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    Barriers which prevent people accessing health care, including charges and co-payments

    Breaking down language barriers for better medicine on the front line

    Access to quality healthcare goes long way in bettering a person’s health, but we often neglect to consider the importance of translation and interpretation as an essential tool for saving and improving lives across language barriers.

    Medical translation has many benefits, but perhaps the most important is its ability to advance medical research. Medicine is truly an international field, with researchers all across the globe tackling a wide range of medical issues and sharing their findings with medical professionals across the world.

    In each case, the initial research will have been undertaken in the native language of the country in which it was conducted, which is going to have its own particular nuances and specific medical words and phrases unique to that language.

    The ability to move between languages not only advances medical research, but truly enhances the sort of medical attention and overall health care provided to individuals. Here, we examine where multilingualism in medicine is key to breaking down barriers for better medicine on the front line.

    Hospitals and primary healthcare facilities

    Medical translators need a good working knowledge of medical science and treatments to convey information clearly and precisely. As this NPR feature reports, discussions in the hospital room that become lost in translation can have fatal consequences. What’s more, if a patient doesn’t fully understand policies, from insurance to medical history, release forms to billing, accessing medicine can become an administrative nightmare.

    The NHS acknowledge that they have a “statutory and moral responsibility to patients” to provide medical translators to all the communities they serve, and aim to offer a strictly confidential service in a wide range of languages. A dedicated administrative team works to supply translators and interpreters in all cases where patients, relatives and carers may have difficulty discussing medical conditions and giving informed consent for procedures.

    Luis Asciano is fluent in French and Spanish, and works as a medical interpreter in a clinic in Washington DC. “You are sort of a bridge,” he says. “And it is very important that you do not obscure the context of the conversation.” The role of the interpreter is two-fold: to convey the facts of the situation as accurately as they are able, but to do so empathetically: Medical interpreters must have an ability to convey emotion, tone of voice and assuage patients’ fears too.

    However, according to an analysis published in Health Affairs, more than a third of US hospitals in 2013 did not offer patients similar language assistance. In areas with the greatest need, about 25% of facilities failed to provide such services. This despite the fact that over 60 million people in the country do not speak English as a first language. Further, studies reveal that nearly all claims for medical malpractice filed by foreign nationals in the US were the result of poor documentation in the patient’s native language.

    The need for specialised translators and interpreters really can be a matter of life and death. A study by the American College of Emergency Physicians in 2012 analysed interpreter errors with clinical consequences, and found that the error rate was significantly lower (12% compared to 22%) for professional interpreters than for ad hoc interpreters. For industry-trained professionals with more than 100 hours of study, errors dropped to 2%.

    As leading translation agency Global Voices point out, “Medical and pharmaceutical translation is highly specialised and requires great accuracy and expertise.” To achieve the utmost accuracy, they only work with linguists who have at least 5 years experience performing medical translations and interpretations.

    With all of this in mind, then, it becomes apparent that medical translators create a better environment not only for the treatment of patients, but also their sense of ease and comfort when faced with illness or injury.

    Crisis Events

    Disaster response can be a truly international affair, with medical, support and logistical staff hailing from all corners of the globe. The international staff who comprise the organisation Médecins sans Frontieres work in nearly seventy countries around the world.

    Instructions for disaster procedure and relief can be difficult enough to communicate within language borders, let alone across them, which is why translation accuracy is key. The misinterpretation of just one word or phrase can lead to anything from stagnation to outright disaster, highlighting the extreme importance of proper translation in the medical field.

    The Translators Without Borders group respond in such crisis events with their Words of Relief Programme, the first crisis relief translation network intended to improve communications with communities during and after humanitarian crisis response efforts by eliminating linguistic barriers that can impede vital relief efforts.

    Relying on translators in the field is obviously going to be of great use, but having important medical information, as well as disaster relief information, present in the native language is of great import to the recovery process as well.

    In the last year, Translators without Borders have assisted in the translation and dissemination of vital documentation and advice regarding transmission of the Ebola virus and monitored social media and web communications in affected countries in order to detect where support is most needed.

    From February 2015 to February 2016, roughly 712 healthcare articles in 54 languages were added to Wikipedia’s medical pages thanks to TWB volunteers. Elsewhere, developers are working to bring a digital translation tool facilitating communication with refugees from the Syrian crisis.

