Liverpool Care Pathway 'wrongly blamed'

27 January 2014 Last updated at 07:43 By Dr Claud Regnard Newcastle upon Tyne
There is now debate over what should replace the Liverpool Care Pathway For 10 years the Liverpool Care Pathway (LCP) was used to monitor care at the end of life, but negative media reports raised concerns it had led to poor care and even deaths - and last summer a panel led by the Baroness Neuberger decided that the LCP should no longer be used.
But writing in Scrubbing Up, Dr Claud Regnard, a consultant in palliative care medicine in Newcastle-upon-Tyne, suggests the media, government and Neuberger panel were wrong to blame the LCP and questions whether the ban was justified and will benefit patients.
The distressing stories of poor care presented to the panel looking into the LCP could not be ignored.
The panel rightly laid the blame at many different doors including poor communication skills, inadequate attention to the need for food and drink, questionable decision making and insufficient training.
These have been noted before in many reports or research papers and they always deserve repeating.
And yet, the report rejected the accusation that the LCP was a means of deliberately hastening someone's death and even praised it as an effective tool.
A University of Nottingham review that accompanied the report found no evidence that such pathways cause harm.
The panel did criticise checklists like the LCP, but was apparently unaware that used intelligently and compassionately they are crucial to ensure safety - on your next flight try telling the pilots they cannot use a checklist.
Many improvements in the care of dying patients in the last 45 years are thanks to hospice and specialist palliative care teams and, had they been included in the panel, the outcome for patients might have been different since there was nothing in the report to justify banning the LCP.
The LCP wasn't perfect - nothing ever is. But it had improved over 10 years and could have been improved further.
The LCP never required patients to be denied food or drink and never demanded that patients be sedated.
When these happened inappropriately they occurred because of poor decision making, not because of the LCP.
Care 'vacuum' risk
The LCP did require patients to be regularly monitored for any sign that they might improve and benefit from treatment to reverse the cause.
It also required carers to communicate clearly and work in partnership with the patient and relatives.
Ignoring these requirements happened because of poor skills and training, not because of the LCP.
Continue reading the main story

Many health professionals are frustrated at the loss of the LCP, and some fear that that care of the dying may be set back years. ”

End Quote The Neuberger report wanted the LCP phased out by July this year, but it is now clear that no-one wants to create a replacement that may be banned by a future similar panel.
The consequence will be a vacuum in monitoring care with the risk that poor care continues without hindrance.
It was easy to make the LCP a scapegoat, but this has been a disservice to dying patients. Banning the LCP was like banning the Highway Code because of a few bad drivers.
What now?
Relatives who received excellent care under the LCP have already expressed their surprise at the ban.
Many health professionals are frustrated at the loss of the LCP, and some fear that that care of the dying may be set back years.
But one recommendation in the Neuberger report may provide a way forward: to set up a national leadership alliance to improve end of life care.
There are cases of poor care, but there is also a remarkable amount of compassionate care that still exists in all health care settings with a determination amongst health professionals to work in partnership with patients, partners and families.
Some good may come from this, despite the decision to ban the LCP.

Medic's lifesaving gift in Uganda

19 March 2014 Last updated at 13:46

 

Andrew Jones used his own money to buy anaesthetic, sutures and drugs needed to save this patient A Welsh anaesthetist has told how he paid for a patient's treatment in Uganda rather than watch him die.

Andrew Jones, who works at Morriston Hospital, Swansea, was on secondment with the UN in Mityana, Uganda, where patients must fund their own treatment.

The burns specialist said it would have been "inhumane" to stand by and do nothing.

Mr Jones said the experience taught him how fragile life was and how UK hospitals waste precious equipment.

"It's really, really basic out there," he said.

"Anyone who comes into the hospital as a patient has to provide everything themselves - gloves, anaesthetic, syringes, the lot. If they don't have it then they don't get treated.

"But I couldn't sit by and watch that - it's inhumane."

Village births

Carmarthen-born Mr Jones, who is also clinical tutor at Swansea University's School of Medicine, put his hand in his own pocket and paid for local anaesthetic, sutures and drugs to treat patients.

"If a lady who is pregnant comes in to give birth they have to have what's called a baby pack," he said.

"This has everything they need to give birth but if they don't have it they don't give birth in the hospital. Simple as that. They go back to the village and give birth alone."

