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Mid Staffs NHS scandal shows compassion is the quality that should inform all healthcare | Yvonne Roberts

Category : Business

Senior managers’ reluctance to take the blame for the deaths at Stafford hospital indicates a sickness in the system

Patients die in abject misery in Stafford hospital; another five trusts are under investigation. The Care Quality Commission warns that thousands of psychiatric patients are also receiving substandard care. Meanwhile, the Francis inquiry offers 290 recommendations that spin a thick, impenetrable managerial cocoon around an abstract notion that the culture was culpable but another culture will somehow be the cure. Since this new culture is to be built on the jelly-like foundation that nobody can be held to account, something is missing.

It is missing in the health and social care system and it manifests itself in the actions of many of the professionals, personified in the shameful refusal to resign of Sir David Nicholson, NHS chief executive, who was at the time the head of a body responsible for standards at Stafford hospital. What’s missing is an understanding of how human beings behave. What really makes the milk of human kindness flow?

Over several years, a number of inquiries have been conducted into medical training and “modernising medical careers”. One report, “Aspiring to Excellence”, quotes Sir William Osler, the father of modern medicine, who defined the medical role as “to prevent disease, to relieve suffering and to heal the sick”. What that leaves out is how human beings tick above and beyond their symptoms and, sometimes, because of them. That may come with experience, but a solid and sustained grounding during training would help.

It would also help the way managers and care staff work with each other. Why, for instance, has the desperately needed integration of health and social care proved so difficult to deliver? Is it again a question of “culture”? Or, more specifically, the unwillingness of consultants et al to become team players? Ask district nurses why they can’t deliver good preventative care in the community. Answer? Because some GPs say that’s trespassing on “their” territory, and they prefer to leave a vacant lot. Under the Labour government, “nudging”, the science of suggesting, rather than imposing, behaviour, became the vogue. Show a person the word “wrinkles” and he or she walks more slowly. The government’s behavioural insights team is still at work. A letter to individuals informing them that most people in their area had paid their tax, for instance, increased repayment by 15%. “Behavioural insights could save millions of pounds”, was the Cabinet Office’s proud headline. In early training in health and social care, it could also save lives.

The qualities required in care are well understood. “Compassion in Practice”, published in December, for example, refers to the six “cs” – care, compassion, competence, communication, courage and commitment. What’s absent is practice and a perception of what happens when you mix lists with human nature. For the most part, training for health professionals gives cursory attention to ethics, psychology and simulated patient exercises, while managerial bonding adventures are not enough to remind us that behind the targets behaviour, sometimes aberrant, also requires accounting.

Cut frontline staff and collaboration splinters. My father had a dedicated consultant during years with dementia. Much of her work was reduced to tick box online diagnosis; remote control management. It may be the prevailing culture, but that’s not how you bring out the best in people. Or for people.

Hospitals face new army of inspectors in wake of Mid Staffordshire scandal

Category : Business

Landmark report into hundreds of unnecessary deaths at NHS hospital to call for overhaul of regulatory system

Hospitals should face tough new scrutiny of their care by beefed-up teams of inspectors including doctors and nurses, a landmark report into hundreds of unnecessary deaths at an NHS hospital will recommend next week.

The public inquiry into the Mid Staffordshire scandal will propose the change as part of a series of measures to overhaul the array of regulatory bodies that, despite numerous warnings, did not detect serious failings in patient care for over four years or intervene soon enough to stop them.

According to sources close to the inquiry, the long-awaited report, published next Wednesday by its chairman, Robert Francis QC, will say sweeping reforms of how hospitals are policed are needed to stop a repeat of events at Stafford hospital, where an estimated 400-1,200 patients died between 2005 and 2009 as a result of “appalling” care and neglect.

Many patients relied on relatives to ensure they ate and drank because food and drink was left out of their reach, misdiagnosis of medical problems was common, pain-relieving drugs were not given or given late, and hygiene was so poor that relatives had to clean toilets themselves to avoid catching infections. “Many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives,” said Francis in his first report into the hospital in 2010.