    During such disasters, there’s just as much of an emotional and psychological toll wrought on the populace as there is a physical one. Providing support and materials in native languages is truly instrumental in providing those in need with the psychological building blocks necessary for recovering. Breaking down language barriers is therefore instrumental in facilitating medical care around the world, not just in research, but on the front line too.

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    but they don’t relieve pressure from A&Es

    The rise and fall of the NHS walk-in centre

    Walk in health services of one form or another feature in many healthcare systems, including Canada and the United States. In England, the first NHS walk-in centre opened in the late 1990s but only became prominent in the late 2000’s following a policy initiative that led to the opening of around 150 new facilities.

    Offering extended hours and with no requirement for patients to pre-book or register, many new centres had proved highly popular with local residents with minor illnesses and injuries such as colds, eye infections, sprains and cuts. But despite this popularity, during the last parliament around a fifth of the facilities shut their doors, with a number of others, for example in Redruth, Hereford, and on Teeside, also currently at risk.

    Taking sides

    Why the services should have closed in such numbers is not immediately clear: the scale of local opposition to some closures – for example in Jarrow, Worcester and Southampton – was intense. Their supporters argue they reach new groups of patients, provide easy and convenient access to care, and take pressure off other stretched NHS services.

    At the same time, commissioners closing centres argue they represent a poor use of funds as many attendees have minor conditions that have little need for medical attention, and those that do could readily be treated elsewhere.  Some have cited the need to fund seven-day-a-week access to GP services as a more pressing priority.

    While not the whole story, one important question in these debates is whether walk-in centres divert patients from attending busy hospital A&E departments. This may be desirable since crowding at A&E is associated with high mortality and can have knock-on effects by reducing the capacity for hospitals to carry out planned medical treatments. In addition, many attendees at A&E have low severity needs which could be safely treated outside a hospital setting. Treating these patients as emergency cases in hospitals is considerably more expensive than treating them in walk-in clinics.

    Building the evidence: do walk-in centres divert patients from A&E?

    Until recently there was no conclusive hard evidence – from either side of the Atlantic – either way. When surveyed, around a quarter of patients attending walk-in centres say they would otherwise have attended a hospital A&E. However, academic research using statistical methods has been unable to detect any such effect.

    My research provides new evidence that goes some way to filling this gap. Combining detailed information contained in hospital records with difference-in-difference statistical techniques, I provide credible estimates of how patients’ use of A&E departments changes in response to the opening or closure of a new walk-in centre close-by.

    Two main findings emerge. The first is that walk-in centres do significantly divert patients away from attending A&E. The second, however, is that relative to the number of patients attending walk in clinics the effect is small, with calculations suggesting only around five to 20 per cent of patients attending a walk-in clinic would otherwise have gone to casualty. The implication is that they only make a small dent on the overall A&E figures.

    The research points to something of a dilemma for decision-makers. Easy access services such as Walk-in Centres are popular, which suggests they are valued by patients. The evidence suggests they do make a small contribution to relieving pressure at over-stretched emergency services, but with low diversion rates from A&E they may be an expensive way to do so. The cold reality of a chilly funding climate points to hard choices in allocating scarce NHS resources to best meet local demand. With this in mind, fights over the remaining centres look set to continue.

    this article first appeared on LSE Business Review.

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    A working party looking into the inclusion of placebos in surgical trials has led to a recommendation for greater use of the controversial method by the Royal College of Surgeons of England.

    Although placebo control groups are used in drug trials across the world, placebo-controlled surgical trials are extremely rare, with only 75 such trials published up to October last year.

    Often labelled with the misleading term ‘sham surgery’, it has long been argued that because placebo surgery is more invasive than placebo drugs it is difficult to justify its use.

    However a new paper resulting from the working party, ‘When should placebo surgery as a control in clinical trials be carried out?’, supports evidence to show they should be increasingly considered as part of surgical studies to produce the very best research evidence and be of the greatest benefit to patients.

    The research found that in half of the placebo-controlled surgical trials carried out up to 2013, surgery was no more effective than the placebo, calling into question the surgical procedure for the conditions treated.