Mr Jones knew just how horrendous the conditions would be when he accepted the opportunity to use his specialist burns knowledge at the Mityana Community Foundation.

Mr Jones wants to return to Uganda in October to continue the work he started

The charity began as a result of a terrible tragedy in the town.

"A couple of years ago there was a school out there that, for security reasons, the children were locked inside overnight," Mr Jones said.

"But one night a candle tipped over and all the children were killed. That's how the charity was started up."

In the two weeks Mr Jones was in Uganda, he performed 37 procedures - some as a result of gunshot wounds, hit-and-run incidents and stabbings.

Makeshift mortuary

"The conditions are absolutely incredible," he said.

"A 21-year-old lad was knocked down by a motorbike and died. But because the mortuary roof was damaged we had to do the post mortem in a room in his house with his parents there."

Mr Jones also carried out five caesarean sections on pregnant women to deliver their babies.

"A lot of the patients had torn uteruses or placentas but they couldn't get from their village to the hospital," he said.

"They don't have transport so you have to go out to them. We did some of the c-sections in the villages, but there were others we did in the hospital."

Continue reading the main story

Everyone should do this as part of their training. I put myself on call from the moment I arrived until I left”

End Quote Andrew Jones The conditions also made for difficult, and dangerous, deliveries.

"Once we had the lights go out mid-operation," he said.

"The generator failed and it was pitch black. You literally couldn't see anything.

"Luckily I had a head torch in my pocket. One of the nurses put it on my head and I had to work with that. It was crazy.

"There would a legal battle if something like that happened in this country, but it's a part of life over there."

Mr Jones said basic equipment used in the UK is just not available in Uganda, which costs lives,

"The thing we use most in theatre is a surgical diathermy machine, which basically stops you from bleeding to death," he said.

"But they don't have that machine because of the power supply out there, which basically means patients bleed to death. There's nothing you can do."

On returning to Swansea, Mr Jones said he has learnt not to take equipment for granted.

"I think there are certain skills they've taken from me, such as how to separate waste," he said.

"I've noticed how much we waste equipment in this country. Syringes only cost 2/3p but they're a huge thing to them.

"I try to not waste anything."

He added: "Everyone should do this as part of their training. I put myself on call from the moment I arrived until I left... I was very sad to leave and I cannot wait to go back."

'Ban junk food TV ads until 21:00'

 

An analysis of TV ads showed chocolate was promoted during family shows Children are being exposed to TV adverts promoting unhealthy food which should be banned during primetime family viewing, says a campaign group.

Action on Junk Food Marketing analysed 750 adverts shown during the X Factor on ITV and the Simpsons and Hollyoaks on Channel 4 over 20 hours.

It found one in 10 promoted fast food restaurants, confectionery or supermarket 'junk food'.

But the government said advertising was not to blame for childhood obesity.

Continue reading the main story

The UK's evidenced-based approach to the advertising rules works, balancing sensible protections with the freedom to advertise”

End Quote Ian Barber Advertising Association The analysis, which was carried out by researchers at the University of Liverpool, found that unhealthy food items accounted for 11% of all adverts and around half of all food adverts.

They said the most frequently shown adverts for unhealthy food products came from supermarkets such as Aldi and Morrisons, followed by fast food chains such as Dominos and Kentucky Fried Chicken (KFC).

Chocolate manufacturers like Lindt and Cadbury and brands such as Clover and Flora Buttery were also included on the "unhealthy" ads list.

The researchers looked at adverts shown during 10 hours of X Factor programmes and another 10 hours of early evening Channel 4 programmes during the run-up to Christmas 2013.

Peak viewing

The campaign group Action on Junk Food Marketing, whose members include the Children's Food Campaign and the British Heart Foundation, said children's TV viewing peaks around 20:00 but laws to protect children from targeted advertising only cover children's programmes, which tend to be broadcast earlier in the day.

Simon Gillespie, chief executive of the British Heart Foundation, said: "Parents don't expect their children to be bombarded with ads for unhealthy food during primetime TV, but that's exactly what happens.

Pizzas were one of the most common fast-food restaurant products advertised

"Even when the show is over, junk food marketers could be reaching out to young people online. A lack of regulation means companies are free to lure kids into playing games and entering competitions - all with a view to pushing their product."

Prof Mitch Blair, officer for health promotion at the Royal College of Paediatrics and Child Health, said advertising junk food during family-friendly programmes like the X Factor is known to work.

