The next PM...

[The Accountant, OBE, KC]

Yup that's right - let's blame the feckless - that'll teach em!!!!

Not even sure what that comment means. It's a fairly straight-forward concept in business that can be adopted for healthcare. The dentists seem to have managed it. Vets manage it for everyone's "fur babies" that are like members of the family. If you were supposed to be at an appointment and you miss it and you don't have a good reason to miss it, you will be charged if you try to make another appointment. It's not blame, it's just the reality of adults living in a capitalist economy where prices are allocated to goods and services due to costs incurred. If taxes can be raised to cover all these costs, fine. But people who want to raise taxes seem to have a hard time getting elected in Britain so let's assume that we can't get the money from taxes and will have to find alternative funding. So charging when an opportunity presents itself seems more sensible than not charging, unless it doesn't prove to have a deterrent effect and therefore does not save the NHS money.

Alternatively we could actually fund the NHS properly and stop blaming patients for problems that aren't caused to any significant degree by one in 20 appointments being missed, costing (even using the theoretical cost) about 0.1% of the NHS budget, when the NHS has a staffing crisis with 105,000 vacancies.

Yes we should fund the NHS properly as well. There is an issue with productivity and with recruitment. While we are waiting for all these extra people to materialise and fill the vacancies and for the funds to appear to pay people enough so they would be willing to do the jobs, we can also experiment with fines for missing appointments.

[The Accountant, OBE, KC]

Yup you could do both I guess, but I don't think fining people for non-attendance at appointment should happen for practical reasons, but I guess also on principle, which you might consider to be ethical.

Not sure I agree with you that there aren't ethical issues, and the BMA certainly thinks there are - from their response to the proposals:

"Charging patients for missed appointments would not only undermine the essential trust between doctor and patient, but ultimately threaten the fundamental principle that the NHS delivers free care at the point of need, for all. The BMA has always stood firmly against the idea of charging patients for missed appointments.

Yeah I don't agree. I would still trust my doctor even if I got charged for a missed appointment. What choice do I have if I need medical help than to go see the doctor even after they had charged me.

While it is frustrating when patients do not attend, the reasons why this happens should be investigated rather than simply resorting to punishing them. Financially penalising patients inevitably impacts the poorest and most vulnerable in the community. This may discourage them from rebooking, exacerbating already worsening health inequalities and costing the NHS more."[/i]

Yes sure if we had the funding via high taxation to investigate the causes, it would be an interesting exercise. But given we seem to be underfunded, I guess we won't find out in the near future.

I would have thought that doctor/patient trust is fundamental medical ethical issue. As is justice (one of the four cornerstones of medical ethics along with autonomy, beneficence and non-maleficence). Bringing in something that would disproportionately impact the poorest and most vulnerable in the community seems to me to be a clear medical ethical issue around justice.

Not really seeing the injustice as I think it is only supposed to impact the disaorganised and those who prioritise other events in their lives over NHS appointments when they should have turned up for the appointment.

[ProfessorDavey]

The dentists seem to have managed it. Vets manage it for everyone's "fur babies" that are like members of the family. If you were supposed to be at an appointment and you miss it and you don't have a good reason to miss it, you will be charged if you try to make another appointment.

Not relevant comparisons as you are talking about private, paid for services, rather than free-at-point-of-care services funded by the tax payer.

[ProfessorDavey]

Yeah I don't agree. I would still trust my doctor even if I got charged for a missed appointment.

You might, but the BMA is clear that it is concerned that fining patients would impact doctor patient trust, so they clearly think there are plenty of people whose trust would be impacted. That you aren't one of them is irrelevant.

[ProfessorDavey]

Yes sure if we had the funding via high taxation to investigate the causes, it would be an interesting exercise. But given we seem to be underfunded, I guess we won't find out in the near future.

Actually there has been a lot of research on this, and on what interventions work and don't work. And 'couldn't be bothered to turn up' and 'decided to do something else' don't feature high on the list of reasons.

Typically 'forgot' is up there, but of course a lot of people accessing GP services may have mental health issues, cognitive impairment or decline where 'forgot' is hardly an unreasonable excuse. Also challenges getting to the GP is another one high up and again many patients cannot get to a GP appointment without others helping out - indeed may be entirely reliant on others to book appointments, get them to the GP etc - it is fair to penalise those patients when inability to get to an appointment may be entirely beyond their control.

'Got better' is another common reason and I agree those people should cancel, but 'difficulties cancelling appointment' is another common reason. For many people getting an appointment requires sitting on the phone, on hold for ages (often at a specific time of day) - cancelling an appointment may require exactly the same rigmarole and of course not all people are able to wait in a phone queue at 8am for 20 minutes to get through (that's the process at my GP) - for example if you are at work.

