016

How Can I Trust the NMC?

On the 14th September (1), Pauline Cafferkey was cleared of all misconduct charges brought against her but why did the Nursing and Midwifery Council (NMC) (2) even allow this to get a tribunal? They were so obviously unfounded charges.

Ms Cafferkey was accused of not reporting her temperature, when she returned to Healthrow after volunteering to nurse Ebola patients in Sierra Leone, and allowing an incorrect temperature being recorded on her. She was accused of being dishonest. She was not on duty, she was not carrying out any clinical work, shed had her temperature taken for her. She was tired and ill and walked into the chaos that was screening process at Healthrow airport, which Public Health England failed to organise.

After a one day hearing, were the NMC lawyer ended up arguing against her own case (1), the following day the tribunal dismissed all charges against Ms Cafferkey. But why did the NMC allow this complaint to go to a tribunal? For a case to fall apart so quickly there was not such substance to the charges, yet the NMC does not seem to have investigated them. If they had properly investigated this complaint that could have saved Ms Cafferkey the stress of facing a tribunal, a woman who has survived Ebola, and saved all the expense of a tribunal.

The original complaint against her was made by Public Health England (1), the very organisation that failed to organise effective screening of the returning healthcare workers when Ms Cafferkey landed into Healthrow airport.

Again, the NMC is left looking like the villain of this story. They are seen attacking a nurse who selflessly volunteered to care for Ebola patients, herself contracting Ebola. No one caught Ebola from Ms Cafferkey, she caused no cross infection. At the time this incident happened she wasnt even on duty as a nurse. Why did the NMC let this complaint go to a tribunal?

How can nurses have confidence in the NMC, the governing body of our profession, after their treatment of Pauline Cafferkey?

From their own figures (3), in a document they sent out to all nurses in 2015, two-thirds of NMC tribunals dismissed the charges brought against the nurses. 87% of nurses yearly registration fees goes to funding the NMCs Fitness to Practice hearings (NMC tribunals) (4), but only 2% is spent on education of nurses (3). All nurses have to pay their yearly NMC fees to be able to stay working as nurses because the NMC also manages the registry of all practicing nurses in the UK.

Why is the NMC spending so much of our money on Fitness to Practice hearings? Have they no process to weed out the malicious and untrue complaints? Their website certainly gives no reassurance to nurses, and we are the people who fund them (2).

The NMCs persecution of Pauline Cafferkey gives me no confidence. What if a patient makes a false or malicious complaint about me? How can I trust the NMC to treat me fairly when they treated Pauline Cafferkey like this? What am I paying nursing resignation fee for when the NMC mismanages it the way they did with Pauline Cafferkey?

(This was originally written as an opinion piece for Nursing Standard)

Drew Payne

3 NMC Update, Issue 3, 2015

Monday 24 October 2016

PrEP or When Healthcare Isn’t Fair

We have a drug that is 86% effective at preventing a certain health condition (1), at its best the seasonal flu vaccination is only 50% effective (2), yet the NHS will not provide it on prescription. The argument is that it’s too expensive (3). If this drug prevented heart diseases or diabetes we would jump on it, but this drug is PrEP (pre-exposure prophylaxis) and prevents HIV, which that still carries a heavy stigma in this country.

NHS England argued that PrEP should be funded by Local Authorities because it is a preventative treatment (Since 2010 Local Authorities have had the responsibility for public health) but Local Authorities argued that they couldn’t afford it, and it being a medication NHS England should fund it. Deadlock, and people who need PrEP cannot get it on prescription.

At the beginning of August The National Aids Trust won a landmark victory (4). The High Court ruled that England NHS can fund PrEP, not that they should fund it only that they can. It took a court case to decide this, to say whose responsibility it is to fund PrEP. It took the shame of a charity having to take NHS England to court to obtain this ruling, like cowboy builders being taken to court to be made to do the actual job they were meant to do. But NHS England has already said it will appeal the decision, saying that PrEP is too expensive to fund. This still leaves people needing it unable to get it on an NHS prescription.

How expensive is PrEP? A Tory Lord has already claimed that it is too expensive for the NHS to fund (15).

A private prescription for PrEP costs £400 per month (5) (this includes the doctor’s
prescription for it because it is only available via a prescription), without the private doctor’s fee it can cost as little as £45 per month (16). Evolocumab and Alirocumab, anti-cholesterol medication (also preventative medications) cost the same as PrEP (6). The lifetime cost for treating one person who is HIV+ is about £380,000 (7) and there are 103,700 living with HIV in this country (8), with 6,000 new people diagnosed each year (9). Even if no new people were diagnosed with HIV and the cost of antiretroviral treatment didn’t increase, that is still a cost of £39,406,000,0000. How can PrEP be more expensive than treatment of HIV? Also HIV can severally impact on a person’s quality of life (14)

What this does highlight is the poor state of funding of the NHS.  Since 2010 the NHS has seen severe cuts to its funding (10). In 2009, under Gordon Brown, NHS funding had increased to 8.8% of GDP, in line with most other EU countries at the time. Since then, since the Conservatives came into Government, NHS funding has rapidly decreased, it has now fell far behind the other EU countries. We currently spend 7.3 of GDP on health (compared to 10.1% in the other EU countries) and there is no sign of any real increase in funding from Theresa May’s government.

PrEP is an easy target for not funding because HIV still carries such a stigma in our society.
When the High Court ruling was announced the Daily Mail ran a headline calling PrEP a “lifestyle drug” (11). Botox and hair growth supplements are lifestyle drugs. PrEP is a proven and effective preventative drug, yet the stigma of HIV runs too deep to allow us to have a reason debate about PrEP. A Nursing Standard Twitter poll found that 54%, of people who responded, thought PrEP should be self-funded, 42% thought it should be funded by the NHS and 4% thought local councils should fund it (12). This was a poll of nurses, people who should know the benefit of preventative treatment, but the stigma of HIV has a long shadow. It seems as if we can never escape the prejudice, homophobia and scaremongering of the 1980s when HIV is ever mentioned (13).

This all leaves the people who need PrEP the most out on a limb. Some people are going to different Sex Health Clinics or A&E Departments, saying they have just had unprotected sex with someone who is HIV+ and asking for PrEP, called “clinic hopping” (17). Clinicians are, at present, only allowed to prescribe PrEP as treatment for exposure to HIV, it is a single months course only. But is no way to take PrEP as an effective preventative. There is no one monitoring the person’s health, regular blood tests, monitoring any side-effects, helping with compliance. And what if they can’t find another clinic for their next month’s supply? It can be bought privately, but it needs a doctor’s prescription for each month’s supply, it can’t be bought over-the-counter like paracetamol. A private doctor’s fee can be £55 for 15 minutes, up to £145 for an hour (18), and this doesn’t include blood tests and follow-up monitoring. Also this doesn’t guarantee that the doctor is familiar with PrEP and knows how to prescribe it safely? A full private medical service for regular PrEP (including monitoring, screening, support, regular and appropriate blood tests) can cost £400 a month (5). This is well out of the reach of a lot of people and this isn’t available across the country.

We need more preventative treatments, with the cost and demand for healthcare spiraling ever upwards we cannot afford to simply just treat the symptoms of long term health conditions. We need to prevent people developing these conditions, and calling them “lifestyle factors” and blaming the person who developing the condition is no answer. We need to move to a preventative medical model, not just a treatment medical model. But all the prejudice and stigma that quickly rose to the surface with PrEP shows that our society hears them over medical evidence.

The NHS cannot afford to fund PrEP yet this isn’t the headlines that PrEP generates.

Drew Payne