"Not only are children and young people easily influenced and parents worn down by pester power, but food companies wouldn't spend huge amounts of money if it wasn't effective."

Continue reading the main story

We are all eating too many calories and too much salt, fat and sugar which impacts on our health”

End Quote Dr Alison Tedstone Public Health England Campaigners want the ban on "junk food" advertising to be extended to 21:00.

"Children should not be commercially exploited and the advertising industry must take some responsibility for helping tackle the growing problem of childhood obesity," Prof Blair said.

Sensible rules

The government said advertising was just one aspect in determining children's choice of food and one part of the package aimed at tackling childhood obesity and poor diet. It added that it was keeping "this area under review".

The Advertising Association went further saying the report was "lobbying dressed up as science" and the current rules on advertising were working.

Communications director Ian Barber added: "The UK's evidenced-based approach to the advertising rules works, balancing sensible protections with the freedom to advertise, allowing companies to compete - to the benefit of us all - and providing important funding for free-to-air TV."

But there is general agreement that with around one-third of UK children now overweight or obese, encouraging families and children to eat healthier diets is important.

Dr Alison Tedstone, director of diet and obesity at Public Health England, said they were working with the food industry to promote healthier products on TV through their Change4Life campaign.

"We recognise that we are all influenced by food adverts on TV. We are all eating too many calories and too much salt, fat and sugar which impacts on our health, causing obesity which increases our risk of cardiovascular disease, type-2 diabetes, and some cancers."

'Threat of extinction' to GP service

23 March 2014 Last updated at 15:18  GPs have been the bedrock of the NHS, says the royal college A funding crisis and increased demand for care means general practice as patients know it in the UK is "under severe threat of extinction", the head of the Royal College of GPs has warned.

The royal college's president, Dr Maureen Baker, said failing to properly fund GP surgeries could have an impact on the sustainability of the NHS.

Some practices were already closing due to lack of staff, she said.

The Department of Health said it recognised the "vital" job GPs do.

Continue reading the main story

We are fiddling while Rome burns and the four Governments of the UK must wake up to the critical state that general practice is now in”

End Quote Dr Maureen Baker RCGP chairwoman Health think tank the King's Fund agreed that GP services were under increasing pressure, but said talk of "extinction" was "a huge exaggeration".

'Toxic mix'

While general practice deals with 90% of patient contact, it only receives 8.39% of the overall NHS budget, the RCGP said.

Dr Baker urged governments in London, Cardiff, Edinburgh and Belfast to take action to address the "huge and historic imbalance in funding".

"General practice as we know it is now under severe threat of extinction," said Dr Baker. "It is imploding faster than people realise and patients are already bearing the brunt of the problem."

She said: "For generations, GPs have been the bedrock of the NHS and provided excellent care for patients.

"But we can no longer guarantee a future for general practice as our patients know it, rely on it - and love it.

"GPs are doing all they can but we are being seriously crippled by a toxic mix of increasing workloads and ever-dwindling budgets, which is leaving patients waiting too long for an appointment and not receiving the time or attention they need and that GPs want to give them."

'Grave concerns'

Funding for GPs is vital to protect the future of the NHS as a whole, Dr Baker said.

"Cutting funding to the bone is a false economy - by investing in general practice, we are shoring up the rest of the NHS from collapse," she added.

"We are fiddling while Rome burns and the four governments of the UK must wake up to the critical state that general practice is now in."

Continue reading the main story

Spending less on something is not necessarily bad if it is a sign a service is becoming more efficient.

The figures quoted by the Royal College of GPs include funding for areas such as pay, IT and drugs. Arguments could be made that squeezing all three is justifiable.

Pay rises across the rest of the NHS - and the whole economy for that matter - have been suppressed in recent years. So why shouldn't GPs also share the pain?

Meanwhile, there has been a drive to increase the use of cheaper generic drugs and get better value for money out of IT systems.

The big question is really whether patient care is being hit. The government argues not, but not everyone agrees. There are plenty of GPs and patient groups that claim getting appointments is becoming more difficult as services are stretched.

If there is not sufficient funding in the 2014/15 budget rounds, the RCGP has "grave concerns for the sustainability of the NHS", according to its president.

The royal college says that funding for general practice in England has fallen by £400m in real terms over the past three years.