    Lead author and Deputy Vice-Chancellor (Education and International) at Brunel University London, Professor Andrew George, said: “This is a controversial issue, but the benefit to clinical research of placebo-controlled surgery is just as great as in drug treatment, as long as it follows correct surgical practice.

    “The misconception is that this method would replace treatment in a control arm that is known to be effective, but that would not be the case. Placebo surgery should only ever be used when there is uncertainty about the relative benefits of an experimental intervention and placebo, and when any potential harm is minimised and reasonable.

    “Most importantly, controlled trials could potentially avoid future harm to patients if they demonstrate that a particular treatment is ineffective and should not be adopted into clinical practice.”

    Placebo surgery varies from minor procedures such as making an incision in the skin so that the patient doesn’t know whether they have been treated, to a full surgical procedure.

    In all cases ethical guidelines must be followed with patients being made aware of, and giving consent to, being part of a randomised trial.

    The paper is published here. The Royal College of Surgeons of England has released a position statement in support of greater use of placebo surgery here.

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    Migrants’ free access to the NHS and the perceived health care costs associated with it have generated much debate in the UK and even resulted in the introduction of a fee for certain non-EU citizens. Some politicians have blamed migration for the increase in waiting times, particularly in A&E.

    In order to inform this heated debate we have started a new project at the University of Oxford, investigating the relationship between immigration and the NHS. Our first paper investigates the link between immigration into an area and waiting times for A&E, outpatients (referrals) and elective care (pre-arranged, non-emergency care, including scheduled operations).

    Using data from 141 local authorities in England, merged with administrative information drawn from the Hospital Episode Statistics (2003-2012), we found no evidence that immigration increases waiting times in A&E and elective care. In fact, we found that higher immigration in an area actually reduces waiting times for outpatients there. On average, a 10 percentage point increase in the share of migrants living in a local authority would reduce waiting times by slightly more than 9 days. Using previous estimates of patients’ willingness to pay for a reduction in waiting times, we estimate that a 10 days reduction in waiting time would be equivalent to a person receiving about £38 in 2013 prices.

    The “healthy migrant effect” and UK-born mobility

    We look at two alternative explanations for our results. First, we confirm findings from previous research which suggest that migrants are younger and healthier than UK-born individuals, which in turn suggests a smaller impact on the demand for healthcare. Migrants in England are also 8 percentage points less likely to report a long-term health problem than their UK-born counterparts. By using data from the Understanding Society survey we also show that migrants’ likelihood of using hospital services is not statistically different from the UK-born. Moreover, recent migrants (i.e. those who came after 2000) are significantly less likely to use hospital services compared to the UK-born.

    Second, we find that higher levels of immigration increase the likelihood of UK-born individuals moving from that area, a conclusion that has also been supported in previous studies. This means the effects of immigration on the demand for health care services are dispersed throughout the country via internal migration.

    Evidence for the period immediately following the EU enlargement

    We test the robustness of the results by including data up to 2007, to focus on the years immediately following the 2004 EU enlargement. The enlargement induced a sharp increase in the number of recent migrants and it could have affected waiting times, at least temporarily. Our overall results are not affected by this change. Immigration has a statistically significant negative effect on waiting times for the period 2003-2007.

    We also explored geographical differences on the impact of immigration on waiting times during this period. We explored two possibilities in this regard. First, we exclude London from the analysis. The exclusion of London results in an insignificant effect of immigration on outpatient waiting times for 2003-2007.

    As a second possibility, we analyse differences in our results by level of deprivation of the area, and find that immigration increased waiting times for outpatient referrals in deprived areas outside London during this period. The effect for deprived areas is not significant for the whole 2003-2012 period, but only for the period immediately following the EU enlargement (i.e. 2003-2007).

    Immigration not to be blamed in most cases, but location and time matters

    The ultimate effect of immigration on NHS waiting times in a specific area depends on the characteristics of that area. For most areas, immigration has no overall impact on waiting times for A&E and elective care, and leads to a reduction in waiting times for outpatients. Yet, this is not true of every single area every single period. Policymakers should take these differences in impact across areas and time into account when creating policies to reduce NHS waiting times and/or manage the consequences of immigration.

