<h3>Ambulance handovers</h3>
HS Improvement said some NHS trusts were applying “unacceptable rules” to delay or restrict ambulance access to hospital emergency departments. A letter from NHSI to Trusts has reached the Health Service Journal. It said that NHS Trust chief executives must really take the problem of delayed handovers from ambulances to A&E departments seriously, giving it “their immediate attention”. The letter also directed Trust CEO’s to ensure that all handovers taking over an hour were escalated to ‘higher echelons’, at the time they occurred. Did somebody say “micro-management”?

<h3>Casualty, revisited</h3>
In 2013 NHS England publically anticipated that between 40 and 70 of the existing 185 A&E departments would become “major emergency centres” with the rest becoming “emergency centres”. Emergency centres would be capable of assessing and initiating treatment for all patients whilst major emergency centres would be much larger units, capable of providing a range of highly specialist services.

The controversial proposal was opposed by many senior emergency doctors, and seems to have been shelved before the 2015 general election because of the political fuss likely about closing or downgrading A&E departments. There were also doubts that service centralisation was so beneficial, except for stroke, heart disease and neurosurgery. The Health Service Journal has recently investigated plans for re-categorising A&E departments and concludes that about 24 downgrades are likely (HSJ 6th February 2017) – not enough to transform the NHS but plenty to get the ambulances queuing and the media catastrophising.

<h3>Money: now you see it, now you don’t</h3>
On 24 January, NHS Trusts were told by NHS Improvement that their capital spending plans for the rest of 2016-17 were unaffordable. On the same day, reports the Health Services Journal, NHS England encouraged Trusts to apply urgently for digital technology funds that needed to be spent before the end of March 2017. Soon after Trusts submitted formal expressions of interest NHSE announced that the funds had been withdrawn. This is how NHS ‘planning’ works, by wasting management time in rushed applications that are all too often pointless.

<h3>Shopping around</h3>
Medical tourism is in the news as the Department of Health seeks to tax ‘medical tourists’ in advance for non-urgent medical care, but medical tourism runs both ways. For example, the number of UK residents seeking fertility expertise reached 51,266 over the past year, according to private healthcare search engine WhatClinic.com. Almost six out of ten (59%) enquiries were for overseas clinics. The top five medical tourism hotspots for Brits seeking IVF treatment abroad were Spain, Czech Republic, Turkey, Ireland and Greece and prices range significantly. The average price for IVF in Czech Republic is £821 while in Spain it costs £3,360, on average.

<h3>Decision-making</h3>
In a landmark case the Court of Appeal has ruled on the side of patient choice versus medical paternalism.  Hearing Sebastian Webster v. Burton Hospitals NHS Foundation Trust [2017], a case brought by Heather Butler after her son Sebastian suffered serious disabilities following his birth at Burton Hospital, the Court decided his mother’s wish to be induced should have been followed. The consultant obstetrician, under whose care she was under, believed that she should have a normal delivery. Following the precedent set by the decision of the Supreme Court in Montgomery v. Lanarkshire Health Board [2015], the case constitutes the first appellate decision where the Court of Appeal has emphatically ruled in favour of patient choice.

The Court of Appeal found that it was for the patient to decide the risks they wished to take concerning their body – including the risks posed to an unborn child. The role of the doctor, the Court ruled, was as a medical advisor and not the decision maker. They set out the standards of advice which medical practitioners must give to patients to enable them to make appropriate choices. The advice which is given must be clear, comprehensible, it must deal with the alternatives which are available to the patient and, importantly, the advice must be given dispassionately and without seeking to pressurise the patient to a particular course of medical treatment. It was not a defence for the doctor to say there were other doctors who would have acted in the same way. Older News from Nowhere moles who can remember the feminist movement in the 1980s to de-medicalise childbirth might have expected all these conflicts had been resolved. Sadly, not.