In October, it published a report saying that £8.5bn had been invested in 2012-13, compared with £8.3bn in 2009-10, which is the equivalent of £8.9bn in 2012-13 prices.

And in November, it published figures with the National Association for Patient Participation showing GP funding across the UK at a nine-year low.

Between 2004-05 and 2011-12, the proportion of the NHS budget spent on general practice had fallen from 9.47% to 7.78% in Scotland and from 8.58% to 7.77% in Wales, it said.

In Northern Ireland, the figure dropped from 8.22% in 2010-11 to 8.1% in 2011-12.

Dr Baker told BBC Radio 5 live that while budgets had dwindled over the past three years, demand for GP services was increasing - from 300 million consultations in 2008 to 340 million in 2012.

She warned that "in some areas, we believe that some practices are already shutting down".

She welcomed government moves to train more medical staff, but called for immediate action "to shore up the service in the next few years, until these new doctors, nurses and support staff come on stream".

Increase in trainees

Prof Chris Ham, chief executive of health think tank the King's Fund, said that factors such as the ageing population and the complex needs of patients were putting GP surgeries under pressure, and he agreed their share of the NHS budget had fallen in recent years.

But he added: "I'm not denying the real pressures and the lack of funding, but it's a massive leap from saying that to saying GPs face extinction."

He said some surgeries were finding ways to cope with the pressures, including by offering more services by telephone and email.

Labour's Andy Burnham said appointment delays were "simply unacceptable"

An RCGP survey found that 62% of 1,007 people questioned thought the number of consultations carried out by GPs each day, believed to be between 40 and 60 in most cases, risks the standard of patient care they provide.

More than a quarter, 28%, said the last time they tried to book an appointment with their doctor they could not get one in the same week.

Four in 10 were worried that the amount of time they have to wait to see their GP could affect their health.

The poll, carried out by ComRes, also showed that 60% of the public want funding moved to general practice from other parts of the health service.

Shadow health secretary Andy Burnham said it was "simply unacceptable" that some patients had to wait up to a week for a GP appointment.

He said this was putting pressure on hospital accident and emergency departments.

A DoH spokesperson said: "We recognise the vital job that GPs do.

"This is why we have cut GPs' targets by more than a third to free up more time with patients, and are dramatically increasing trainees so that GP numbers continue to grow faster than the population."

NHS England said its funding for GP services had increased by a third in real terms since 2002-03. It said recent changes to the GP contract would free up doctors' time by removing "rigid performance targets".

MP disputes 'no NHS evidence' claims

 

Ann Clwyd says she had received 'several hundred' complaints about the Welsh NHS Labour MP Ann Clwyd has defended claims that she has not given the Welsh government facts or evidence to back up her concerns about the Welsh NHS.

First Minister Carwyn Jones told AMs Ms Clwyd had provided "unattributable" comments that "can't be investigated".

The Cynon Valley MP agreed the identity of patients had been protected in some cases.

But she insisted she had provided Mr Jones with a comprehensive summary of the complaints raised.

Ms Clwyd led a UK government-commissioned inquiry on how NHS hospitals in England handle complaints, and said she also received hundreds of letters from Welsh patients outlining poor experiences they had suffered.

During First Minister's Questions on Tuesday, Mr Jones said Ms Clwyd had been asked "on more than one occasion" to produce the evidence to back up her claims.

Continue reading the main story

As I have explained on a number of occasions, unless people want their names and addresses released then we cannot do it”

End Quote Ann Clwyd Cynon Valley MP He said information she had provided so far could not be investigated because it was "anonymous".

Ms Clwyd insists she has provided substantial evidence, but said it was important patient confidentiality was maintained.

"As I have explained on a number of occasions, unless people want their names and addresses released then we cannot do it," she told BBC Wales.

"We have had several hundred people with complaints about the health service in Wales and the best thing we could do was give him [Carwyn Jones] a list of the kind of complaints that people were making.

"I have been on about it for a year. I wrote a very comprehensive letter to Carwyn Jones dated December 10 after a meeting I had with him a couple of days previously."

'Confidentiality breach'

Her latest comments come a day after she called for the chair and chief executive of Cardiff and Vale Health Board to resign claiming it released private details on the investigation into the death of her husband Owen Roberts.

She claimed he spent 27 hours on a trolley at Cardiff's University Hospital of Wales before dying, in 2012.

The health board confirmed information about her husband's case was released in response to a Freedom of Information request, but denied breaching confidentiality.

It said the details released were statements already in the public domain and were part of the outcome of the investigation, which was completed some months ago.

But Ms Clwyd said she had previously refused permission for the information to be released.

The MP said she would be making a complaint to the information commissioner and considering legal action.

Dog disease could be medical boon

23 March 2014 Last updated at 00:40 By Lizzie Crouch BBC Radio Science Unit

 

Texas has been diagnosed with OCD Texas is a very energetic, smart and playful German shepherd dog. "He always tries his best to please me," said his owner Helene Bäckman.

But when Texas was six months old, Helene noticed that he started to behave unusually.

He started to jump and bite the air repeatedly.

"It´s like he sees something. He jumps and when he´s biting, he bites hard," she said.

"You can hear his teeth against each other.

"He can do this for hours and he gets more and more stressed when he´s doing it. He never rests between jumps."

The reason for Texas' unusual behaviour? Obsessive compulsive disorder (OCD).

OCD is well described in humans and the dog version of the disease presents with similar repetitive behaviours.

Whereas people might wash their hands multiple times or hoard objects, dog symptoms include constantly chasing their own tails or shadows, blanket sucking or repeated grooming.

Texas' symptoms include a behaviour called fly-catching.

This is where dogs snap or chomp at the air as if they're trying to catch imaginary flies.

"It hasn't been easy to get him diagnosed because nearly all people around me have said that just the way he is," said Helene.

"I live in the north of Sweden and had to drive 700km to [the vet who diagnosed him] in Stockholm."

OCD is one of hundreds of disease which the domestic dog suffers from that presents in a very similar way to the human form of the condition.

Other 'human' conditions that dogs are susceptible include:

EpilepsyNarcolepsyHaemophiliaCancerMuscular dystrophyRetinal degeneration

Although seeing our canine companions suffer may be upsetting, these shared diseases mean that dogs are emerging as one of the most important animal models of human hereditary diseases, advancing our understanding and paving the way for new therapies.

Genes for disease

Recent studies have identified genes that might cause the canine form of these conditions.

"It is much easier to find disease genes in dogs than in people," said Professor Kerstin Lindblad-Toh, of Uppsala University and the Broad Institute.

This is due to the fact that humans have been breeding dogs for hundreds of years.

Continue reading the main story Golden retrievers get breast cancer. So do jaguars, kangaroos and beluga whalesSiamese cats and Dobermans get OCD. Some are on ProzacCanaries, fish, and even Yorkshire Terriers dogs faint when they're stressed outMares can become nymphomaniacsDinosaurs suffered from brain cancer, gout and arthritisKoalas catch chlamydia, rabbits get syphilisReindeer seek out narcotic escape in hallucinogenic mushroomsGorillas experience clinical depression and eating disordersStallions self-mutilate Source: ZoobiquitySelecting dogs to create pups with specific characteristics has resulted in a certain amount of inbreeding, allowing disease-causing genes to become widespread in certain breeds.

This breeding history also means that all dogs within a breed are very similar genetically.

"This makes the search for the specific disease mutations less complex," said Prof Lindblad.

"In dogs we can find [disease-causing] genes with only a few hundred sick and healthy dogs, whereas in people thousands of patients and controls are needed."

In 2005, Prof Lindblad-Toh's team analysed all the genes of a female boxer called Tasha to produce an extremely accurate genetic sequence for the dog.

They, and other groups, have shown that the genetic sequence that makes up dogs like Tasha are quite similar to humans, meaning that many of the genes causing a disease in dogs may also be behind the manifestation of the condition in humans.

Prof Lindblad-Toh and her colleagues have recently published a study in Genome Biology which has identified four genes that are associated with OCD in dogs like Texas.

They are currently carrying out studies into whether these genes are also implicated in the human condition.

"Since the disease symptoms and medications used in dogs and people are similar, we expect that the same genes or other genes with similar functions will be responsible for the disease also in humans," said Prof Lindblad-Toh.

Pets are often used for these studies. The fact that they live in the same environment as us gives the dog another advantage over other disease models.

"Dogs are exposed to many of the same stressors that contribute to health problems," said Jon Bowen, behaviour consultant and veterinary surgeon at the Royal Veterinary College in the UK.

"Their diet often contains the leftovers from human meals, they are exposed to family stress (such as arguments and conflict), and are relatively socially isolated from members of their own species."

It is known that the environment can have an effect on how genes are expressed, and so any gene-environment interactions that cause human disease also affect our canine friends.

The role of rodents

Currently, researchers still rely heavily on genetically engineered mice to further our understanding of a whole range of conditions.

Whether ethically right or not, our knowledge of human disease has progressed considerably as our understanding of how we can genetically induce disease in mice has advanced.

But there are limitations. Research is done primarily in specific strains of young mice, specially bred for research and genetically manipulated to induce a disease.

Gorillas develop depression

You have to have some understanding of what genes you need to manipulate in order to induce the disease, and not every disease can be induced through such genetic manipulation.

"Naturally occurring diseases in animals are a lot more complex," said Holger Volk, professor of veterinary neurology and neurosurgery at the Royal Veterinary College.

"In a rodent you simplify a lot of things."

But these simplified diseases in rodents are far removed from the complicated reality of naturally occurring diseases.

"When you look at certain diseases in humans, there are so many factors which could be involved [in causing that disease]," Prof Volk said.

These factors, and the fact we are a complex organism, can often hinder our search for the underlying genetic cause of a disease.

The relative ease with which you can find disease-causing genes in dogs, combined with the shared organism complexity and environmental factors, means it is likely that understanding hereditary disease in dog will take us further in understanding human diseases that rodents can.

To human medicine

Using the dog for investigations into physical diseases has had already led to significant advances in our understanding.

For example, the identification of the genetic basis of narcolepsy in dogs led investigators to a previously unknown pathway in the brain, while other studies have led to the development of a new gene therapy for haemophilia, which is showing promise in clinical trials.

Experts say that there is increasing recognition of the value that veterinary medicine can bring to human medical studies.

"Wherever we can, we try to present our work at medical meetings and conferences, so that the medical profession can see what we are doing. Universally this gets a great response," said Mr Bowen.

There are also large schemes, such as the One Medicine Initiative, that hope to bring together researchers in medicine and veterinary medicine to solve health problems, currently being carried out that recognise the important link between the two fields.

"My research is driven to improve animal health," says Prof Volk. "And by doing that I can also help the human counterpart; it's a win-win situation for both species."

Hospitals feeling the pinch

21 March 2014 Last updated at 08:59

The attention of many households has been on budgets this week. In the NHS, it has been a similar story.

On Thursday the NHS Trust Development Authority - part of the Department of Health - released its latest financial forecast for hospitals in England. It made grim reading.

Of the 99 hospital trusts it keeps an eye on - it has no jurisdiction over those trusts given foundation trust status - 26 are predicting they will record a deficit this financial year based on the situation to the end of January.

It means the NHS hospital sector is facing an overall deficit of £247m once the trusts with surpluses are taken into account.

This is much worse than previously forecast, although it must be said the situation looks much rosier once foundation trusts, which tend to be the better performers, are factored into the equation. They are expected to post a surplus of over £100m.

Nonetheless, if that does happen the hospital sector would still finish the year in the red - the first time that will have happened for eight years.

There are a number of reasons why problems are mounting however. Demands are rising, while the amount hospitals get for treating patients has been squeezed as have their training budgets.

Biggest expense

But does this really matter? After all, hospitals are not like a business or households that face the prospect of not being able to pay bills or going to the bank to borrow money.

Instead, the shortfalls are covered by the Department of Health. But that misses the point - and here's why.

The debt is still recorded against the individual trust's balance sheet. This means they have to draw up plans to rectify their financial position and recover the debt.

For those with the biggest problems that can prove very difficult. This was the case for South London Healthcare, the trust which was abolished last year after racking up the biggest historic debt in the NHS.

In drawing up those plans, the 26 NHS trusts forecasting a deficit - and indeed their foundation trust counterparts which are in a similar position - will face some difficult decisions, as the NHS TDA's Winter Report hints.

The next 12 months will see more pressure on hospitals to ensure they have safe nurse staffing levels and meet the requirements of seven-day working. Both these pushes will increase labour costs - the biggest single expense in the health service.

The government argues hospitals can become more efficient. But most would say that will require long-term structural change to the hospital sector. In the short-term hospital bosses say they are faced with a tricky choice: go further into debt or cut back on care.