    It is worth noting that because of its demographic composition, immigration may have a greater impact on maternity services. Effects could also change in the long-run as migrants become older. In particular, as low-skilled immigrants are more likely to work riskier jobs, morbidity in this group may increase in the long-run. Our project is currently looking at these two aspects.

    This article by Osea Giuntella, Catia Nicodemo and Carlos Vargas-Silva was first published on the British Politics and Policy blog

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    In the 1976 film All the President’s Men, the informant, Deep Throat, advised the investigative journalists, Woodward and Bernstein, to “follow the money” if they wished to get to get to the bottom of what was going on. And the same advice is likely to apply if we are to evaluate national and local government policy priorities in addressing inequalities.

    The vast bulk of public spending in Wales is undertaken by local health boards and local authorities. Probably correctly, the Welsh Government has decided that “big is best” in terms of the size of the these bodies to delivery these services.

    Whatever the advantages in bigger delivery bodies they can can create problems in terms of transparency and public accountability as power is concentrated further from communities and citizens. And as our public bodies become bigger and more centralised “following the money” becomes more and more difficult.

    A substantial amount of Welsh Government funding is allocated to our health boards and local authorities through needs based formulae. But once the money makes its way to these bodies it is very difficult to monitor if it is being spent in line with the allocation principles. And as these recipient bodies get bigger this task becomes even more difficult.

    Local authorities in Wales do not like hypothecation of Welsh Government funds. They wish to be free to make local decisions in line with local needs. But the methodology of resource allocation at a local level is often very opaque and it is very difficult to hold our councils to account in terms of their spending priorities.

    In this era of austerity there is no doubt that our most disadvantaged citizens and communities are bearing the heaviest burden. The Welsh Government is working hard to mitigate this though a range of policies but it is crucial that this intention is mirrored where it really matters — at the front-line grass-roots level.

    At the end of the day it is outcomes that matter most and it is excellent that programmes such as the Foundation Phase and Flying Start are subject to regular independent evaluation. But in many cases evidence of outcomes can take some time to emerge. In these situations intermediate or proxy measures have to be used and resource allocation ( qualitatively and quantitatively) is often an important guide.

    Our most vulnerable citizens and communities are more dependent on public services. They are therefore the most vulnerable when vicious austerity programmes are being implemented. It is vital that effective means are put in place to make sure that our reduced levels of public investment goes to where the need is greatest. Our public bodies must have clear and transparent funding streams in place and that both local and national scrutiny take place to ensure that best outcomes are delivered.

    Welsh Health boards cover populations from 132k in Powys to 678k in Betsi Cadwallader. Within health boards 4% of Powys’ population is in the poorest 20% compared to 39% in Cwm Taf and 27% in ABMU. But do we know that within these health boards that resources are allocated in line with this level of need at a local level?

    In the recently published policy on primary care workforce, A Planned Primary Care Workforce for Wales, the Welsh Government has highlighted the importance of the emerging 64 “primary care clusters” as a basis for health care planning. These clusters have a population size between 25k and 100k. They are therefore a more sensitive unit size for health care planning on the one hand but also for measuring the level of health care investment and outcomes. Some work has already started on this and the Workforce policy is committed to building on this.

    As this information becomes more available it is important that Health Boards “follow the money” and resources to ensure that their allocation is in line with needs and is producing the required outcomes.

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    Three months ago my wife contracted lobar pneumonia – out of the blue. One minute she was completely fit and healthy and the next she was in hospital with ITU outreach buzzing around. It was all very, very frightening.

    She received brilliant, timely treatment – intravenous antibiotics within an hour of arrival in ED, compassionate and skilled care from excellent doctors and nurses – and was home in three days.

    She made a good recovery and there was no paperwork to do or bills to pay. The NHS did what it does best. It was no more or less than I would have expected. My wife and I were both immensely grateful.

    But this is not main the point of this story. Please read on.

    Last month we were due to go on holiday to the United States. It was just over four weeks after leaving hospital but her consultant had given her the all clear to travel. She was well. Just before we were due to depart I realised that our annual travel insurance policy was due for renewal while we were away. It would run out three days before we were due to return home. We had used the same company for 20 years without ever making a claim.

    I attempted to renew on line as usual but immediately hit the question about recent hospital admissions. It was not possible to do it on line – I would have to make a phone call. Then followed the most difficult and upsettinging series of telephone calls that I have had to make for a very long time.