Oh, and of course more research into this would be helpful, but this wouldn't be funded from core NHS funding - it would be funded by research organisations, potentially medical charities such as the Wellcome Trust and Kings Fund. So conducting more research wouldn't impact on NHS funding, except that using the research to improve services may make the NHS work better.

[ProfessorDavey]

Not really seeing the injustice as I think it is only supposed to impact the disaorganised and those who prioritise other events in their lives over NHS appointments when they should have turned up for the appointment.

Justice in Medical Ethics terms is quite specific - here is one mini-primer:

https://www.themedicportal.com/application-guide/medical-school-interview/medical-ethics/justice/

Note:

"It also means that we must ensure no one is unfairly disadvantaged when it comes to access to healthcare. Justice is one reason why the NHS has certain entitlements, such as free prescriptions for lower-income individuals."

So I'm a little bewildered as to how you are unable to see how your proposal (see reply 193) fails to meet the concept of justice in medical ethics. Here are just a few examples:

1. Your proposal is fundamentally regressive, in that the same about (e.g. £10) is charged regardless of the individual. £10 for some people is neither here nor there - for others it is a huge deal, hence the reason why prescriptions are free some some patients while others pay £9.35 - for some people paying £9.35 is a major issue so without free prescriptions those people are unfairly disadvantaged.

2. Your proposal will disproportionately impact those who are most vulnerable and disadvantaged. So for example patients over 90 are roughly twice as likely to miss appointments than any other age group and 220% more likely to miss appointment than the average. Similar those in the lowest socioeconomic groups are twice as likely to miss appointments. So your proposal will disadvantage people who are already likely to be vulnerable and already disadvantaged.

3. Your two-strikes-and-you-are-out proposal (i.e. fining after two missed appointments) will unfairly impact people with multiple healthcare needs and therefore have to visit the GP very often - note that 40% of all GP appointments are taken by just 10% of the population. So a person who has 20 GP appointment in a year and misses two (so a 10% non attendance rate) would be hit by your proposal yet a person who has just two appointments, and misses one of those (a 50% non attendance rate) won't be. The more appointments you have the more likely you are to be impacted - so people with multiple, complex health care needs would be unfairly disadvantaged.

4. Having a system which requires people to pay a fine first (in order to be able to access further healthcare) but with an appeals process will disadvantage those who will find appealing difficult, for example people with significant learning difficulties or other challenges to engaging with an appeals process, e.g. mental health issues that means that such a process creates significant anxiety issues. They would either be left out of pocket (although they might have perfectly legitimate reasons for missing an appointment) or would be denied ongoing healthcare. Again that doesn't fit with the principle of justice.

I could go on, but I won't. Hopefully you can see how your proposal isn't really compatible with the principle of justice in medical ethics.

[ProfessorDavey]

Latest numpty proposal from the race-to-the-bottom tory leadership race - this time from Truss.

Apparently she wants all triple A* A-level students to be automatically given and interview for Oxbridge.

So let's unpack that for a moment.

So A-level results come out in August - at that point there will be no way that a triple A* student would be able to be offered a place for that year (unless there is a complete change in the admissions process so that all applications etc are made after A levels). So this would be for the following year - so a triple A* student getting their results in Aug 23 may get a place in Sept 24. The only exception would be for courses that have clearing places, but if the have clearing places then that student would get a place under the current system. And of course Oxbridge courses don't do clearing!

So that student will have to wait a year (see later for the impact of that) and need to apply to Oxbridge the following year. But the issue is that even the most competitive Oxbridge courses have offers lower that A*A*A* - the highest is A*A*A. So if a person is applying with actually banked down grades of A*A*A* as opposed to just a prediction of grades for exam not yet taken, will they get an interview under the current system? Well of course they will - so Truss' proposal will make absolutely zero difference in practice - knee-jerk click-bait cat-nip for the tory membership.

But there is another element here, even if it did result in students getting an interview who wouldn't have otherwise, you need to ask who would benefit. Well to benefit you'd need to be prepared to take a year out as any offer wouldn't be for the upcoming academic year but the year after. Fine if you can happily take a gap year or drop yourself into a nice internship etc. But that isn't the case for the kinds of students under-represented at Oxbridge, those who may come from highly deprived backgrounds, perhaps the first in their families to got to universities. It is much less likely that those students will be able to simply take a year out even if it meant being able to go to Oxbridge a year later. They simply don't have the means to fund that year out.

