UKH

So A&E targets are to go, as it's bad for the NHS, not due to any embarrassment to the government.

https://www.theguardian.com/society/2020/jan/15/matt-hancock-accident-emerg...

If only the experts would listen.. I mean, seriously?

'Dr Taj Hassan, the president of the Royal College of Emergency Medicine, said: “In our expert opinion scrapping the four-hour target will have a near-catastrophic impact on patient safety in many emergency departments that are already struggling to deliver safe patient care in a wider system that is failing badly.”'

For a side trick he claims they will solve the social care crisis in a year.  Amazing given the infrastructure and staffing issues look like they need a plan and a decade of determined effort. 

I dunno on this one, a consultant friend of mine told me they were a waste of time as there was no prioritising, so it was a bit of a useless management tool in this day and age.Somebody who has a minor injury that can wait will always be at the back of the queue.That is the way it should be compared with life threateining situation.

Yes but for how long?

In an ideal world I might agree with you but those pesky experts have pointed out that the system is in such a mess that the target has become an important safety backstop rather than a measure of performance. Do you really trust Matt Hancock enough to lose one of the few measures of change we have to show things are as bad as they have ever been and getting worse in A & E...all backed up by things like queues on beds in corridors or in ambulances before they even enter the department to start the count.

You are right to say that life-threatening situations should be prioritised ahead of minor injuries. This is one of the purposes of the triage system. That does not mean it is right for those suffering from minor injuries to be left waiting for indeterminate periods. Scrapping A&E targets would mean that hospitals would be under no pressure to improve services as long as they are able to cope with serious life-threatening cases. Of course, we could then expect to see a debate as to what constitutes 'life-threatening'. 

To think I used to have some small measure of respect for him - seems like a long time ago now.  It's not so much that he's a cynical compulsive liar like his boss, but he just seems like a slightly dim middle manager, well-meaning but totally out of his depth in an executive position and being given a hospital pass by the board of directors.

Turin it round , have the medics not been saying for years that these targets are a waste of time. 

you cannot have it both ways!

Too early to say. He just approved a £40 million upgrade in IT to stop medics having to do 15 logins to get into medical records. 

He needs a good few years track record to prove he is the next Grayling . Give him time 

Yes, I suppose so.  He's an enigma.  Clearly he isn't actually dim, but he performed a slightly awkward volte face in the leadership election (which did seem a bit cynical) and quite a lot of what he's said since just doesn't really make much sense. 

Funny that.  Tory ministers consistently warble on about the 'failing' Scottish NHS, despite the Scottish NHS consistently beating them by a large margin on this statistic.  So they decide that they should stop collecting it.

He also de-carbonised air travel this morning in a radio interview, he's on a roll!

Have they?

Well the medics I know have been. 

bit like teachers who are always complaining about ofsted. 

Must depend on hospitals I guess. I'm married to doctor so spend far too much time in the company of doctors (they tend to socialise together). They all thought* that though a broad brush the target was a good idea and a very good indicator of what was going on in the department and that this was a bad idea when launched last March (assuming it's the same proposals).

*Apart from one, but he has been known to contribute to Matt Hancock's speeches so........

That made me smile. My mum (primary school teacher) once got inspected by someone she'd failed. It did not go well.

Turn what round? The expert quote on the A&E target was from the president of the Royal College of Emergency Medicine: it's hard to think of someone better informed on the current concerns across the sector.

Latest...  Matt just ignored it seemingly... if we are to define a lifetime unit of political incompetence as a Grayling,  Matt is relatively young and seems already well on the way to achieve that.

https://www.theguardian.com/society/2020/jan/16/staff-say-hospital-bosses-m...

If someone had put such senior management behaviour in a satire I'd have thought it was maybe pushing the bounds of possibility. Yet this is where we are now with 'trust'  in that Trust. Fingerprint and handwriting experts to uncover a whistleblower and veiled threats to staff to release personal biometric information so the leak can be indentified.