    It was just two days before our date of departure and we found the company would not renew the travel policy because my wife was now considered a “high risk”. An early question when talking to alternative providers is “have you ever been turned down for travel insurance”? You have to answer honestly and no surprise, they would you prefer to take your business elsewhere.

    Eventually I went back to my original company and told them we would cancel the holiday and claim back the cost against our existing policy. Only then did they agree to cover us for the extra three days until the end of the holiday, but they still refused to renew our annual travel policy.

    Insurance companies are risk averse. They only like to insure people they consider to be low risk. They can pick and choose who they take on and you, the customer, have no comeback.

    But this is not main the point of this story. Please read on.

    Have you caught up with recent advances in genetic testing yet? It is brilliant. Automated gene walking machines can map your DNA and can tell you your future risk of all sorts of diseases in a matter of days. For £125 you can find out if you are susceptible to everything from cancer to dementia. A bit pricey I know but the technology is developing so fast that in a very few years’ time you will be able to get a comprehensive health risk assessment for a few pence and a bit of spit.

    Imagine what the health insurance companies will be able to do with this genetic information. They can tailor your insurance costs to the actual risk of you making a claim. Great news for those with healthy genes but a bit of a blow if there is rogue DNA in the family.

    And don’t think they will not do it. They are in business to make the money and they will use any means they can to maximise profits. We are all vulnerable to the health effects of the random throw of our own genetic dice. The new technology will turn genetic bad luck into a personal financial catastrophe.  It will take very strong, new legislation to protect the public from exploitation – unless of course you live in the UK and have a National Health Service which is free at the point of need. For an up to date report on DNA Discoveries, please click this link.

    The NHS pools our collective health risk and shares the burden equitably. The cost to individuals is determined by their ability to pay and not their susceptibility to disease. Without the NHS we will be looking forward to a future of increasing inequality of health care provision.

    Do not underestimate the importance of this effect. In future our world will be populated by individuals whose wealth as well as health will be determined by their genes. The new technology will create huge distress and social upheaval across the globe.

    We in the UK are very fortunate to have the best answer to this problem already in place. We must not squander our NHS just when it is likely to become more import than ever before.

    First published on the Big Up The NHS blog

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    A long-awaited information standard was launched on July 3 by NHS England that will improve healthcare for millions of people has been welcomed by Action on Hearing Loss (formerly RNID).

    The standard requires all NHS and adult social care organisations to meet the communication needs of people with a disability, impairment or sensory loss by 31st July 2016, including the one in six people living with a hearing loss. It will include making sure patients get information in suitable formats and that, if needed, support from British Sign Language (BSL) interpreters is guaranteed.

    A survey of over 600 people with different levels of hearing loss to explore the experiences they have when accessing healthcare found:

    • One in seven respondents (14%) had missed an appointment because they had missed being called in the waiting room.
    • more than one-quarter (28%) of people with hearing loss had been left unclear about their condition because of communication problems with their GP or nurse
    • 68% of profoundly deaf British Sign Language (BSL) users asked for a sign language interpreter for a GP appointment but did not get one. 41% of BSL users left a health appointment feeling confused about their medical condition because they couldn’t understand the interpreter.
    • One in seven missed an appointment – the NHS estimates this costs £14 million in England every year due to missed appointments.

    Roger Wicks, Action on Hearing Loss’s Director of Policy and Campaigns, said:

    “It is vital that everybody understands the information and advice they receive from their GP or hospital. The Accessible Information Standard is the first time the NHS has provided clear guidance on what people with hearing loss and deafness should expect from health and social care services, and what staff should provide. So long as it’s properly implemented, it will enable patients to access services, to understand information they are given, to manage their own health and to participate fully in decisions about their treatment – things that many of us take for granted. While it can’t be denied that these adjustments will come at a cost, it’s now time for providers to acknowledge hearing loss for the serious health issue that it is, and to reap the benefits of enabling proper access.”