There is a further reason why this is a really bad idea, particularly if the aim is to get bright kids from disadvantaged backgrounds into Oxbridge.

There is incontrovertible evidence that when you match students from state schools and independent schools in terms of A-level entry grades that state school students do significantly better in terms of final degree outcomes compared to independent schools. This has been recognised over a number of years, and unsurprisingly I have access to data looking at every single student over a number of years with their entry grades compared to their final degree outcome.

So typically matched by A-level entry (e.g. both get ABB) a state school student will attain 8% higher in their degree than an independent school student - that is nearly a whole degree classification range. Put it another way you would predict that a state school pupil with A level results two points below an independent school student will be likely to attain the same degree result. So AAA for an independent school pupil is the equivalent in terms of potential to do well in their degree to AAB, even ABB for a state school pupils.

University admissions is all about trying to identify students most likely to do well so should be taking this into account (although they often don't for fear of provoking the ire of the right wing press etc).

So let's look at Truss' proposals - it only applies to A*A*A* (most of these students will be in the independent sector) - but we know that state school students two points lower have a similar potential. So A*A*A* from an independent school is equivalent in potential terms to A*A*A or even A*AA in the state system. So if you have two students (of equal potential) - independent school student with A*A*A*, state school student with A*A*A (this person likely has the greater potential), who gets the automatic interview ... err ... only the independent school student.

Truss' proposal actively advantage independent school students over state school student of equal potential.

[Nearly Sane]

Well, that was quick

https://www.politicshome.com/news/article/liz-truss-civil-service-pay-row-levelling-up

[ProfessorDavey]

Well, that was quick

https://www.politicshome.com/news/article/liz-truss-civil-service-pay-row-levelling-up

Wonder if she will u-turn on her non-sense proposals on Oxbridge admission which will disproportionately benefit private school students if there is any impact at all.

[Aruntraveller]

The argument about charging for missed appointments is purely academic anyway:

[ProfessorDavey]

The argument about charging for missed appointments is purely academic anyway:

Very good.

And of course in many cases the process for cancelling an appointment, that you may no longer need or be able to attend, is as complicated and lengthy as the process to get an appointment in the first place. There was a letter in the Times yesterday making this very point.

My GP practice has no special route to cancel an appointment - the only ways are to go to the surgery in person or to phone on the same line used to book an appointment. A typical wait to get through is about 15-20 minutes in my case. Is it reasonable to fine someone for not cancelling an appointment because they are unwilling or unable (for lots of people this is impossible, e.g. they might be at work) to wait on hold for 15-20 minutes to cancel their appointment.

Sorting out the whole process of appointments, including ease of cancellation is the way to go if you want to reduce missed appointments - and there have been a number of studies that have looked at interventions to reduce missed appointments that have concluded the same. This the conclusion of a comprehensive interventional study from 2020 (my emphasis):

"Forward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient."

[Nearly Sane]

Ooh, that Rishi Sunak's hard! The competition for most idiotic policy continues.




https://www.theguardian.com/politics/2022/aug/02/former-counter-terrorism-police-chief-attacks-rishi-sunaks-prevent-plans

[Udayana]

Ooh, that Rishi Sunak's hard! The competition for most idiotic policy continues.




https://www.theguardian.com/politics/2022/aug/02/former-counter-terrorism-police-chief-attacks-rishi-sunaks-prevent-plans

I'm convinced that they have racks of these policies all ready to pull out for the media ... filed under:
"Be tough on ..."
"Look empathetic to ..."   
"Distract to threat from ..."
"Stop waste in the ..."
"Raise NHS funds by ..."

...
 with appropriate sub-categories.

Of-course they don't need to actually implement anything whether or not the statements have had the desired effect.  At worst, they can pass a law (or set rules) then just not bother enforcing them.

[Nearly Sane]

I'm convinced that they have racks of these policies all ready to pull out for the media ... filed under:
"Be tough on ..."
"Look empathetic to ..."   
"Distract to threat from ..."
"Stop waste in the ..."
"Raise NHS funds by ..."

...
 with appropriate sub-categories.

Of-course they don't need to actually implement anything whether or not the statements have had the desired effect.  At worst, they can pass a law (or set rules) then just not bother enforcing them.

I don't doubt it but they seem to be choosing fron the idiotic pile 

[Nearly Sane]

Truss in Scotchland


https://www.thedailymash.co.uk/politics/my-adventures-in-scotchland-by-liz-truss-20220803224015

[SqueakyVoice]

Turns out Liz is flying for every vote.

https://liveapp.inews.co.uk/2022/08/03/liz-truss-charters-luxury-private-helicopter-to-campaign-in-tory-leadership-election/content.html

Liz Truss charters ‘luxury’ private helicopter to campaign in Tory leadership election

So confident, she won't even keep her feet on the ground.

[SqueakyVoice]

(It took me about five attempts to finally get it right...grrr. )

[The Accountant, OBE, KC]

Not relevant comparisons as you are talking about private, paid for services, rather than free-at-point-of-care services funded by the tax payer.

I am suggesting change the concept of free at point of care e.g. except where you miss appointments without a valid reason.

I understand that someone has to make a decision as to what is a valid excuse and what isn't. Some people might have problems making decisions on this but not everyone feels too squeamish to make these kind of decisions, even though they know there is a possibility they might make the wrong call. I don't think I would as I would see it as necessary decisions that need to be  made for the service to still be available for the majority.

I think it's a good thing that people do not all feel the same way about issues and therefore different people are available to carry out different taks based on their individual ability/ aptitude/ perspective.

[The Accountant, OBE, KC]

You might, but the BMA is clear that it is concerned that fining patients would impact doctor patient trust, so they clearly think there are plenty of people whose trust would be impacted. That you aren't one of them is irrelevant.

I don't think it's irrelevant. If there are enough people who feel similarly to me, then the BMA's view might become irrelevant.

[The Accountant, OBE, KC]

Actually there has been a lot of research on this, and on what interventions work and don't work. And 'couldn't be bothered to turn up' and 'decided to do something else' don't feature high on the list of reasons.

Link please

Typically 'forgot' is up there, but of course a lot of people accessing GP services may have mental health issues, cognitive impairment or decline where 'forgot' is hardly an unreasonable excuse. Also challenges getting to the GP is another one high up and again many patients cannot get to a GP appointment without others helping out - indeed may be entirely reliant on others to book appointments, get them to the GP etc - it is fair to penalise those patients when inability to get to an appointment may be entirely beyond their control.

And a lot of people who forgot may not have mental health issues at all. Would be good to find out how many people who forgot have a mental health issue that leads to forgetfulness. Lots of people have mental health issues while still being able to funciton, do homework, study for exams, carry out responsibilities at work etc. without forgetting. Or if they do forget they get penalised at school or work for forgetting - they don't just escape all consequences because they have mental health issues.

'Got better' is another common reason and I agree those people should cancel, but 'difficulties cancelling appointment' is another common reason. For many people getting an appointment requires sitting on the phone, on hold for ages (often at a specific time of day) - cancelling an appointment may require exactly the same rigmarole and of course not all people are able to wait in a phone queue at 8am for 20 minutes to get through (that's the process at my GP) - for example if you are at work.

Would agree with this.

Oh, and of course more research into this would be helpful, but this wouldn't be funded from core NHS funding - it would be funded by research organisations, potentially medical charities such as the Wellcome Trust and Kings Fund. So conducting more research wouldn't impact on NHS funding, except that using the research to improve services may make the NHS work better.

Ok. If the research organisations have funding, great.

[The Accountant, OBE, KC]

Justice in Medical Ethics terms is quite specific - here is one mini-primer:

https://www.themedicportal.com/application-guide/medical-school-interview/medical-ethics/justice/

Note:

"It also means that we must ensure no one is unfairly disadvantaged when it comes to access to healthcare. Justice is one reason why the NHS has certain entitlements, such as free prescriptions for lower-income individuals."

So I'm a little bewildered as to how you are unable to see how your proposal (see reply 193) fails to meet the concept of justice in medical ethics. Here are just a few examples:

1. Your proposal is fundamentally regressive, in that the same about (e.g. £10) is charged regardless of the individual. £10 for some people is neither here nor there - for others it is a huge deal, hence the reason why prescriptions are free some some patients while others pay £9.35 - for some people paying £9.35 is a major issue so without free prescriptions those people are unfairly disadvantaged.

2. Your proposal will disproportionately impact those who are most vulnerable and disadvantaged. So for example patients over 90 are roughly twice as likely to miss appointments than any other age group and 220% more likely to miss appointment than the average. Similar those in the lowest socioeconomic groups are twice as likely to miss appointments. So your proposal will disadvantage people who are already likely to be vulnerable and already disadvantaged.

