FrontPoint Systems Ltd

Finally something about IT, I was getting a bit concerned.

E-Health Insider carries news of guidance issued to the SHA’s about the detail of the Summary Care Record Service i.e. the Spine.

The gist is that

Patients can choose to dissent from data sharing, in which case a patient’s summary record will be restricted to the authoring GP only.

If patients do not opt-out an initial text based summary of their medications, allergies and adverse reactions will be uploaded to the spine.

After the upload patients have two options. They can choose to remove some items from their summary record, known as ‘tailoring’ and done by the clinician, or they can send a blank summary update which includes demographic information only and a message that the patient has chosen not to have a summary record.

So patients can consent to sharing their summary, dissent from sharing but still have the information uploaded in case they change their minds or dissent from sharing and have no summary uploaded.

I wonder why it took so long to get to this stage, these principles are the ones that should have been applied from the start. Though there is still the opt-in v/s opt-out issue.

The first wave of the early adopter programme will begin in the first quarter of 2007/8 with a small number of practices in one PCT, followed by roll out to more practices in that PCT and the trial of the programme in a second PCT. In the last two quarters of the year second wave practices will go live with the SCR. Access to the SCR via Healthspace will be available from May or June 2007.

But considering that the initial consultation with patients to gain consent for data sharing is currently taking 2 hours, I wonder how this will work in practice. Not to mention the issue of exclusion -

“Dr Hannan admits the system isn’t for everyone, though. He has many patients from the Bengali population - and none of them have so far come forward for internet access to their records.”

And there still is no clarity about the governance arrangements & the resources available to the Caldicott Guardians or others taking on the governance role.

There is also the Guidance from the DH on preparing local IM&T plans. I struggled to find guidance on obtaining actual clinical input into these plans.

Also, some detail previously released by CfH about Sealed Envelopes and the philosophy behind them .

See the new Private Eye dated 2 March - 15 March for a ripping yarn on the tribulations surrounding the NHS IT programme. The article is not available online but I hope to do something about that soon. The image posted below is blurred on purpose to avoid copyright issues.

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Quite a few snippets in the press today, the news ranging from bad to worse.

The BBC reviews the process of service reconfiguration & the willingness of local councils to question the fait accompli. It is all about consultation after all, though there is still the problem that after a mammoth listening exercise, there is still no requirement for those concerns to be taken into account.

More from Patricia Hewitt on NHS funding.

Also coverage of a review of the performance of children’s services in the NHS from the Healthcare Commission with rankings.

The investigation by the Healthcare Commission, the health services regulator, today says that 70 per cent of 157 trusts scored only “fair” and five per cent scored “weak” when measured against national standards set by the Government, three years ago.

Lack of training of staff, from nurses through to surgeons and anaesthetists, in communicating with children was a common criticism.

But then there have been other priorities which is why pretty much all funding for training has been cancelled, including for life-support courses, let alone communication skills.

Some coverage in the Telegraph of the ongoing dispute between consultants & private insurers such as BUPA who want to restrict fees.

And finally, more about money.

The FT suggests that below inflation pay rises can be expected by NHS staff with staged increases for consultants & GP’s. Funny how they are not willing to let market forces decide this one. I am told there is a marked shortage of locums, I wonder if that would have anything to do with the NHS Professionals cartel & the derisory rates of pay offered.

This is on top of previous talk of capping GP pay.

With additional scare-mongering about pensions. Sorry chaps but pensions are part of the pay contract & are earned, not a gift that can be revoked at will. The staff are not to blame for poor accounting.

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The Audit Commission’s report on the pilot study to validate PbR is something I missed earlier.

Between April and August 2006, the Audit Commission piloted the external clinical coding audit and benchmarking components of the PbR assurance framework in two health economies – South Yorkshire and Avon, Gloucestershire and Wiltshire (AGW).

Key findings

The pilots show a relatively high level of clinical coding error, which is leading to inaccurate payments under PbR. The HRG error rate, averaged across the 12 participating acute trusts, is 11.9 per cent. There is also considerable variation across trusts, ranging from an overall Healthcare Resource Group (HRG) error rate of 3.5 per cent to 28 per cent, and across specialities. Diagnosis coding has a higher error rate than procedure coding and the error is more likely to impact on payments. There is greater and more material error among non-elective episodes.

With error rates of nearly 12% in the limited sample above, is this system fit for purpose?

The coding error has resulted in both overpayment and underpayment to trusts for individual episodes – underpayment for seven trusts and overpayment for five trusts. The absolute impact of the error on individual trust payments ranges from £7,091 to £67,698 for the sampled 200 episodes, representing between 5 per cent and 14 per cent of the total sample value. Although it is difficult to extrapolate the impact on accuracy of payments to a trust overall with any confidence, we can say that clinical coding error is clearly impacting negatively on payment accuracy and that mechanisms should be in place to address this.

I am not aware of too many organisations that can stomach this level of payment instability without going out of business.

Both coder and non-coder errors are contributing to the high error rate. Quality of clinical documentation and clinician involvement are some of the non-coder issues that are contributing to the error rate; while low numbers of accredited coders, insufficient training, and insufficient guidance on coding practice locally (for example, absence of a complete and up-to-date policy and procedure document) are the main causes of coder error. Error rates are noticeably higher where there is a low proportion of accredited coders or a poor coding process (for example, coders are not coding from case notes).

There still isn’t an easy way to get detailed coding information to be completed by the clinicians & there will not be until there is full-scale computerised record keeping. The use of various smaller consumables is not recorded & is only estimated. Most coding is done away from the coal-face by non clinical staff who have to infer details from hospital records not meant for this purpose.

There is evidence of overcoding (recording more diagnosis/procedure codes than is necessary) in some trusts, but in some cases this has been a historic practice, and without access to prior audit reports it is difficult to attribute to the financial incentives under PbR. There was also evidence of trusts actively working to optimise their coding to maximise income, but within existing coding rules (that is, the practice is not fraudulent). There is some concerning practice emerging, for example, where the clinical coding team reports to the director of finance, and is involved in discussions about the financial impact of coding changes on a regular basis. This increases the likelihood of manipulation and it will be important to have a protocol in place to refer cases of suspected fraud to the NHS Counter Fraud and Security Management Service (CFSMS).

There is some gaming of the system but not in a fraudulent manner.

Coding auditors have also raised concerns about the appropriateness of admissions in some trusts, where it appeared from the case notes that patients should have been treated as outpatients and there was no obvious reason for admission. This is a big issue in both pilots. However, current data definitions are ambiguous and their application is subjective, leading to different local practices in the treatment of day cases/outpatients – until this is resolved it will be difficult to address this area.

Seems like a value judgement & second-guessing of clinical decisions to me, I wonder whether there were any clinicians actually on this audit team?

While there is no agreed standard or target for clinical coding error in the NHS, the reported level of HRG error seems intuitively too high, particularly in a system where clinical coding is the primary determinant of payment. The level and nature of clinical coding error is not so high as to destabilise the PbR regime, but it does undermine it, raising concerns about the accuracy and fairness of funding flows. In addition, it has major data quality, epidemiological and clinical implications.

I agree, though I am more concerned about the stability of the system, especially given the other pressures acting on the NHS. It will be interesting to see whether this has filtered through to the decision makers & if PbR still goes ahead as planned on the current timetables.

The pilots demonstrate that there is a need for a centrally co-ordinated external clinical coding audit programme, which ensures objectivity and independence of results. Even where there are strong local monitoring arrangements in place at commissioner and provider level, there is a need for an external and independent audit to supplement and provide additional impetus to improve data quality. Both pilot sites have commented on the value of the audits in highlighting data quality and payment issues from an independent and objective perspective, and in opening dialogue about this between commissioners and providers and across the health economy.

An audit programme will help, but accurate coding capture can only happen at the point of treatment, not after the fact & certainly not at time and distance removed. If we are to go down this road, a well-designed EPR system that facilitates clinical participation is a must & is one we are sorely lacking.

In addition to the local benefits, a comprehensive audit programme has an obvious national benefit in improving the quality of data in the NHS and refining the policy framework (for example, the audits have highlighted inconsistencies in coding rules and/or the HRG grouping algorithm). There is also a benefit for patients. It is the first time that this kind of information has been made available, and various stake-holders have commented on its value and the opportunity to share lessons learnt and good practice.

Yes, but given that the report goes on to describe a shortage of accredited clinical coding auditors even to complete a pilot study which meant that the number of cases reviewed had to be cut & does not make any mention whatsoever of having clinicians on hand to interpret the case notes suggests that there is an awful lot more to do before any of this can be trusted.

The previous post on PbR is here.

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The horror that is MTAS has come to pass & there is mayhem in the land.

Is this a system you would entrust your future to?

This new system has turned all of the old indicators of what makes a ‘good candidate’ on their head. It doesn’t matter any more which university you went to, what class your degree was, where or with whom you have been trained, how hard you worked, how much you impressed your senior colleagues, whether you actually care for your patients, how much love and effort you put into your work, how easy you are to get on with, whether you are a good learner, whether you have any spark, personality or ambition and so and so on.

All that matters now is your ability to bullshit the answer (in 150 words) to questions such as:

“Mistakes can and do happen in medical practice. Describe a specific example where the outcome of action you took in response to a clinical mistake/error (made by you or someone else) caused you to reassess how you subsequently dealt with similar situations. What action did you take at the time and how has your practice now changed?”

Read it carefully. What is it asking? How are you going to condense the answer into 150 words?

A good answer to this question is worth more points towards getting an interview than having spent 3/4 years completing a PhD in one of the world’s leading universities, studying the speciality to which you have applied.

Who would you prefer to have treating you? A good bullshitter or a highly trained doctor who may well know as much about your disease than anyone in the world?

Anyone, sufficiently coached, can answer the above question perfectly. You don’t need any medical experience, the scenario doesn’t even have to be real. Who the hell could ever check?

What makes this even more galling is that the ‘mark schemes’ for questions such as the one above have been leaked to a chosen number of candidates in advance of the application deadline. They, but none else, knew that the question above could only score full marks if the mistake described was your own, not someone else’s. Read the question again. Did it say describe your mistake? Or did say ‘yours or someone else’s?

Add to this the completely shambolic manner in which the applications were scored. Website crashes, supposedly anonymous applications with names visible, an online system reverting to old fashioned paper print-outs, non-trained assessors dragged in at the last minute to shift through forms, consultants scoring hundreds of forms in the final hours before the shortlisting deadline, deadlines missed, people hanging in limbo, ‘final data check in progress’, people officially advised to apply for the wrong training level, people for the whom the right training level doesn’t exist and available posts being a fraction of those in previous years.

In my speciality, in the hospital I work at the moment (Oxford), 100 people applied for 3 jobs. There were 8 available in “London, Kent, Surrey and Sussex”, 1 in Bristol (60 applicants), 2 in Leeds, 2 in Newcastle. If you are prepared to take a job ’somewhere in Scotland’ there were another 9 or so. Choose 4 of the above & good luck.

Currently we don’t know whether there will be a similar number of jobs next year, or whether most of them will be ring-fenced for people who came in at a lower level this year. ‘They’ simply haven’t told us. In reality this is because they haven’t decided.

Training programmes in English speaking countries worldwide are about to be bombarded with very highly qualified medical graduates. Not wanting to go too far from home, I am seriously thinking about which European language I need to start learning while I’m doing my PhD over the next 2/3 years.

The best student from my comprehensive school in north Liverpool, 5 grade As at A-level, Cambridge undergraduate degree and medical training, raced through post-grad exams in minimum possible time, universally esteemed by my consultants, a bit quiet and serious but mostly get on with the nurses, research done, papers in, prizes won, courses attended, PhD in Oxford. Currently being trained by the country’s (if not the world’s) experts in the field I want to work. I know my patients like me and I like them. Dr Crippen would be impressed with my communication skills & empathy (I think, but very hard to prove in 150 words).

Today I realised that this country doesn’t want or need me anymore.

Dan | 26.02.07 - 11:41 pm

A couple of other posts about MTAS.

As I said previously, it is open season on the medical profession at the moment & they are being treated worse than lab rats with nary an apology. I know that this presumption that psychotic mumbo-jumbo can help select good candidates is common enough in certain rarefied professions & in business but was thankfully kept out of the health service - until now. And as for the “leaders of the profession” who did not stand up to be counted in opposition & indeed acquiesced in the dirty work, ……………..

Reposting from earlier, because I can ……

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Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a fxxxing big lottery. Choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security. Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the speciality before, foundation programmes you have no control over, and hospitals you don’t want to work in. Choose being treated by ‘trained doctors’ rather than ‘doctors in-training’, even though the average consultants training hours have been cut from 40,000 to 10,000. Choose Hospital At Night and no-one knowing the patients anymore. Choose being an SHO lost in the middle of it all, with nothing but a sparsely updated web-site to inform yourself. Choose seniors who know nothing about the system and seem powerless to influence it. Choose an internal office with no windows in your brand new PFI hospital while the doors fall off and middle managers sit in their swanky boardrooms munching on biscuits that your taxes are paying for. Choose paying £10 a day for the privilege of parking at your work-place while you work non-compliant rotas and get bullied into lying on your EWTD monitoring forms. Choose sitting at that PC filling-in mind-numbing, spirit-crushing objective assessment questionnaires. Choose PMETB-approved curricula and competency-based assessments no-one has properly validated. Choose your third choice career path and wondering who the fxxk you are on a busy post-take ward-round. Choose rotting away at the end of it all, pishing your last in a miserable Non-Consultant Career Grade post, nothing more than an embarrassment to the under-experienced, ‘fit for purpose’ FY’s you’ve trained to replace yourself.

Choose not to choose your future.

Choose MMC.

Image & text courtesy of Dr Rant & Doctors-Net UK

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Payment by Results is another of those ideas that is superficially attractive in theory, especially to health economists & policy makers but as I mentioned yesterday in response to Chris Ham’s comments, is executed so incompetently that it will cause immense harm.

This is more so the case when no one is sure if the hospitals are reporting from the same baseline, the methodology by which the tariffs were arrived at is opaque, there are no accurate estimates for the proportion of simple or complex cases used to derive the costs & they are at variance with most hospitals own calculations. And given that the clinical coding regime that produces the data used for these calculations is in its infancy & has been criticised from here to eternity, it appears to be all smoke & mirrors.

Of the few PbR tariffs I looked at, there was so much wide variation between trusts in different parts of the country that if paid according to them, they could not continue in business, especially when the simpler cases had been creamed off by ISTC’s, for whom the excuse is that they do not have critical care facilities that can support the more severely ill patients. But the whole edifice of IS involvement is built on the idea that simpler cases can be moved to these centres with little or no effect on the NHS. This problem is recognised internally at the DoH but there is no appetite to challenge or even to analyse or model the impact of these or any other similar policies.

….. an accounting error built into the NHS, an error which means that, despite the most drastic measures, such as ward closures, staff cuts and withdrawal of certain treatments and services, the books can never be balanced.

The introduction of the NHS tariff in 2002 - a standardised price list for operations and procedures to apply nationally - was intended to reform hospital accounting.

It was also seen as crucial to the war on waiting lists, helping to ensure better use of beds and theatre time by allowing patients to travel around the country for their operations with the procedure being paid for by their own primary care trust (PCT).

Money following the patient in this way was a fine idea in theory, but in practice the tariff has one massive flaw.

Every price for every procedure on the list is a guesstimate. No one in the whole system can say for certain that the price hospitals charge a PCT for work has any relation to the real cost of that procedure. In the majority of cases, it is simply wrong.

When the tariff was first set up, financial directors from hospitals around the country were asked to submit the price they put on a particular procedure.

The figures varied enormously, so the administrators took a mean figure and decided that was close enough.

None of the participating hospitals performed an audit to crosscheck the figures they had submitted.

No one asked the surgeons if they thought these figures were correct. Whitehall signed them off - and the price list was fixed.

Mr Steve Cannon, for example, runs a unit dealing with complicated sarcomas (bone and soft tissue cancers), and correcting complications of knee and hip surgery.

Cannon estimates that inaccurate pricing means he loses about £1,000 a case.

“We used to balance the books by performing arthroscopies [exploratory joint surgery],” he says.

“But if you remove these simple procedures, sending them to ISTCs or special NHS clinics, we can’t make any profit. The proposed tariffs for what we have to do are inadequate.

“For an operation to excise a soft tissue sarcoma, the tariff allows £1,428 per case. Add in a minimum of three days in hospital, perhaps one night in intensive care, and a top-up payment, as it is a specialist area, and the cost we can claim is £5,216 each patient.

“At present, even with all our cost-cutting measures in place, each of these cases actually costs us £8,674. We will be short by £900,000 next year on that group of patients alone.

As has been argued before, PbR should not have been brought in before the data underpinning it had been validated. The fact that Version 1 of the tariffs had to be withdrawn immediately should have warned policy-makers that Version 2 was not fit for purpose either & that any pricing mechanism would be better off awaiting a systematic analysis & rigourous approach to tariff development. Unbundled tariffs breaking down the cost of each headline item are promised in 2008 but it is anyone’s guess as to how accurate they will be, especially since there still isn’t the data to base them on & allow for local variances.

Meanwhile, in the good old US of A, even after all these years of dealing with priced healthcare, they are discovering that there is nothing rational behind it. Is this the world we want to enter?

And in the meantime, here we are still going ahead with these!

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To add to these, I wonder who will be paying for them 30 years down the line.

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Never attribute to malice what can be explained by mere incompetence.

For the health service is on the cusp of being subjected to European competition law and, should that happen, hospital bail-outs might cease to be legal. The liberalised health service would then resemble Pandora’s box - something which, once opened up, could not again be closed.

Member states have enjoyed autonomy over health, and the European court continues to accept that countries have a right to organise healthcare on non-market lines. However, the court has recently been stressing that if countries decide to run their healthcare as a market then they must play by market rules. And, as new research from the Centre for Health Economics concludes, a host of government reforms in the English NHS - from business-style bankruptcy rules to official classification of hospitals as commercial bodies - effectively invite the court to deem the service a market.

The implications could be profound. Ken Anderson, who recently left the top commercial liaison job in the Department of Health, has said the NHS could soon lose its right to decide which services to deliver itself. If that is correct, neither politicians nor NHS managers could punt work towards public hospitals that need it to remain viable. For if a private company wanted to make a bid for that work, it would have a legal right to be properly considered. Attempts to foster “third-sector” provision, for example nursing co-operatives, would also falter, for such providers could not lawfully be privileged against commercial players.

There are hard-headed economic reasons for not treating healthcare as just another market. Gordon Brown has argued that untrammelled choice can work against rather than for efficiency, given the risk of providers cherry-picking the easier cases, the need for cross-fertilisation between specialisms and the impracticality of patients making decisions about where to receive emergency treatment. Whether his case is accepted or not, it is surely better that it falls to elected politicians - rather than to judges or bureaucrats - to determine where the balance of public and private provision lies.

The main complaint against the current set of changes is that they are not fully thought through & what better illustration of the danger they pose can there be than this, scaremongering though it may seem?

Most of the dangers being warned about are already imminent, the relationship between cause & effect not being strictly proportional.

Speaking of the Commercial Directorate, having a department full of people with minimal experience or knowledge of the health service & very little strategic awareness or consideration towards the wider situation interpret & implement ministerial wishes is not a very good way to reform the NHS, rather an easy way to damage it. It is about choosing process over product & quite a lot of the blame for the current brouhaha about the market based reforms can be laid at the door of expedient decisions.

I wonder what Chris Ham or other advocates of market based reforms have to say about this?

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Chris Ham who was director of strategy at the Department of Health from 2001 to 2004 and one of the authors of the current programme of reform tries to writes in today’s Guardian that the current reforms need tweaking. Lets look at his arguments, shall we?

When it comes to hospitals, paying a fixed price for delivering care will drive efficiency improvements in the case of treatments where patients can choose (If the prices are set appropriately, there is transparency about what is being charged for & they are unbundled, if the burden is shared equitably i.e. an equal case-mix of patients or if this is not possible, appropriately weighted payments, both of which are not catered for. Why is that?), but that is doubtful in cases where patients have little or no choice (true). Most hospital beds are in fact occupied by patients admitted as emergencies, often as the result of an acute exacerbation of conditions such as diabetes. Many of these patients can be helped to remain at home if GPs and community nurses anticipate their needs and work closely with hospital specialists (Well, as recognised by most people, one of the consequences of the reforms has been financial instability & subsequent cutbacks by PCT’s. And not just in community services either).

The government’s reforms offer GPs incentives to avoid hospital admission. But so far most GPs have been slow to take up these opportunities. It is unrealistic to expect this initiative to be a major driver of improved performance (We are not enlightened as to why, but perhaps the incentives might be no such thing? GP’s are not fools, they are under no obligation to take up ideologically & politically motivated changes which deliver little or no clinical benefit.).

Equally questionable is whether the reforms will support the development of integrated care to reduce the use of hospital services. The continued separation between GPs and hospitals, and increasing diversity of provision to support patient choice, has brought further fragmentation, not closer integration (And yet we have the insistence on choice & the prospective introduction of the Extended Choice Network in a few weeks).

With healthcare organisations competing for a bigger share of the NHS budget, there is little incentive for them to collaborate to provide care in the community (Yes, & when you are talking about the health of a nation, what is required is an integrated healthcare strategy, not piecemeal purchases). Of greater concern still is the ability of the organisations that control NHS resources to negotiate on equal terms with NHS and private-sector providers. Primary care trusts are expected to bring about improvements in performance by becoming smart purchasers of care for their populations.

The government has strengthened the provision of care by introducing NHS foundation trusts and independent sector treatment centres (Not really, some of the acute trusts are tottering). But it has given scant attention to the development of primary care trusts. This has created a fundamental weakness in the design of the reforms, with the purchasers of care lacking the necessary expertise and resources to make the healthcare market work efficiently (This reads like justification for the introduction of the Commissioning Services Framework, allowing the PCT’s who are no good at commissioning to hand it over to other organisations who will be able to aggregate purchasing & run things efficiently i.e. provide a gatekeeper service, never mind that the health insurers who do this in the USA & are the basis for this policy are not exactly known for their efficiency). The levers and incentives do not exist to reduce variations in productivity and performance on the scale needed to fund future medical advances. (And don’t mention the transaction costs)

This article appears not to suggest any serious review of the current reforms but to argue the case for their extension into the areas being identified as weaknesses.

There is a review in the Guardian which gives more background.

I don’t know, I side with Allyson Pollock myself. For one, she has actual medical experience in public health & knows the system from the inside. And she has the right approach.

One of her basic tests …… “does it work?”. Kept firmly grounded in the reality of the health service by weekly attendance at UCLH Trust management board meetings, she says: “Our work is case-study based and highly empirical. It is all about evaluating what is going on on the ground from a public-health perspective: its impact on patients, staff and the wider population, and its relationship to the bigger picture.”

Further reading

Prof Colin Leys’ Paul Noone lecture

NHS Plc

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Now that the 3rd quarter deficit figures are in & there is no immediate threat of resignation, lets look at this again, shall we?

In her interview with the Mirror Patricia Hewitt said:

“More money will be going into nurses in all fields to transform the quality of life and care for people in their home or closer to home”. Untrue according to the govt’s own statistics & according to the Royal College of Nursing who have been predicting unemployment among nurses.

“That will mean fewer emergency admissions, so you need fewer beds”. Possibly correct at the end of a programme of reform, not at the beginning. There is a lot of catching up to do given the number of patients whose health needs have been poorly met so far.

“Fewer beds are a sign of success - not a sign of failure”. Not in this context, they are not. This excuse was used for every single PFI build & is also partly responsible for the burgeoning Hospital Acquired Infection problem.

“This is not about cutting services or downgrading, it is about improving things, it will save lives. If we put more of the money into community nurses, we can transform lives, particularly for elderly people.” The problem is that community nursing services have been under the axe for so long, they are not newsworthy anymore. Unfilled posts, staff not being replaced when on maternity leave, overwork etc. are a common thread across most PCT’s. There simply isn’t the money going into community services.

At the time, this claim was met with ridicule.

I mean, headlines like these are simply no good.

Liam Halligan at the Telegraph trails his interview with Health Secretary Patricia Hewitt for Channel 4’s Dispatches programme which is due for broadcast tomorrow.

I hope he & Channel 4 forgive me, but hey, we are atleast talking about him, which is good!

“It was the best year from the patients’ point of view. More people were treated, faster than ever before and more lives were saved than ever before,” she said.

“Of course it has been a difficult year for staff, as we have had to sort out the large over-spend. But it is now clear we are absolutely back on track to get the NHS into financial balance by the end of the year.”

I tell the Health Secretary about the new survey conducted for the Dispatches programme on Channel 4, which I am presenting that shows almost half the NHS hospitals in England are now delaying operations to meet an end-of-year financial target.

In many of the hospitals surveyed, treatments are being postponed for more than 20 weeks, despite staff and equipment being available. In some, the imposed delays are approaching 28 weeks - the Government’s much-vaunted maximum wait that ministers so often crow about.

“Yes, I accept that in some places, for a temporary period, while we get the finances sorted out, minimum waits may be necessary,” she said. “But we have to get the NHS back into balance. The system must live within its means.”

With the tensions between us increasing, I put it to the Secretary of State that she is desperately trying to rein in the deficit, in an unrealistic time-frame, to save her own political skin. For the first time, she loses her cool, and the interview comes alive.

“That is an absolute insult to thousands of NHS staff across the country,” she retorts, her eyes wide with anger. “That is an insult to NHS staff across the country who have worked their socks off this year to make difficult decisions.”

I point out that I am addressing her and not anyone from the NHS, and that many friends working in the health service have asked me to put exactly this point to her.

“You are simply reflecting a cynical media view. Let’s deal with the reality. It is a frustrating situation but the NHS has to live within its means - so, in some places, for a temporary period, minimum waits will be necessary.”

I pull out a letter from one regional PCT, dated last month, ordering local doctors to observe a three-month “suspension” of referrals for many conditions, including wisdom teeth, joint injections and varicose veins. I tell her that doctors who have received such letters have told me that they are deeply offended that their scope for referral is being limited in this bureaucratic way. In the words of one such GP: “Morale among my colleagues is at its lowest ebb for the 25 years I’ve worked in the NHS.”

“Look, after 60 years of NHS waiting lists, we’ve got them to their lowest level ever,” replies Ms Hewitt, still staring at the PCT letter in my hand. “The health service has been transformed. Now, of course there are problems, but you must acknowledge that we have lowered waiting times overall.”

It is a pity that Liam Halligan’s researchers did not cast their net a little wider, there is a lot more that could have been put to the Health Secretary. I for one will be watching on Monday night.

Of course, Patricia Hewitt has a bit part in the latest political embarrassment of the day, the comments by Margaret Beckett.

“No disrespect to Patricia [Hewitt] , but DTI is always a bit of a handful.

RB: I think she’s a bit out of her depth there actually.

MB: Yeah. That’s what a lot of other people say to me.”

Could easily have been said today about her health portfolio.

References:

A detailed but sanitised look at the cause of the deficits.

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Two thirds of ambulance trusts are missing targets because of a lack of funding.

Millions of pounds needed to fund extra vehicles and crews are instead being withheld as local health authorities struggle to balance their books before the end of the financial year, ambulance leaders say.

But despite a streamlining of the service last year designed to improve performance, the latest figures obtained by The Times reveal that 8 of the 12 mainland ambulance services are failing to achieve a 75 per cent success rate for attending serious emergency calls within eight minutes.

The current situation, using year-to-date figures, compares with the end of the previous financial year when three quarters of the 31 ambulance trusts in England were hitting the target for 75 per cent of ambulances to attend priority calls within eight minutes.

Richard Diment, chief executive of the ASA, said that the reorganisation of the service, an increase in demand and a lack of funding had all contributed to a fall in performance since July.

“The number of category A calls has risen by about 10 per cent week-on-week compared with last year, and the total number of calls by 6 to 8 per cent,” he said.

“The public and the Department of Health expect ambulance trusts to perform to national standards, yet PCTs are saying, ‘We know these are the targets but we just do not have the resources to help you meet them’.”

There is of course Unison’s In the Interests of patients report which is covered in the BMJ

I will return to this later in detail.

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The Times, the BBC & The Independent catch up with stories about hospital acquired infections.

The chaos in the health service brings to mind the feeling that the govt would like to fix things, to remove the failings of the NHS from the headlines but doesn’t quite know how. It flails around looking for easy answers, trying this & that, anything that snake oil salesmen promise in order to please His Masters Voice. As shown in this quote re Iraq which is a greater priority if such a thing were possible than the NHS.

In the world of General Practice, the ongoing tender for GP Systems of Choice gets a mention as does the recent decision by the South Central SHA to contract with Price Waterhouse Coopers for a review of commissioning.

There is also of course the Kings Fund suggesting that the NHS will not collapse in the next few years due to a lack of money. I agree, the threat is from unstructured, haphazard reform & its effects but the health service will limp along.

IT has been a little neglected of late but Dr Crippen highlights the continuing irritants caused by poor clinician involvement.

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