    1 Comment
    Dear Andy
    I have read your new Health Manifesto which contains some significant steps forward in our health care but I am deeply concerned that I cannot find how our Manifesto redresses the attack on our District hospital A&E and Maternity Units. As a result there is no equity in provision of acute care, especially in the rural areas.
    As Chair of SOS Grantham Hospital and Labour County Councillor for Grantham South (and current District councillor for Grantham St Anne’s Ward) I can advise that we are about to lose what remaining A&E we have.
    The Hospital Trust (ULHT) are strapped for funds and are reviewing all acute care in the County. They propose a new Ambulatory Care Unit goes in, that is little more than a minor injuries unit and will not meet the acute medical needs of the population of people living in the East Midlands A1 corridor.
    Newark Hospital lost its A&E and now has a Minor Injuries Unit. At the time the cut was justified on the grounds Grantham could provide A&E services. This area has become a vacuum as far as A&E provision is concerned with acute services being ‘sucked’ away into the cities, despite the presence (and therefore associated high risks) of main rail routes, poor internal mainly single carriage A roads, the A1 and a mix of industry including agricultural, oil and mineral extraction. We also have a significantly increasing elderly population as people leave the South East and move up to Lincolnshire and extensive coastal area.
    I recall drawing this issue to your attention at your Workshop in Nottingham and understood you were going to address the loss of A&E Units which progressed under our former Government but I cannot see how the current Manifesto achieves this important step.
    The whole of Lincolnshire is to see a centralisation of its acute medical care. This is simply unacceptable when we consider it is the second largest county in the country and one of the poorest. It is very simple. If we allow this to happen then the free access to the NHS services we are committed to for all will not be delivered. Only those with a car will seek emergency medical attention unless in a critical condition. Our ambulance crews are already overstretched regularly taking up to an hour to respond (with the added travel time of an hour and more to an A&E Unit).
    The Golden Hour, once lauded as vital, especially in stroke situations, will be a thing of a the past for the majority of residents of this county.
    We have campaigned against cuts to our services ( a 25k petition went to Downing St) over historic threats (under your watch). The Labour Government did listen and whilst under Labour there were some reductions in service the A&E and Maternity Unit remained.
    Under the Tories despite a 7.7k signature petition objecting to the threats to our maternity unit being closed (so now 1000 mums to be a year are forced to travel from the Grantham area in labour) we lost a super Maternity Unit.
    Now our A&E unit is facing a death knell in the guise of an Ambulatory Care Unit. Despite thousands of petition signatures the United Lincolnshire Hospital Trust and SW Lincs Clinical Commissioning Group have paid lip service to the views of the  public.
    Again, on this front our proposals to sit round a table with the hospital managers seem promising but I doubt will make any difference unless there are real teeth to the proposals that ‘require’ the administrators to take the views of the public into account AND to demonstrate how their views have been reflected in the outcome of any consultation through changes to the proposals. (I am a Business Improvement Consultant). As a councillor I have to send a questionnaire to all households affected by a resident parking scheme and have a majority in favour for changes to go ahead yet the hospital trusts can withdraw vital healthcare provision with no such level of public engagement. This should be addressed.
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    The NHS is our country’s most precious institution and Labour’s proudest achievement – the embodiment of how by the strength of our common endeavour we achieve more than we achieve alone.

    Its founding values – compassion; cooperation; healthcare based on need, not ability to pay – are as important today as they were in 1948, but the health challenges we face today are very different. An ageing population, the increasing prominence of mental health problems and particularly the growing numbers of people with multiple conditions – all of these pose challenges for our health and care services.

    Our services haven’t yet changed to reflect this new reality. They look at each of our needs separately, rather than the whole person behind them. The result is that care is fragmented, problems get missed and patients and families can feel passed around from one organisation to another.

    Far from reshaping services so they can rise to these challenges, the Conservative led Government has taken things in the wrong direction. The Health and Social Care Act distracted the NHS from the vital task of service reform and imposed a market framework on the NHS that is fragmenting services and making integration harder. Social care is close to collapse after billions have been removed from council budgets. Primary care and community services that help people stay healthy outside hospital have been stripped back, leading to A&Es and hospital wards becoming overwhelmed. And short-sighted cuts to training and recruitment have led to staffing shortages and huge pressures on the frontline.