Francis is understood to call for hospitals to undergo more regular, and much more far-reaching, inspections to ensure standards are being met through improved surveillance. He will also highlight the need to tackle a shortage of experts with clinical experience, such as doctors and nurses, among the 955 inspectors used by the Care Quality Commission (CQC) to visit NHS hospitals. Many have backgrounds in social care, such as care homes and social work, rather than NHS care.

Francis will also pin much of the blame for why poor care persisted so long at Stafford on NHS managers and regulators. “The criticism Francis will make of the NHS will involve him saying that in effect there was a self-protecting elite that refused to countenance complaints from patients and their relatives which compounded the agony that they felt. He will be excoriating about NHS managers,” said a source familiar with his thinking.

Francis’s first report revealed how the hospital trust cut staff, especially nurses, and neglected quality of care as it sought to balance its books in its determination to become a foundation trust.

In future, Monitor, which regulates NHS trusts, will be expected to share concerns about financial problems so the CQC can check if that is also affecting the care it provides.

Francis will also recommend that the CQC boosts its collection and use of intelligence about hospital care – drawing together patient complaints, media reports and the results of clinical audits – so that action can be taken as soon as such information suggests that a problem has emerged.

Francis, whose inquiry took two and a half years and cost £13m, wants the CQC to co-ordinate a drive with several other key NHS bodies to share all forms of information about how a hospital is performing, clinically and financially, as the two are often closely related. That would also include patient feedback and data from the new local quality surveillance groups that the commissioning board plans to create across England.

But sources say it is uncertain if Francis will back two changes which campaigners say are vital to protect patient safety: legal minimum staffing levels, which the Royal College of Nursing supports, and for every NHS employee to have a legal “duty of candour” to disclose to patients any mistakes they make, which is being sought by lobby group Action against Medical Accidents and has been supported by Liberal Democrat health minister Norman Lamb.

Some of Francis’s recommendations could give the government a dilemma over whether to agree to act on them all. Ministers have recently instigated several changes to the monitoring of hospitals, such as introducing a ‘friends and family’ test and exploring a system of Ofsted-style ratings, which they may cite as evidence that they have already addressed many of Francis’s key concerns. The health secretary, Jeremy Hunt, will not guarantee to implement all the recommendations despite his predecessor, Andrew Lansley, appointing Francis.

Letters:Tax-break treatment for health firms

Category : Business

You quote David Cameron as saying he wanted to “turn the NHS into a fantastic business” (Private NHS providers in line for tax cut, 14 January). The NHS was not conceived as “a business” but as a service for everyone in the UK, free at the point of delivery. A business will, rightly as a business, seek to provide a good profit and return on investments.

Yes, the NHS faces difficult decisions – such as where should be the boundary between free treatment and conditions that should be paid for (eg some cosmetic procedures). But improvement to the operation and efficiency of an organisation is likely to be best achieved using knowledge and resources already within that organisation – not by turning part or all of it into private business activities.

If companies want to offer health treatment facilities, fine, and there is a need for that. But that is done on a business model, within a business environment – and that includes paying VAT and corporation tax. It is not a “level playing field” to compare an organisation, such as the NHS or a charity, with a business.
John Chubb
Cheltenham, Gloucestershire

• Your article inaccurately states that Monitor has written a draft of the Fair Playing Review report “sympathetic to the private sector demands” for exemption from corporation tax on profits made from NHS services. The article quotes a source claiming to have seen a draft of the final review, when in fact no such draft has been written.

Monitor has received representations concerning tax from providers from the charitable sector as well as the private sector. In addition we have received representations that other factors disadvantage the public sector, such as complying with FOI requirements or employee benefits. We have had responses and held detailed conversations with providers from all sectors and we are taking time to analyse the evidence before drawing our final conclusions.

The secretary of state asked Monitor to undertake the Fair Playing Field review as an independent report. It will report at the end of March. Monitor has a statutory duty to promote and protect the interests of patients and any suggestion that we are working on behalf of the private sector misrepresents our core duty.
Dr David Bennett
Chief executive, Monitor

• Social enterprises are not to be conflated with private firms that distribute profits to shareholders. While some employee-owned businesses are social enterprises, many, including Circle Healthcare, are not. Social enterprises exist for the people – they reinvest their profits to improve patient care, have strong track records of delivering health services and are accountable to the taxpayer. As health markets are opened up to competition, it’s crucial that the distinction is clear in the minds of the public and commissioners.
Peter Holbrook
Chief executive, Social Enterprise UK

• Paying corporation tax seems to be a more than fair exchange for the opportunity to make a profit off the back of medical staff whose degrees were funded by the taxpayer. There is no shortage of private companies bidding for NHS contracts under the current terms, so no “incentive” is required; tax breaks would be a cynical misuse of public money earmarked for the NHS.
Clare Brown
Bridford, Nottingham

• The NHS has professional and educational development responsibilities for doctors, nurses and all healthcare staff, all of which is a hidden cost. If there were a professional education and development tax on all former NHS staff working in the private sector, related to their years of pre- and post-qualifying training, this would be a fairer playing field.
Professor Colin Pritchard

• Reports that the government wants to give tax breaks for private companies in the NHS come as no surprise to those like UCU fighting similar plans in higher education. Private companies have been lobbying hard for the VAT exemption granted to charitable universities and colleges. We must stop the government indulging in yet more corporate welfare at the expense of public services.
Sally Hunt
General secretary, University and College Union

NHS being ‘atomised’ by expansion of private sector’s role, say doctors

Category : Business

Over 100 healthcare firms to be allowed to provide basic care, prompting fears local hospital services may go out of business

More than 100 private firms will be paid by the NHS to treat patients as a result of the coalition’s first major expansion of the private sector’s role in the health service.

Department of Health figures show that 105 healthcare firms have been granted “any qualified provider” (AQP) status, which allows them to provide basic NHS services including physiotherapy, dermatology, hearing aids, MRI scanning and psychological therapy.

Some private firms, such as InHealth, Specsavers and Virgin Care have already taken advantage of the controversial extension of competition to establish new services. The Department of Health says that 87 providers of different kinds, 38 of which are private and 26 from the NHS, have recently begun treating patients with various conditions under AQP.

But the scale of the private sector’s new incursion into the NHS has led senior doctors to voice fears that the health service is being “atomised” and that it will force existing NHS services to close. Private companies, some of which already earn up to £200m a year each from NHS-funded work, say AQP is a major opportunity to increase their role in the health service.

Under the new rules, each NHS primary care trust in England must open up at least three health services to “any qualified provider”, whether they are from the NHS, private sector, charity, social enterprise or voluntary organisation. By 23 October last year, 105 private firms and 140 NHS organisations, mainly hospital trusts, had been approved by PCTs and clinical commissioning groups (CCGs).

AQP is still being rolled out and many providers have yet to be chosen. But InHealth, which specialises in adult hearing services and diagnostics such as MRI scans, has already been authorised to start operating in 95 places. “Clearly AQP represents an opportunity for significant geographic expansion”, said Patrick Carter, managing director of the firm’s community healthcare services division. It currently earns about £80m a year from working with NHS patients in London and the south-east but plans services at 100 extra locations from Southampton to Newcastle.

Care UK plans to increase the £190m a year it earns for delivering healthcare services to NHS patients through 35 new contracts it has won under AQP to provide diagnostic services, elective surgery and diagnosis and treatment of musculoskeletal conditions in the NHS. AQP “will give scope for other organisations to provide services and should increase competition on the basis of patient satisfaction and clinical outcomes”, areas in which it had “an outstanding track record”, a spokeswoman said.

Specsavers, the high-street glasses and hearing aids firm, has won adult hearing contracts in at least 33 places. Virgin Care, part of Richard Branson’s empire, has been awarded AQP status in the 10 areas for which it applied for contracts. It plans to offer dermatology, ophthalmology, ultrasound, podiatry and back and neck pain services and fracture clinics. BMI Healthcare has begun winning contracts to provide MRI scanning and non-obstetric ultrasound. A BMI spokesman declined to say exactly how many it had gained.

AQP was intended to let small, local private firms become NHS providers. But 24 of the 105 were large companies, with at least 250 staff, and the other 81 were small or medium-sized enterprises, with fewer than 250 staff, according to Dr Leonid Shapiro, the managing partner at healthcare consultants Candesic, who obtained the figures when the Department of Health allowed him to view its AQP database.

AQP could ultimately prove to be a big bonanza for such firms, said Shapiro. “While off to a measured start AQP could spread to cover the bulk of NHS services. We are only at the beginning of what could be a significant driver of private provider revenue and volumes,” he wrote in a detailed analysis of AQP in Health Investor magazine.

Ministers insist AQP will enhance patients’ choice of who treats them and raise standards. Unlike previous NHS outsourcing policies, those with AQP status are simply allowed to offer their service, alongside others, in a PCT or CCG area. It does not guarantee a set number of patients or income.

“AQP will help to atomise the NHS. It’s causing the NHS to be split up into thousands of different providers of health services,” said Dr Clare Gerada, the chair of the Royal College of GPs.

“It’s also atomising the patient into individual parts – their eyes, ears, mental health and so on – which is wrong and unhelpful, and forcing them to interact with multiple different services rather than just their local NHS.”

The fact that as many as 13 different providers of the same health service have been allowed to start operating in the same area will “baffle” both patients and GPs, who will not know which is the best to be treated by, Gerada added.

Dr Laurence Buckman, chair of the British Medical Association’s GPs committee, warned that private providers would start advertising to attract and retain patients, and that NHS organisations would have to follow suit in order to remain viable. Some local hospital services would go out of business in the face of competition under AQP, he added.

“AQP will be the government’s opportunity to fragment care and finally do away with any notion that there is a national health service. Logically if other people start providing a service, those who are providing it at the moment are going to have their viability reduced. The result of that is that the hospital service shrinks,” he added.

The Royal College of Physicians, which represents hospital doctors, also voiced concern. “The RCP is concerned that the extension of any qualified provider could destabilise existing services and damage integrated care pathways,” said Dr Patrick Cadigan, its registrar.

“No one area of the health service operates in isolation, the entire system is interdependent. Services link together to form care pathways to ensure joined-up care, and NHS trusts offer education and training to the next generation of doctors and nurses,” he added.

Andy Burnham, the shadow health secretary, said: “By opening the door to so many private providers, ministers are fragmenting the NHS and taking it further away from the integration they claim to support. They risk leaving the NHS increasingly beholden to the private sector and less able to provide its own services.” AQP should be halted pending a review of its effects on the NHS, Burnham added.

Earl Howe, the health minister, dismissed doctors’ objections. “This is about offering patients more choice, control and driving up the quality of their care, and the idea that this will have a negative impact on healthcare and patients is nonsense.

“Patients have already had choice for non-urgent hospital treatments like joint replacements for several years and this hasn’t destabilised services,” Howe added.

NHS privatisation fears? Grow up | Ian Birrell

Category : Business

Competition works. This bizarre, nostalgic prejudice against profits only damages the health service

Nearly one in five patients having hip replacements and hernia repairs are handled by private companies, thanks to reforms introduced by the last Labour government. Every week, 60 patients have gall bladders removed by private operators. Silently and stealthily, hundreds of profit-driven health providers have made incursions into our sacred National Health Service in the past decade.

The genie is well and truly out of the bottle. Yet anyone looking for a pantomime villain only has to mention “privatisation of the NHS” to get an audience booing and hissing. Labour politicians, whose party unleashed this revolution, curse competition for cheap applause. Medical union leaders, their members earning good incomes as private contractors, proclaim the end of their world. Now the Guardian joins the chorus of disapproval, running a hostile series on private providers.

For those who care only about ensuring the NHS survives and thrives, such blinkered conservatism is highly depressing. It panders to the nostalgic worship of a monolithic institution that never existed except in the mind of its devotees – in which doctors are all saints, and profits the dirty work of the devil.

The reality is rather more complex, which is why this view is so damaging at such a critical time for our health service. The NHS is slowly starting to turn from the centralised institution founded by Aneurin Bevan, designed to fight infant mortality and infectious diseases in big hospitals, to a community-orientated one that can cope with complex conditions thrown up by an ageing society and rising levels of disability.

At the same time astonishing scientific advances are increasing not only life expectancy but also the costs of healthcare. Budgets remain static in real terms, but health inflation and rising demand means we are staring over a financial abyss. Britain simply cannot afford to continue this ridiculous and outdated debate over the role of private medicine. The only thing that matters is what works in the most efficient and effective manner to ensure the best possible care that is free at point of delivery.

So deep is this bizarre prejudice against profits in the health world that one Downing Street study found taxpayers would prefer to pay nearly 50% more for services provided by the state than for identical services offered by private outfits. Yet most GPs have always been private contractors and increasingly, given a choice, patients are choosing private centres for treatment.

This stance seems strange when viewed from abroad. Forget the smokescreen of the US, since no one is demanding we import their system. Look instead at Germany, with more profit-driven hospitals than publicly run ones. Or Spain, where private firms provide huge chunks of healthcare in some regions. Even in Sweden, for so long the left’s nirvana, market-led reforms have transformed health services.

Competition works in health, just as it works elsewhere. This is why the introduction of personal budgets is so potentially transformative for long-term patients, especially those with complex needs. One study found hospitals in areas with more choice had lower death levels. Another last year found it was associated with faster falls in 30-day mortality rates after heart attacks. A third found higher quality of care when GP surgeries were closer together.

Of course some private provision is poor, substandard and sometimes cruel; think only of those people with learning difficulties bullied so badly at the Winterbourne View care home. So are some state services, as Labour MP Ann Clwyd discovered with the dreadful lack of compassion shown to her dying husband. Remember the biggest health scandal in recent years occurred in two NHS hospitals in mid-Staffordshire, where hundreds of elderly patients died in the most hideous circumstances.

Britain needs to grow up when it comes to the NHS. We must raise standards, ensuring elderly and disabled patients are not repeatedly failed as they are at present, at a time of rigid austerity. The key issues are ones of management, regulation and harnessing of technology, not who provides the consequent care and treatment. The truth is that those protesting so loudly over “privatisation” are harming the institution they seek to protect.

Healthwatch England aims to ensure the voices of service users are heard

Category : Business

Health and social care services should be built around people, rather than the system, says Healthwatch England’s chair

My whole working life has been about consumer advocacy: I worked at Which? for many years, and was also chief executive of the National Consumer Council. My challenge now, as chair of Healthwatch England, is to make sure the design and delivery of health and social care services is based on what people value and need, and is built around the person not the system.

The world of health and social care is not always people-friendly. It too often carves us up into a variety of ailments or conditions, each met by a different part of the system or a different group of professionals. Healthwatch England will join up the pieces by strengthening the collective voice of consumers and users of services in England. We will ensure their voices are heard and responded to by the people who plan and run care services, from the secretary of state for health, through regulators, to providers.

We are hosted by the Care Quality Commission and I sit on its board. We share central services, such as finance and human resources, but have complete independence when it comes to what we say and do, and we are accountable to parliament, to which we will report every year.

This is the first time there has been a national consumer champion with independent and statutory powers to speak on behalf of users of health and social care. We are not here to inspect or regulate, but to find out what consumers think needs to change and to convey that to those who have power.

We will be part of a new Healthwatch network – including 152 local Healthwatch organisations – that will launch in April 2013. These will be organisations rooted in their communities and able to act as ambassadors for local people. Each local Healthwatch will be commissioned by and fully accountable to its local authority, and will replace the Local Involvement Networks. We will lead and support the new Healthwatch network, collating the findings and using them to strengthen our case nationally.

Of course, we can’t do the job on our own. We are already working with other experts to bring together the intelligence and clout needed to make real change.

We have been up and running for a matter of weeks and hold our first public meeting on Wednesday where our priorities will be discussed. The Healthwatch committee members bring a range of expertise from local government and the third sector, to health, children’s services and disability. Our newly appointed chief executive is Katherine Rake who joins us from the Family and Parenting Institute. Deciding where we focus our energy and resources is important – we have to ensure we add value where it is needed.

As the consumer champion for health and social care, Healthwatch England has a crucial role to play, based on identifying the most important things for the users of services.

• Anna Bradley is chair of Healthwatch England

Lloyds may inherit troubled care homes

Category : Business

Companies linked to Southern Cross Healthcare could become responsibility of bank, which lent to them in 2007

The taxpayer-backed Lloyds Banking Group could shortly find itself the owner of a string of care homes housing many thousands of Britain’s most vulnerable elderly residents, as a second wave of financial troubles hits companies linked to failed Southern Cross Healthcare.

Through its notorious Bank of Scotland corporate lending unit, then headed by Peter Cummings, the bank was among a handful of lenders who became rapidly interested in the care home sector before the advent of the credit crunch in 2007.

Bondcare, which owns 39 homes formerly operated by Southern Cross, is among the companies that could see itself – in part or entirely – transferred to Lloyds. No part of Bondcare is insolvent but this summer Bank of Scotland appointed receivers from Ernst & Young to part of the business.

Meanwhile, Bondcare’s chief executive, Leib Levison, has stepped down from the board of several group subsidiaries. The holding company, BC Limited, has not filed accounts since September last year, at which point it said: “The group is dependent on continued support of its lender.” Part of the group has changed its name to Akari Care.

Elsewhere, Lloyds Banking Group’s controversial Uberior Ventures investment arm has a stake in another care home landlord group called PSX, which owns 21 properties. PSX sites were largely run as Southern Cross homes until the operator unravelled last year and the landlord group was forced to find another operator, receiving much lower rents. Alongside Lloyds on the share register, PSX is co-owned by the investment tycoons Nick Leslau, Nigel Wray and Tom Hunter. Lloyds is nearly 40% owned by the taxpayer,

Accounts filed last month reveal that PSX made a pre-tax loss of £3.3m for the year to September 2011. It owes £100m to Lloyds – loans on which the group has already defaulted because of the Southern Cross fiasco. The bank has promised not to call in the loan until the end of this month in the hope that a sale or debt restructuring deal can be reached.

In March Cummings’ corporate division within Bank of Scotland was identified in an investigation by the Financial Services Authority as having been guilty of “very serious misconduct”, for which Lloyds only escaped a “very substantial penalty” because the conduct dates from before its parent, HBOS, merged with Lloyds and received a huge taxpayer bailout.

Lloyds is not the first bank to find itself heavily exposed after backing the forays of financial engineers into the care home sector. Four Seasons Health Care, which operates 445 homes and looks after 22,000 people, was sold in July by Royal Bank of Scotland, which is 40% owned by taxpayers. The deal took place only after the bank twice wrote off hundreds of millions of pounds of investment.

Four Seasons was bought by Terra Firma, the private equity business run by Guy Hands, which hopes to add other distressed care home groups to expand the business.

Hands was one of the pioneers of the new techniques in financial engineering that fuelled the UK private equity boom between 2002 and 2007. The borrowings he has used to acquire Four Seasons, however, are to reduce its debt burden.

For the past three years Hands has been living in Guernsey, in effect a tax exile from the UK.

Care UK buys Harmoni, the firm that beat it to NHS phonelines

Category : Business

Health and social care firm pays £48m for out-of-hours GP service, to create company that could treat 15 million patients

Care UK has paid £48m for England’s biggest out-of-hours GP service, Harmoni, in a deal to create a new private health concern that could treat 15 million patients.

Harmoni, a former GP co-operative, was the largest private firm providing out-of-hours services and won 12 NHS contracts to run the new non-emergency 111 health phone lines – beating a joint bid from Care UK and Capita. Last year it had revenues of £100m from the NHS.

Care UK recently lured a top civil servant from the Department of Health – Jim Easton, who oversaw the NHS 111 procurement process – to become its managing director.

Care UK said the deal was about making “sure that patients get the right treatment at the right place without unnecessarily occupying hospital beds”.

Mike Parish, the chief executive of Care UK, said: “We understand the urgency with which the NHS needs to be able to reduce unscheduled and inappropriate hospital admissions of patients who can and should receive treatment elsewhere.”

Harmoni began as a GP co-operative in north-west London in 1996. Care UK now runs more than 50 primary care services – including GP and walk-in services, out-of-hours and diagnostics centres – and six hospitals that carry out NHS work.

Annual assessments for doctors ‘will improve care and cut legal costs’

Category : Business

Department of Health study finds £100m yearly cost of new system of revalidation would pay for itself in 10 years

Giving all doctors annual assessments and detailed checks every five years will result in better care for patients and reduce compensation claims, but may see an exodus of experienced medics from the NHS who are reluctant to be tested, a government study has warned.

The announcement last month that doctors would undergo “fit to practise” checks for the first time surprised the medical world after a decade of seemingly fruitless negotiation. The system, called revalidation, will begin in December.

In new evidence, the government argues that the cost of the checks – about £100m annually – will be outweighed by benefits to patients and the profession. Better care and fewer court cases against medics will save nearly £1bn over 10 years, so revalidation would almost pay for itself, the government says.

The study, released on Tuesday, shows that about one in hundred patients who would have died or suffered harm in the course of being treated would “be avoided” because of revalidation. Even more striking is the drop the cost of litigation in cases where doctors are taken to court over mishaps resulting from their care.

The Department of Health (DoH) says payouts for medical mistakes has spiralled from £400m in 2003 to £860m in 2011. “The prevention of deaths and incidents of harm, as well as the introduction of a stronger culture of accountability, is expected to result in fewer incidents that would lead to litigation payouts. The data showed that a 3% reduction in future payouts as a result of revalidation can be anticipated,” said the report.

However, the DoH says the new tests may see an exodus of experienced staff from the NHS. “One possible consequence of revalidation … is that some doctors may choose to leave the system rather than undergo appraisal and revalidation processes that would be new to them. This may particularly be the case for older doctors, who would take with them many years of experience and expertise.”

Health minister Dan Poulter, who still works a session a week as a hospital doctor, said the UK will be the first country in the world to regularly review its doctors, batting away criticisms that the scheme is too expensive and would divert money from frontline services.

“Revalidation will cost an estimated £100m each year, or less than 0.1% of the NHS’ total budget. The evidence published today shows that this cost is outweighed by the enormous benefits that regular fitness to practise reviews will bring – increased trust in doctors, safer care, fewer claims for clinical negligence and positive cultural change in the profession,” he writes in an article for the Guardian.

“As a doctor myself, I welcome this support for my own clinical practice. It will make medicine safer by eliminating poor practice through supporting those doctors who need to improve some of their clinical skills, and by tackling the tiny minority of doctors who are not fit for their roles.”

Poulter says that even the “best, most qualified doctors can be let down by poor communication. Regular appraisals will target the quality of their bedside manner and include genuine patient feedback, so that all doctors … are supported to improve their relationship with patients and to build up that essential trust”.

The report also pointed out that doctors working outside of the NHS would also face regular check-ups. The DoH says that only one in 20 of the 157,000 practising doctors in England work solely in the private sector. “The … data showed that there are considerably lower appraisal rates in the independent sector”.

However, the government acknowledges that there will be an extra cost to private health. “These are costs which might be expected to be passed on to the consumer, who would in turn experience the resulting benefits.”

The General Medical Council will be responsible for revalidation, which will be on the basis of a dossier of evidence of a doctor’s competence compiled over five years. This will include annual assessments and patient questionnaires.

Negotiations with doctors’ leaders at the British Medical Association over how revalidation would be carried out has caused some of the long delays. The BMA has traditionally been wary, while saying that it supports the principle.

Plans were under way at the time of the Shipman inquiry in 2005, but Dame Janet Smith, who chaired it, was strongly critical, saying the proposals would not ensure that failing and bad doctors were picked up, so they had to be reworked.

Cancer fight stalls amid push for profits, doctors say

Category : Business

Newer drugs fall short of hopes and cost too much, say experts who pledge to improve care in poorer countries

Progress against cancer is stalling, with the latest targeted cancer drugs failing to live up to expectations and priced so high that treatment is becoming unaffordable even in rich countries, according to experts at a meeting of nearly 100 eminent cancer specialists from around the world.

At the two-day meeting in Lugano, Switzerland, the doctors agreed a 10-point declaration, to be published early next year, which will chart the way forward for cancer care around the globe. Much needs to be done, they believe, to improve treatment, care and prevention both in the developed world and in poor countries, where cancer rates are rising even faster. They agreed to embark on an ambitious plan to get essential cancer care to those who are dying early in developing countries, in the same way that Aids doctors took on the fight to get HIV treatment into hard-hit Africa.

The meeting of the World Oncology Forum, organised by the European School of Oncology and attended by experts such as epidemiologists Sir Richard Peto and Prof Michel Coleman as well as the government’s national cancer director, Sir Mike Richards, agreed urgent action was needed on many fronts.

Only a few years ago, many cancer experts thought the arrival of targeted medicines, designed to attack the genetic makeup of the tumour, would make dramatic inroads into cancer deaths. That has not happened. Instead, these therapies have only bought a few extra months of life. If the question was whether the world was winning the war on cancer, said Douglas Hanahan of the Swiss Institute for Experimental Cancer Research, who outlined the latest state of drug research, “in general, for most forms of human cancer, the answer is clearly no”.

The excitement generated by targeted drugs, which interfere with specific molecules involved in tumour growth and suppression, has been short-lived.

Doctors reported apparently miraculous results from the use of the BRAF-inhibitor vemurafenib in advanced malignant melanoma, a usually fatal form of skin cancer. Within two weeks, the tumours had melted away.

“But six months later, [the cancer] is back with a vengeance,” he said.

Other drugs working in a similar way – including erlotinib (Tarceva) for a form of lung cancer, bevacizumab (Avastin) for breast, colorectal and other cancers, and sunitinib (Sutent) for renal cell carcinoma and gastrointestinal sarcoma – have also not done so well, said Hanahan. Resistance to the drugs builds up, sometimes very quickly. “All came on line with great expectations. The reality check is they are all working in the important first step, but we have a long way to go in terms of winning the war.”

The future is probably using these drugs together or in combination with other, older types of drugs, but the price is likely to be prohibitive.

A year’s treatment with vemurafenib alone would cost £91,000. Even though the manufacturer, Roche, has offered an undisclosed discount to the Department of Health, the National Institute for Health and Clinical Excellence said in June it was too much for the NHS to pay. No health service will be able to afford to put a patient on two or three such drugs at the same time.

Doctors at the meeting said pharmaceutical industry prices were unsustainable – and the pursuit of profits stopped companies taking part in trials of combinations of their drugs with those of their competitors, which might help patients. They were also said to be not interested in testing their drugs combined with older drugs that are out of patent.

Prof Alexander Eggermont, general director of the Gustave Roussy Cancer Institute in France, said the “economic models of molecular medicine are very uncertain, because if you don’t produce cures, you don’t know if it is going to sell”.

Decades ago, genuine breakthrough drugs were discovered which continue to have a huge impact on the disease. Peto, an epidemiologist at Oxford University, pointed out that five years of tamoxifen reduces mortality in most breast cancers by a third and the benefits continue even after a woman stops taking it. It now appears that taking it for 10 years is even more effective. Nobody knows why resistance does not develop, as it does with the new drugs.

But the meeting agreed that while changes are needed in research, regulation and funding to speed progress on new drugs for intractable cancers, a great deal could and must be done now to tackle cancer in less well-off countries where children and women, in particular, are dying of preventable and curable diseases.

“The divide is such that in Canada almost 90% [of children with leukaemia] can hope to survive while in the poorest countries of the world, 90% are expected to die,” said Prof Felicia Knaul, director of the Harvard University global equity initiative.

Between a third and a half of all cancers – 2.4m to 3.7m a year – are preventable, said Knaul, and 80% of those are in lower- and middle-income countries. Preventing and treating them would offer potential productivity savings globally of more than $130bn (£80bn) a year – far more than the cost of treatment.

Cheap vaccines and basic screening can prevent and detect cervical cancer, which kills young women and mothers; cheap hepatitis B vaccination protects against liver cancer; and screening picks up breast cancer early. The dire shortage of morphine and other opioid drugs in developing countries to relieve suffering from cancer pain must be addressed, the doctors said.

Rifat Atun, professor of international health management at Imperial College Business School, called on doctors and scientists to have “bold ambition” and follow the lead of clinicians involved in the Aids response.

“Prevention is important and we need to do it. That does not mean we should not be providing treatment,” he said. A decade ago, people said it was not possible to get antiretroviral drugs to patients with HIV in Africa. There are now more than 8

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