Aren't we sick to death of experts? I thought it was experts that got us into the trouble we're in.

Saying that something could or should be improved isn't necessarily the same as supporting scrapping it with no replacement and no other improvements.

I've been complaining about the shortcomings of my car for years but I'd still be upset if I leave work today and find somebody's nicked it.

There are many reasons to disapprove of such a simplistic measure of performance and the perverse incentives it potentially creates. Many medics have said so. But that doesn't make them hypocrites to say it shouldn't be scrapped just because it's embarrassing the government.

Of course it was... experts being experts led certain politicians to feel it better to insult and attempt to bypass them and spin fairy tale alternative realities instead.....the country then rewarded such dishonest behaviour with a whopping Parliamentary majority. As a student of Orwell I'm incredibly worried about the next few years.

I watched the BBC 10 O'clock news last night to see the reporting on this. There was NONE.

WTF? If I had any doubt about the independence of the BBC before.....

Well the government has indicated it will review the licence fee.

And of course we don't want pesky poor performance results from the four-hour targets not being met.

What would potential buyers of the NHS from the US think?

I wouldn't be complaining if they scrapped Ofsted and targets for children at 16 based on unreliable data from when they were 10.  

Ofsted is such a drain on schools energy and it makes things about them and not about the children as individuals.  

There have been cases where what ofsted will think, or what the data will show has been used to prevent or force students GCSE choices.  

Ditto, without the Orwell stuff

Boris' new motto seems to be "Lie before you try"

I am wondering if this is all part of the setup for some enterprising American company to say "Hey we can see you are not hitting your times, let us come in and open 10 hospitals to help bring this down" or some such

One of the reason the target can be useful is indeed because there is no prioritising, as it limits the effects of errors made in prioritisation.

I am being treated for a tendon injury next week. I was offered treatment at various local NHS hospitals, and also at the local private hospital at no charge under the NHS. Explain to me why this is bad thing, to have more choice and increased capacity at zero cost to the patient.

Because profit can't be reallocated as a surplus could. Free at the point of service doesn't mean the system costs the same to run privately as publicly.

The NHS doesn’t generate a surplus. And if it can buy the service from a private provider at the same cost that it can provide the service itself then there is no reason not to have an extra arrow in its quiver. Apart from your ideological objection of course.

Or to extend the comparison. Would you rather have your potentially life-saving scan diagnosed by a NHS radiographer with a lifetime’s experience or sent off at a cost to the NHS, but not to you, to a venture capital private funded AI scanner which has mapped for comparison every scan ever made everywhere in the world and which can diagnose tumours faster and with more accuracy? Innovation is not the NHS’s strong suit.

Do you honestly think that the private provider is the same cost as in house? I would assume that the direct cost to the NHS for this service is far higher than direct. In some circumstances, this will be offset by the flexible capacity, but I think we are a long way from that point.

Flexibility usually comes at a cost, because it is a valuable benefit that brings savings in other aspects of the enterprise.

Yes, that’s exactly what I acknowledged. But flexibility has greatest value at the margin - where a tiny percentage of cases are outsourced.  In many services, we are currently a long way from this point. 

Well, unless you are a HCT executive (and I certainly am not) I suspect neither of us know for sure. I’m questioning the ideological objection to acquiring flexibility, broadening capability and improving outcomes by using private resources while maintaining the principle of free delivery to the patient. 

"at the same cost" - Currently it can't, it's quite a bit more expensive (within the two trusts I have knowledge of within the Greater Manchester area).

The "extra arrow in it's quiver" is fine (ideologically), it's generally the concern that it'll end up as every arrow that has people pushing back already. What's the tipping point? There is also the issue that the burden of any error is borne by the NHS, if your private op goes wrong there emergency cover is normally poor/non existent then you are blue lighted to an NHS hospital to sort you out. Who bears that cost?