    That’s why the general election cannot come soon enough. The answer to the challenges we face is not to set hospital against hospital, but to ensure the NHS has enough doctors and nurses with the time to care and to join up services from home to hospital. We are committed to raising £2.5 billion extra over and above the Conservatives’ plans – through a mansion tax on properties over £2 million, tackling tax avoidance and a levy on tobacco firms – to invest in new staff and support service transformation. And to get more from the money we currently spend, we will focus on prevention and early intervention, rewriting the rules so that health providers are paid for helping people stay healthy outside hospital rather than simply waiting for them to fall ill.

    Underpinning our vision will be powerful new rights in the NHS Constitution, such as a single point of contact for those with complex needs and increasing choice over where you receive treatment – with the home increasingly becoming the normal setting for care. Mental health will finally be given the same priority as physical health.

    Achieving a world-class health and care service will also require tackling the very real problems that we have seen develop in recent years, such as the culture of care visits limited to just 15 minutes and the crisis in general practice.

    And we will repeal the Government’s terrible Health and Social Care Act, not to reorganise structures, but to put the right values – those founding values – back at the heart of the health service.

    Miliband, Burnham and Kandall


    In 2015, the NHS finds itself under threat and its future uncertain. Dragged down by an unwanted reorganisation, services are going backwards and patients are finding it harder to get the care they need. A&E is in crisis, waiting lists are at their highest for six years and one in four people wait a week or more to see a GP.

    Cuts to social care have put even greater pressure on the NHS. Some 300,000 fewer older people are receiving social care compared to five years ago. As a result more older people are struggling and ending up in A&E, while bed days lost to delayed discharges are now at record levels.

    Five more years of decline would make the NHS unrecognisable from the service people cherish and rely on today. Worse still, Conservative plans for extreme spending cuts in the next Parliament mean they simply will not be able to protect the NHS.

    Labour, the party that created the NHS, is determined to rescue and rebuild it as a national health and care service, and this manifesto sets out the steps we will take to get there.

    First, we will restore the right values – co-operation and collaboration, not privatisation and fragmentation. This will enable us to join up care from home to hospital, bringing together three fragmented services into a single service coordinating all of a person’s needs – physical, mental and social. Powerful new rights over how and where your care is delivered will make care truly personal, and help drive the integration of services.

    Central to rescuing the NHS and transforming services will be investing in more doctors and nurses so the NHS has time to care. Our plans include 20,000 more nurses and 8,000 more GPs, helping to ease the pressure in hospitals and provide better care outside hospital. This is essential if we are to tackle the spiralling agency bill that is contributing to the financial crisis so many hospital trusts are currently facing.

    Investment in new staff will help us improve access to care, guaranteeing GP appointments within 48 hours and cancer tests within one week. It will also allow a renewed focus on prevention, early diagnosis and early intervention, which are critical not only to improving health and wellbeing but to ensuring the NHS can remain financially sustainable for the long term. We will pursue a far more ambitious approach to public health than we have seen under the current government. And we will make parity of esteem between mental and physical health a reality on the ground, in particular working to end the neglect of child mental health.

    It won’t be possible to rescue and strengthen the NHS without tackling the crisis in social care. We are determined to drive up the quality of social care services, with new year-of-care budgets to incentivise better care in the home and action to tackle the exploitation of the social care workforce. And it is precisely because we recognise the value of social care that we reject the Conservatives’ plans for extreme spending cuts in the next Parliament, which would see hundreds of thousands fewer older people getting the care they need.

    Labour’s plan is a better plan for the NHS, one that will lift the service out of its current downward spiral and help put it on a sustainable footing so it can meet the challenges of this century as well as it did the last.

    Labour’s better plan for health and care

    • Recruit 20,000 more nurses and 8,000 more GPs, paid for through a £2.5 billion Time to Care Fund, funded by a mansion tax on properties worth over £2 million, tackling tax avoidance and a levy on tobacco firms
    • Guarantee a GP appointment within 48 hours and on the same day for those who need it
    • Guarantee a maximum one-week wait for cancer tests and create a new Cancer Treatments Fund to improve access to drugs, radiotherapy and surgery
    • Join up services from home to hospital with a single point of contact for those who need it – bringing together physical health, mental health and social care
    • Improve access to mental health support, with a new right to talking therapies enshrined in the NHS Constitution – just as people currently have a right to drugs and medical treatments
    • