Association of medical insurance intermediaries summit

I was wearing my private medical insurance (PMI) hat yesterday when I attended the AMII summit held at the Royal college of Physicians in London. Before you click away from this post, please be reassured that this was not about a bunch of brokers bellyaching about commission rates. (Although I must admit that one such gentleman in the audience did embark on a lonely rant about the good old days at one point during a panel discussion)

The presentations and various discussions have been reported in detail in health insurance magazine www.hi-mag.com so I shall just share with you some personal pearls of wisdom gained from the day.

Fergus Walsh, the BBC medical correspondent is definitely my candidate for ‘thinking women’s crumpet of the year award (subsection  healthcare)’. Softly spoken, but authoritative and clearly committed to the cause of improving health knowledge worldwide Fergus was the perfect master of ceremonies. I was particularly interested to learn of his involvement in global healthcare initiatives and his sensitivity in ensuring that his reporting style about often highly emotive subjects is designed to inform but not distress. I shall leave to your imagination the fact that the props that Fergus used for his presentation included a PIP breast implant, some Tamiflu and a bottle of Viagra…

People working with PMI must understand how the NHS works: Regular readers of this blog and my articles in HI magazine know that this is a drum I bang with tedious regularity. I was heartened to note that most of the delegates do have a genuine interest in the Health and Social Care Bill and its implications for their customers and the nation in general. If you are advising your clients on PMI and other private health provision, you really should understand what’s available to them on the state.

We all know that bad lifestyle choices mean that the obesity and lifestyle related diseases are no longer a ticking time bomb but already on slow release detonation. This was touched on in debate and discussion but it’s old news now. That doesn’t mean it should be ignored, quite the opposite, but we no longer need to be told it’s happening.

The Rt Honourable Stephen Dorrell MP is an intelligent, eloquent and impressive individual who appears to have healthcare and the NHS running through his veins. I have heard the Chair of the Health Select Committee speak on several occasions and he talks pragmatic sense. I LOVE that he doesn’t speak in soundbites – ever. Andrew Lansley please note.

Don’t diss the NHS. If you want to sell PMI – don’t knock the NHS. We are still fortunate to have access to a mouth-watering range of healthcare benefits free at the point of delivery and not based on ability to pay. Yes, PMI offers choice, control and flexibility but most of us were born in the NHS and have used its services on many occasions through our lives.

It’s not ‘either or’ – Private medical care must work alongside the state provision. The consensus of formal debate and coffee break chat was that you cannot and should not separate private and public health when planning new PMI products or development of the NHS. It is possible for co-operation for the common good. Really – there is. Careful service design, consensual approach and robust monitoring are the key.

I don’t understand why the new National Director for Patients and Information at the NHS Commissioning Board had ‘cabinet office’ as his slide template. Or that he is a founder of Dr Foster, an information resource often used by the NHS. Probably the less said about that the better…

Circle Partnership is a very interesting organisation. And the managing partner, Mark Aichroth is an impressive individual who described the ‘credo’ of the partnership and spoke with eloquence and apparent honesty regarding the challenges facing the organisation in building new hospitals and partnering with the NHS. One thing no one can deny – the failing Hinchingbrooke hospital has now come top in a patient satisfaction survey less than six months after Circle took it over.

And finally…

Medical insurance intermediaries are good people! Yes – in the good old bad old days health insurance broking was a wheeze. A long boozy lunch with the client, a bit of nifty footwork on commissions and a lot of same old same old used to be fine for all concerned. The clients were happy, insurers happy and the intermediaries were happy too. We have come a long way since then. Most of the intermediaries that I know not only want to do the very best for their clients – they are also genuinely interested in the services on which they advise and the healthcare climate in general. The delegates at yesterday’s event had a tangible thirst not only for the champagne served at the end of the day, but for an understanding of how this industry can move forward and help, not hinder the NHS.

Money and health are inextricable.

There are two big news stories in the UK this week. (Three actually if you count the shocking news that David Beckham has been omitted from team GB Olympic football squad)

The two main stories that I want to discuss are not about health but about money. It was announced this week that the South London Healthcare Trust is on its financial knees with unsustainable debt and no means of reversing of £69m in deficit on an annual turnover of £424m. As money and quality are so often linked, the hospital is also performing badly on key indicators such as waiting times for surgery and accident and emergency treatment. The Trust cites the heavy burden of an existing PFI (Private Finance Initiative) arrangement which funded previous building works and the debt repayments account for 14% of the Trusts’ income.

Andrew Lansley, Secretary of State for Health, is now likely to take the unprecedented step of appointing an administrator to sort out the financial mess, with the unenviable challenge of maintaining acceptable quality of care in the process.

This Hospital Trust is not alone – with an estimated 20 more Trusts facing economic meltdown. The news isn’t even a surprise as warnings of unsustainable balance sheets were flagged at least 12 months ago.

This must now be a priority for the government to sort. What a pity more attention wasn’t paid to the coffers of the major healthcare institutions while Lansley’s Health and Social Care Bill fiddled and tweaked with the niceties of power shifts, administration reshuffles and a blatant disregard for the deal-breaking issues. Like making sure that Hospital Trusts can actually afford to deliver treatment and care to the local community they serve.

As I have quoted my wise old Dad in the past – ‘stop putting good money after bad’.  The legacy of financial burden from badly designed PFI’s and crippling interest rates must be addressed, the slate cleared and Trusts given a chance to function at the appropriate level of quality within budget. The benchmark should be simple – these trusts must be financially and clinically viable to continue to receive NHS funding and where a Trust can demonstrate that it’s worth saving, the powers that be should step in to provide fiscal support.

The other news story? Barclays Bank has been fined £291 million for illegally manipulating bank lending rates. Several other banks are currently being investigated for this cynical behaviour and hopefully further mega-fines will be collected. Talking of banks – the word ‘bailout’ springs to mind and it is frankly shocking and disappointing to the extreme that these institutions should continue to operate on the edges of morality and legality. But while we are talking bailout – what better way of spending some newly found capital?

I can think of several worthy recipients of a share of that £291million windfall - maybe the South London Hospital Trust should be one of them?

 

A summer solstice that has done no good for anyone – neither doctors nor patients.

June 21^st is the longest day of the year in the Northern Hemisphere – with more daylight than any other. 8% of doctors, members of the British Medical Association, chose not to put this extra time to good use. For the first time since 1975, medical practitioners were on strike. They are striking about their pensins and the extended retirement date. They are not striking about NHS reform, patient care or the NHS budget.
The build-up to this event has been remarkably muted since it was announced a few weeks ago. Perhaps the BMA realised they had scored an own goal – and speaking of goals – maybe Euro 2012 has engaged the public more than some petulant clinicians.

To add to the PR disaster for these doctors, the comedian Jimmy Carr (for my overseas readers – a comic who, with a constantly straight face, spends a large proportion of his act criticising corporate greed and the banking community) was lambasted by David Cameron for his personal tax avoidance activity. Why one performer should be singled out for his accountants’   legal methods to protect their client’s income remains to be seen, but it is interesting to note that this was the lead story for most UK news bulletins today. (Is that why you did this David? To divert attention from the open wound that is the NHS?)

Back to the revolting doctors….. What was achieved today by this action?

Nothing. Really – nothing. Well, nothing positive anyway. To say that patients’ lives were not put at risk is frankly ridiculous. Doctors, and all related professions, are not in business just to save lives. They work to help people stay healthy, to improve their quality of life, to avoid or alleviate suffering.

I have no idea if anyone will die as a result of today’s action, but many people will have been inconvenienced, distressed, or even put at risk by the very people who purport to care for them.

According to the Department of Health, 2,000 GP surgeries were working on an ‘emergency only’ basis, 19,000 ‘routine’ appointments were cancelled and 2,700 ‘non urgent’ operations cancelled. Many cancer and heart disease diagnoses follow a ‘routine appointment’. Some ‘no-urgent’ operations such as hip replacements and cataract surgery are life changing. How can a G.P or surgeon really justify prolonging this suffering?

It was interesting to listen to a radio phone –in programme today. There was a striking G.P and a non-striking surgeon. The GP was frankly a little hysterical, suggesting that the government wants doctors to work longer, hastening an early death so the pension burden won’t be as great. The surgeon agreed that, yes, doctors who work for longer under stressful conditions do die sooner after retirement, but he was not comfortable with interfering with patient care by withdrawing his labour.  I suspect that most professions would observe similar events and I’m sure that there are many GP’s who share the surgeon’s view and vice versa.

I have enormous respect for GP’s, surgeons and physicians. I work with them often, with pleasure and sometimes even awe. I know they work hard, in difficult circumstances and under great stress. But to sit in your GP surgery or turn up to your hospital department and refuse to see patients for appointments or routine surgery seems unbelievably callous. What about the man with spinal injuries who was waiting for his MRI results today and now has to wait another week? What about the old lady who took two buses to her GP surgery only to find out that even though the doctor was there, her blood pressure problem would not be discussed? What about the man who has been waiting for 18 weeks for his cataract operation so he can see well enough to drive again to visit his wife with Alzheimer’s’ in her nursing home 30 miles away, but now has to wait another month or maybe more?

The daylight may have shone longer today – but the view isn’t pretty.

The patient at the heart of everything we do? Yes please.

The Department of health has announced that the results of the GP Patient Survey will be published on NHS Choices website shortly. This is a welcomed development but bets are already being hedged by the rider…

‘Important note about the 2011-2012 Survey Results
Please note that due to the changes to the questionnaire design and survey frequency, as well as the change to the weighting methodology, no results from 2011-12, when published on 15^th December 2011 (wave 1) and 14^th June 2012 (wave 2) can be compared to previous years, even where questions remain the same.’

I guess that means that the results are expected to reflect a growing level of dissatisfaction of patients with their primary care services. As with any of these surveys, we know that it is normally the most unhappy customer that bothers to provide feedback, so I shall read the results with a liberal dose of salt. However, if the whinging masses are increasing in number then this could be significant. I suspect that there will be two major areas of concern – out of hours cover and availability of GP appointments.

Speaking of which - tales from the front line continue to wear a path to my door and I must put on record that for every bad experience that I hear, I’m sure there are literally tens of thousands of examples of excellent care being given nationwide. But…

Here alas I have another tale from the front line. I’m hoping that the reality of this flaw in the service will be reflected in the survey results. As usual, this is a simple story of country folk, subtitled –‘Why can’t things be like the old days when we could see a GP when we needed to?’

A friend, suffering from a bladder infection (or a touch of the Duke of Edinburgh’s as it is now known) called her GP at 4.30pm. It was a Friday afternoon and my friend, let’s call her Elizabeth, who has a history of such infections knew that it would be very unwise to leave this condition untreated over the weekend. She was also feeling very unwell and was in considerable discomfort. She was told by her surgery that no appointments were available although they ‘might be able to fit her in to an emergency session tomorrow morning’.

By 8pm Elizabeth was in considerable pain so she called the out of hours doctor. Some time later, after a 20 minute car journey, she was prescribed the antibiotics she needed by an efficient and kind doctor working with the out of hours contract. She then faced the challenge of finding a pharmacy still open and was advised that she needed to travel another 25 minutes by car to the out of hours pharmacy. Unfit to drive, with a temperature and in bad pain, Elizabeth was only able to make this journey because she was accompanied by her husband.  By that time, she was in desperate need of a loo. Anyone who has had a bladder infection will know the meaning of ‘desperate’ in this case.

While the pharmacist was filling the prescription, Elizabeth asked to use the pharmacy toilet and was told ‘no’ because he wasn’t sure if his insurance covered patients using the facility. Nice.

So – if the GP had been able to squeeze her in, if the out of hours service was closer, a 40 mile round trip in the car and much distress could have been saved.

I hope that the latest patient survey will, like the results from the last one, demonstrate that the area of most concern to patients is accessibility of GP services including extended opening hours and local cover to avoid unnecessary delay or trips to casualty.

Forget commissioning, we need GPs to continue to provide vital front line local services in and out of hours.

Is that really too much to ask?

Should doctors strike about their pension and expect the public to support them?

I am saddened by the news that the majority of doctors have voted in favour of the British Medical Association (BMA) ballot calling for strike action. Today, the chairman of the BMA announced that half of its 104,000 members took part in the ballot and a high proportion of GP’s, Consultants and junior doctors will be taking direct action for 24 hours on June 21^st.

Are they unhappy with the NHS Reforms? Are they worried about patient safety? Do they fear for closures of hospitals? Are they concerned about budget or staff cuts, care in the community, public health inadequacies? Probably all of the above. But what are they striking about?

Their pensions.

I spend a significant amount of my working time with doctors and consider myself fortunate to work with such professional, caring and committed individuals (usually). So I am really surprised to read that doctors will, in effect, down tools for the first time in 40 years.

There are quite a few ticking time bombs affecting the health sector at the moment. Obesity, Diabetes, lifestyle generated diseases, chronic conditions…. and pensions. Anyone with an iota of financial acumen and a sense of reality knows that the private sector recognised the pension black hole years ago and started reining in the employers’ exposure. Final salaries pensions are unsustainable without increased contribution form the employee. Average salary pensions are a realistic alternative. Of course no-one wants to see their nest egg depleted through no fault of their own but it’s a tough world out there right now. No-one would dispute that the medical profession is awash with worthy, hard working individuals who care deeply for their patients. But I believe that this call for industrial action is damaging and probably futile.

A BMA statement explains how the strike will be implemented as follows:

‘Non-urgent work will be postponed and, although this will be disruptive to the NHS, doctors will ensure patient safety is protected. All urgent and emergency care will be provided and we will work closely with managers so that anyone whose care is going to be affected can be given as much notice as possible. Patients do not need to do anything now.

“We will also run our own publicity campaign to make sure that members of the public understand what the action will involve and how they can find out what it might mean for them and their families’

What this will 'mean for them and their families' on June 21^st is that although clinical staff will be on-site, most operating theatres will be idle. Outpatient clinics will fall silent, minor procedures suites empty and GP surgeries may be open, but not for their daily business. Patients will be inconvenienced and some may well suffer as a result of delayed consultations, tests or surgery. The resulting backlog will not just affect patients – just imagine the hassle for support staff in hospitals and surgeries dealing with this backlog.

The public purse is being squeezed till it bleeds tears of pain and desperation. Money needs to be allocated with wisdom, compassion and fairness. Taking a day out of the packed theatre lists, clinic sessions and GP appointments will result in a shameful waste of a precious resource.

 
The BMA assures us that patient safety won’t be compromised and I have no reason to doubt this. But one thing that will be compromised is the public perception of a profession that they have long held, with good reason, in very high esteem.

The elderly lady with a crumbling hip surviving on a state pension may not be as sympathetic to the BMA members as they might hope.

Surgery slippage - an unwelcome addition to the NHS vocabulary

Whenever I am wearing my project manager hat, one of the major risks I need to identify, avoid and/or fix is ‘project slippage’. The term sounds quite benign but is in fact a posh way of describing missed deadlines, unforeseen problems or even catastrophic events seriously derailing original plans.

I fear that ‘surgery slippage’ may be a phrase that creeps into the NHS psyche as cuts and reform implementation starts to bite. Rationing is a dirty word within healthcare although every sane commentator would have to admit that we don’t live in a perfect world of unlimited funds and treatments must be offered within that context. Health inequality is an even dirtier word as some PCTs (primary care trusts) or CGGs (clinical commissioning groups) take an inconsistent approach to eligibility and funding for certain conditions. I suspect that surgery slippage may become an insidious way of rationing and creating inequality across regions.

Andrew Lansley, UK Secretary of State for Health has said he doesn’t like targets but quotes outcomes instead. He doesn’t want to measure waiting lists but brandishes figures such as ‘reduced hospital admissions’ as though they were a band of honour. We need to look behind any statistics to emerge from the new regimes borne of the Health and Social Care Bill. Comparing apples with pears is never a good thing. Cancelled or delayed operations for those on a waiting list are distressing for the patient and bad PR for the NHS. This is where targets and statistical reporting can be useful in focussing the mind of Trusts to ensure that patients are not kept on waiting lists too long. But with limited funds and a shift of power to CGGs my concern is not just for the lengthening of waiting lists, but the moving of goalposts when it comes to eligibility for surgery.

In the same way that we delay paying the gas bill or get our car serviced a couple of months overdue to keep our cash flow under control at home, it would appear that some NHS Trusts, PCTs and CGGs are changing eligibility for surgery to delay the point at which a patient joins a waiting list.

The Royal National Institute of Blind People has recently reported on data showing that over half of the 152 NHS trusts in England had imposed their own criteria which were tougher than national standards for cataract operations. This means that patients are waiting longer for sight saving and life enhancing surgery, saving money for the trust but diminishing vision and quality of life for their patients along the way.

It’s not just hospitals making these tough decisions. I was speaking to an orthopaedic surgeon this week who told me that he was about to attend a commissioning meeting with is local CGG. That’s great – I thought – perhaps the NHS future forum really did work and GPs are involving other clinicians in key commissioning decisions. Yes, the orthopod agreed that it was good for him to be invited to this meeting. However one of his challenges is that, presumably to balance their books, the local CGG has changed the criteria for hip replacements, so patient’s joints have to demonstrate a more pronounced deterioration before they are deemed eligible for surgery (and therefore delaying their addition to a waiting list). This surgeon told me that he suspects that a year or so down the line – he will start to see patients with more severely damaged hips which will of course make the surgery more difficult and means that the patient has endured the pain of a crumbling joint for longer. Who is best to decide whether surgery is necessary? Surely that has to be the surgeon.

So there you have it – surgery slippage. An effective cost containment initiative, but hard to quantify or prove and with the potential to be significantly detrimental for the very people these reforms are supposed to help – patients.

Statins – mass prescribing for the healthy may create a different kind of problem.

Healthcare is, like most things in life, all about balance. As each new ‘magic bullet’ - a new medication, procedure or technological miracle is discovered, the balance of one disease or condition may be slightly tipped in its favour, but this is often to the detriment of some other ailment.

I’m not talking about allocation of funds, I’m talking about how solving one problem can either create or expose another. It’s a bit like building a ring road round a major city. In theory, business and leisure travel either side of the conurbation will become easier. But what usually happens? You simply move the traffic jams to another point in the transport system. Just ask anyone who has travelled on the M25, hailed as the end to London’s potential gridlock but now known as the biggest car park in the UK as the motorway struggles to cope with the high volume of traffic it has created simply by existing.

The biggest killer for some age groups in the UK is heart disease closely followed by cancer. Add chronic conditions such as dementia, diabetes and all obesity related conditions and a turgid melting pot of health nightmares bubbles away fuelled by bad lifestyle choices and social inequalities. It is expected that there will be 1 million dementia sufferers within the next decade and there are currently 3.8 million people suffering from diabetes – expected to double in the next 20 years.

Sadly or happily – whichever way you look at it – state funded health care is a victim of its own success. The reason dementia has become such a problem is because we are actually pretty good at keeping people alive for longer. And now there is talk of prescribing statins to everyone in the UK over 50, whether they are obese, sedentary, super fit or just plain average. Following a study by Oxford University, it is estimated that mass prescribing of these ‘cholesterol busting’ drugs will avoid 11 heart attacks per 1000 individuals. Tempting as this may seem, giving drugs with a worrying range of potentially unpleasant or dangerous side effects to healthy individuals feels like a bridge too far, especially if this lets us off the hook for increasing exercise and adopting a healthy diet. In the ‘good old days’ – if your cholesterol was a bit high – you were advised to eat better and move more. Often this was sufficient to reduce the cardiovascular risk.

Yes, of course statins are life savers especially for those with familial hypercholesterolemia, genetically inherited and potential life threatening high level of ‘bad’ cholesterol. But should we be tempted to, as Janice Turner in The Times newspaper so beautifully put it – ‘pop a pill if you’re not ill’.? If the subliminal message is that it’s OK to get fat and don’t  exercise,  but take statins to counteract the damage that high cholesterol will cause, then there may be a new generation of obese patients, living longer but prey to other obesity-related conditions.

As cardiovascular disease falls, cancer incidence may rise.