The NHS is by no means perfect, the US system is dire, there are varying Euro systems that seem to work well but the fundamental issue is that if we want to improve the healthcare in the UK, we ALL* need to pay for it.

*IMHO of course, but the whole "the rich can pay for everything" line doesn't wash with me, if we all paid more, maybe we'd all treat the system with more respect?

It isn't simply a case of ideological objections. The staff who work for the private companies are most likely to have been trained by and poached from the NHS. The NHS pays for the training and the private companies benefit from minimal training costs. They are leeching off the NHS. 

The NHS as a whole doesn't generate a surplus, but some areas do generate profits for individual hospitals, while other areas of activity are loss-making. These areas differ from hospital to hospital depending on their size, set-up, staff grade mix etc etc.

In general terms, most hospitals gain on elective activity (planned procedures, outpatients and other non emergency work) and lose out on non-elective activity (A&E and urgent care). For this reason, private providers cherry picking profitable services whilst choosing not to run things such as A&E can (in some instances) be to the detriment of the financial stability of NHS hospitals.

That said, patient choice is improved by the availability of these private providers, so they're certainly not evil villains.

I suppose its similar to postal firms choosing to do bulk mail delivery in London while leaving Royal Mail with the universal service obligation to deliver to the highlands and islands of Scotland for 61pence.

Where in my response to you is any reference to ideology? Cost of running a service < cost of running a service + profit. Don't try and ascribe motive of which you have no evidence.

I work as a Project Manager for an organisation that undertakes its own work as well as contracting out. Self-delivered is almost always (as in I don't know of any instances where it hasn't been) cheaper. A contracted provider is always looking to carry out as much work as possible to maximise their fee. On a fixed price contract they're looking to minimise do the bare minimum to achieve the agreed scope so they can maximise their profit. That is no criticism of the contractors but merely them acting responsibly towards their shareholders. Self-delivered works benefit in that you're not reliant on (often not brilliantly written) contract KPIs to try an illicit the right behaviour in delivering a job, but rather in direct control of that. Any sanctioned funds not spent delivering a piece of work can be resanctioned back into other jobs rather than disappearing as someone else's profit.

That isn't really relevant to a discussion about the NHS using private sector resources. This would still go on even if the NHS made no use of the private sector. In all industries, some companies do the training and others pinch the staff for a premium. In oil, it's BP and Shell who get pilfered. In IT, it's the big software houses.

One negative impact of using private healthcare providers for NHS care:

https://www.theguardian.com/commentisfree/2020/jan/08/private-healthcare-se...

No. That's an argument for not using private healthcare for private treatment.

Of course it's relevant. It affects the relative costs of public vs. private provision. 

If the cost of using private sector resources is uneconomic then the NHS has the choice to use or develop its own, ie build and staff new facilities. This is a two-way street where the private sector pays the NHS to use NHS resources, eg robotic surgery operating theatres, which are of a cost and scale that is uneconomic to operate in-house.

Did you read the article or just skim the title?

As it points out, the NHS spent £9.2 billion on services provided by the private sector last year - feeding the demand for staff in the private sector who will be poached from the NHS, which in turn increases the waiting times in the NHS, which drives us to send more patients to the private sector.

It's a vicious cycle that will end the NHS, and cost the taxpayer a fortune, unless we end it now.

The sensible way to resolve the issue is to fund the NHS properly, to improve the working conditions and reduce waiting times, retaining the highly trained staff and improving the service to the point where we don't need to outsource.

That would be far cheaper in the long run, than paying the private sector to provide staff with good working conditions, short waiting times, plus corporate profit.

I read the article. The author makes the unsubstantiated leap of logic that using private healthcare inevitably leads to the absolute and complete privatisation of the NHS in its entirety. While there is an argument to be made along the lines you articulated, his scaremongering is of the worst order and aimed at people who do not understand the difference between the concepts of private initiatives within a public service and patient paid treatment.

The issues around staff retention relate to the funding of the NHS, which, to be clear, I am not arguing is remotely sufficient, not some insidious plot to hollow out the NHS by private enterprise. As for your £9.2bn spend, this is meaningless. It's just a cost of providing the service to patients for free, like in-house wages or building maintenance or capital equipment. Would there be no cost if the NHS provided the services itself?

So yes, let's fund the NHS a lot more. But can we cut we cut some of the crap about private = evil? The majority of medical innovation is driven by private initiatives.

"Do you honestly think that the private provider is the same cost as in house? I would assume that the direct cost to the NHS for this service is far higher than direct. In some circumstances, this will be offset by the flexible capacity, but I think we are a long way from that point."

There are two points to address here.

The first is tariff - Private Providers operate under Standard NHS Contracts and are paid exactly the same price for a service as their nearest NHS Trust.

Secondly, there is a growing amount of evidence to suggest that utilising independent sector hospitals for elective surgical procedures is actually more effective and cheaper in the long term for several reasons. Patients are seen sooner so their condition does not deteriorate, and their clinical outcomes are generally better (see PROMs).

There is also the further argument that by allowing the IS to deliver routine elective procedures at tariff, this frees up capacity at NHS Hospitals to treat more complex, urgent, higher cost cases - though this firmly overlaps with the 'cherry picking' argument.

There are, of course, outsourcing agreements which are commercially agreed contracts between NHS Hospitals and Independent Sector Hospitals. This is where there is the greatest amount of variance in pricing. In some cases, the cost of outsourcing will be higher *however* there are an increasing number of outsource agreements I have agreed in the last 12 months that have significant discounts because the IS Providers are able to deliver the procedures at a lower price they charge a lower price.

Everyone also conveniently forgets that GPs are 'Private' too. Primary Care Contracts hold no obligation over GP practices to reinvest any profit they make.

Its not listening to experts thats got us in this mess. The experts in the NHS, teaching etc know what needs to be done. It is the idiots in governments that tell the experts how to run their systems, yet most politicians have limited to no experience in those fields.

The other is to simply kill the NHS and move everything to a private insurance system US style.... not much support for this

Why corporate... why not small businesses, or sole trader profit? 

Much dermatology in sweden is private, you book direct with no referral. My local city has at least two. Both are small concerns employing just a few people. 

The same with physios, I book direct. Many have niches, podiatry, sports, backs etc.. they build their own client list like a purely private business, but a proportion of their costs are state funded. My physio is sport related, they are all athletes, they'll do bike fit too at normal costs and so on. 

It's absolutely not meaningless. It's £9.2 billion spent by the public purse from which a slice of corporate profit will have been taken, when with proper planning we could clearly provide the same service at less cost through the not-for-profit NHS.

Ask the UK government? Care UK has won 17 contracts worth a total of £731m since 2015 and Virgin Care has picked up 13 contracts worth £579m over the same period. These are the people making profit from the privatisation of the NHS.

That's a lovely story, but I'm not sure what it has to do with the current state of the NHS in England?

That a totally state run nhs isn't the only model that works. There is a big grey area between every employee being public sector and some insurance driven US system. 

There are aspects of provision that the state could, with more investment, perform instead of the private sector and at less, or no more cost, than by involving outside partners. But I'm not arguing that and you should have recognised that in my previous comment.

However you are so transfixed by the concept that private profit is a rape of the state that you cannot understand that there are many instances where a private provider can invest, innovate and operate virtuously and in ways that a monolithic institution, operating without the clarity that specialisation and the profit principle bring, simply cannot achieve. And all for less cost to the NHS, yet with better outcomes. A popular example would be Deepmind’s (now GoogleHealth’s) collaboration with Moorfields Eye Hospital.

Which instances of healthcare are you comparing, to talk about 'less cost to the NHS yet with better outcomes'? Being a precise minded business person, I'm figuring you'll have some in mind, along the lines of patients needing treatment for X procedure, which costs so much, with a particular outcome. One wouldn't say that without instances in mind.

Didn’t I just give an example Timmd? It’s well worth reading up on it, as this is a model for massive improvements in health outcomes.

Or how about, from more quotidian instances, your GP, your optician, your dentist and your pharmacy? Would you prefer to drive miles to a hospital to get your prescription or see your GP?

To be honest you might have, I haven't slept since yesterday (a long story, but not a crisis), did you post it further up?

No. It’s in the post you replied to and there is ample coverage on the web for you to research.

Your post isn't (much of) an example, I think, because it's not tracking patients with a particular health need, and then the outcome following their treatment, you've talked about it being great essentially.

Opinions are subjective of course...

I’ve given you the pointer. Do some research.

That's not how things usually work in online discussions, or not on here at least. People bring up arguments or points, and then provide a link, and it moves along from there.

A dislike isn't from me...

I realise you’re short on sleep but the simplest of online searches “DeepMind Moorfields” returns a report by the hospital and another by its private partner on the collaboration as the first two search replies. Is it seriously so daunting that you find it easier to ask me to nursemaid you?

Of course there is, but the reality in the UK at the moment is we're increasingly going down the road of outsourcing wholesale to large private firms. Firms who will operate the contracts as long as they are profitable, and drop them (or go bust) as soon as they run into difficulties. This privatises the profit and socialises the losses - as with all the other essential services we have privatised. Look at the rail system - we hand out subsidies to forms to rum sections of the network, let them go the contracts when they f*ck them up, rebuild the services ourselves, and then hand them back out to private tender. Virgin is a brand heavily associated with privatisation in both services. This sort of behaviour sucks money from the public purse.

I don't think anyone is particularly unhappy with GPs and opticians operating as contractors to the NHS. Small outpatient services will often be a good way to serve the local community.

What I (and most others) are unhappy with is the outsourcing of core NHS care.

Countering that physio appointments can work differently is a complete straw man.

I don't think anyone is saying there is no role for the private sector in research collaboration. The issue is with care being outsourced.

I won't presume to know your thinking, and what may or may not be transfixing you.

Are you deliberately trying to muddy the waters by equating research collaboration to the provision of care, or do you not see any difference between the two?

Do you have any examples of where the wholesale provision of care has been done for less cost to the NHS, with better outcomes, by private corporations?

Do you not think GP’s are the core of NHS care?

There were examples alluded to by AlfaPapa not far upthread in which he claims personal involvement and achieving a discounted cost. As someone closer to the chalk face of traditional healthcare he might be better placed to answer your question if all you’re interested in is basic ward care and routine surgery. Meanwhile I reiterate GP, optician, dental and pharmacy services.

As for DeepMind and Moorfields, this may currently be a research project but it is a proto-business arrangement once the thesis has been proven.

An alternative example would be the selection of Ixico, a UK quoted SME to develop and train sophisticated artificial intelligence (AI) algorithms from NHS medical images and patient data to provide tools for clinicians to speed up and improve diagnosis and care across a number of patient pathways including dementia, heart failure and cancer.

The basic proposition is that the NHS performs the scan and the private partner the diagnosis. It’s a fundamental shift that has not been achievable without private capital and for which you might be mighty grateful sometime in the future.

It's not though, by out sourcing and direct booking of cases that clearly involve eyes, skin, physios etc.  You are lifting a burden from doctors surgeries where all they do is refer people. The specialist gets to deal with you quicker, usually meaning you'll heal quicker, less time off work etc. Higher work force productivity. Or in the case of skincare, potentially faster cancer diagnosis and all the benefits that brings. 

If that's the place at Eland then the staff there tell two thirds of the patients are NHS. It's part of the waiting list initiative.

Another explanation could be the challenge csused by the disastrous PFI hospital in Halifax. Too small, not enough beds and with an ongoing contractual obligations twelve and a half times the capital cost of construction.

Why would we need private outsourcing to lift the burden from doctor's surgeries? 

There's absolutely no reason that a doctor's surgery needs to house specialists - in general these work out of hospitals and specialist clinics. The main benefit for the patient in outsourcing these services is convenience - the patient does not have to travel to the hospital. But that convenience does come at extra cost to the health service - it's much cheaper to run these services from a centralised location (economies of scale and all that).

P.s. funny you should mention skin cancer, when I had a growth on my leg last year, I traveled home to have it looked at by the Scottish (still public) health service rather than wait for the English (part privatised) health service in Newcastle where I am contracting.

It would have taken four weeks here just to get a GP appointment. Back home I walked into the surgery on Monday morning unannounced, was referred same day, saw a specialist (in a hospital) three weeks later, and had it removed two after that.

It cost me a couple of days of lost productivity to travel up and down for appointments, but was worth it for the peace of mind that the English NHS would have taken so much longer to provide.

What on earth makes you think we couldn't find this without private capital? DeepMind is running at a loss of a few hundred million a year - a drop in the ocean to the fifth largest economy in the world.

The companies involved are doing this to reap the financial rewards of selling the technology to us - which is not "evil", it's just what companies do - but don't pretend we wouldn't be better off in the long run developing the technology ourselves.

Much like the PFI (which means will we pay around £300bn for assets worth around £50bn), it's short term savings for long term loss.

It's 50 years since public money put a man on the moon - we can achieve the most when we pool our resources behind a common goal.

Is this not quite closely linked to the current, underfunded state of the NHS though? A properly funded service should be able to see patients promptly, preventing the deterioration, improving outcomes and therefore costing less. 

Why would the private sector be intrinsically better and cheaper? Seems to me like outsourcing is a sticking plaster that's better than continuing to bleed freely, rather than the most efficient long term solution.

Also seems to me that the service has been deliberately underfunded in order to engineer this scenario.

Scotland spends significantly more on the NHS than England, and has 25% more GPs relative to the population- it's no wonder you got a better service.

The two I've had done here took 3 weeks from first contact to biopsy results. It does of course cost £30 a visit, like all specialist healthcare in sweden, regardless of public or private. But that just highlights the UK problem, funding. 

Probably to do with the extra funding compared to England that Scotland receives from the treasury. The Barnett formula means that regardless of what England is given by the treasury, scotland is higher. 

I wasn't being fully, serious with my post.

While I understand your hopes, they are hopelessly idealistic. The history of government IT projects is littered with disasters and I challenge you to name a single successful one*. The future of healthcare is digital, from remote triage via an app, to insulin monitoring via IoT, to cancer diagnosis via AI, to therapy development via genetic sequencing. Yes, the NHS should be active in promoting and harnessing these developments. But a combination of collaboration, procurement and outsourcing is the way forward.

* The National Institute of Healthcare Research (NIHR) research database was a triumph - built by 150 of my (private sector) employees!

I am a bit confused here. You acknowledged that they are littered with disasters but then suggest outsourcing is a good thing? It was that which failed.

I acknowledge the contradiction. But that doesn’t mean the NHS should move all healthtech development in-house, as CIRO suggests, as the record there is abject. Nor was I talking about vast enterprise NHS administration systems of the type that collapsed. It should be obvious from the previous post that I’m referring to the future of diagnosis, monitoring and therapy.

You were using the failure of private sector resourcing as a basis for supporting private sector resourcing. However to leave aside their wider failings and to look at just "cancer diagnosis via AI". When you get past the hype a key advantage when looking at "AI" is what datasets you have access to. Access to computing resources is becoming cheaper all the time so its not immediately clear what advantage private capital would provide beyond that which could be achieved in partnership with universities and other research organisations.

Back to Matt.

https://www.theguardian.com/politics/2020/jan/23/dont-panic-dr-matt-hancock...