3. Your two-strikes-and-you-are-out proposal (i.e. fining after two missed appointments) will unfairly impact people with multiple healthcare needs and therefore have to visit the GP very often - note that 40% of all GP appointments are taken by just 10% of the population. So a person who has 20 GP appointment in a year and misses two (so a 10% non attendance rate) would be hit by your proposal yet a person who has just two appointments, and misses one of those (a 50% non attendance rate) won't be. The more appointments you have the more likely you are to be impacted - so people with multiple, complex health care needs would be unfairly disadvantaged.

4. Having a system which requires people to pay a fine first (in order to be able to access further healthcare) but with an appeals process will disadvantage those who will find appealing difficult, for example people with significant learning difficulties or other challenges to engaging with an appeals process, e.g. mental health issues that means that such a process creates significant anxiety issues. They would either be left out of pocket (although they might have perfectly legitimate reasons for missing an appointment) or would be denied ongoing healthcare. Again that doesn't fit with the principle of justice.

I could go on, but I won't. Hopefully you can see how your proposal isn't really compatible with the principle of justice in medical ethics.

I already responded to many of these points before e.g. the over 90s exemption and exemptions for people categorised as having mental health forgetfulness issues, which explains why I think the policy is compatible with justice.

The only new point you raised is people who have multiple health issues with mutiple apointments. You could set the system to flag missing appointents per department clinic rather than overall. If it's GP appointments, presuamably the practice will know their patients and be able to set the system to ascertain if a particular patient is missing too many appointments and set the trigger for a fine at an appropriate level. I think the principle of fining for missed appointments without a valid reason works - though individual GP practices might tweak the system depending on how they want to implement it. 

[ProfessorDavey]

I am suggesting change the concept of free at point of care e.g. except where you miss appointments without a valid reason.

The point I was making is that it isn't relevant to take practice in the private free-market and simply suggest they necessarily apply to public services. That nature of the manner in which those services are paid for and the notion of choice makes those comparisons irrelevant as far as I am concerned. That some private dentists and vets charge for missed appointments provides no relevant justification that the NHS should impose fines for missed GP appointments, which are not a chargeable service at point of use.

[ProfessorDavey]

I already responded to many of these points before e.g. the over 90s exemption and exemptions for people categorised as having mental health forgetfulness issues, which explains why I think the policy is compatible with justice.

Hmm - so the only way in which your proposal can be made to be compatible with justice in medical ethics terms is to ensure it doesn't apply to groups most likely to miss appointments - seems that basically demonstrates that the basic plan isn't compatible with justice. And if you exempt the groups most likely to miss appointments, what on earth is the point, as that exemption isn't on the basis of justifiable reason, but a mere blanket exemption.

So in justice terms why should a perfectly able 90 year old who couldn't be bothered to turn up as their appointment clashed with a big game at Wimbledon (and they are a big tennis fan) be exempt, while.

A perfectly able 89 year old who couldn't be bothered to turn up as their appointment clashed with a big game at Wimbledon (and they are a big tennis fan) is fined.

Or even an 89 year old with fluctuating alzheimer's who relies on a carer to remember and get them to the appointment - who will be fined and then has to appeal.

[ProfessorDavey]

Link please

Here are a couple:

https://link.springer.com/article/10.1186/1471-2296-6-47
https://link.springer.com/article/10.1186/1471-2296-6-47

Not sure if you can read the full article. From the first article:

The top reason was forgetfulness - but there isn't detail on why, e.g. whether individuals had cognitive decline or whether the GP made any attempt to remind the patient. It is well established that the biggest driver for missed appointments is how far in advance the appointment is made - so appointments in the next day or two are much more likely to be attended than appointment made for 3-4 week in the future. Not surprising really but that is surely an appointment-side issue. I return to my quote:

"Forward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient."

Second highest reason - very hard to cancel appointment. And you seem to agree with me on this. Surely until GPs provide a very easy way to cancel an appointment fining patients for not attending and not cancelling seems totally unreasonable. Effectively GPs would then be fining patients for their own failure to provide a quick and easy way to cancel an appointment.

There is also a clear theme that patients blame misunderstanding or mistakes - and in the most part see those as misunderstanding or mistakes as being on the part of the GP practice.

Would agree with this.

See above - so until a GP can demonstrate that it is straightforward to cancel an appointment how can it be fair to fine a patient who fails to cancel an appointment.

Ok. If the research organisations have funding, great.

They do, so funding of relevant research, which may include trialling intervention studies (as has been the case) won't impact on NHS funding. It may, of course, improve service provision or reduce costs if the fundings are implemented.

[SteveH]

Truss has tweeted her intention to "hit the ground from day one". We can but hope... One is reminded of the Tory MP for Stoke-on-Trent South Jack Brereton's tweeted hope to see his constituency levelled.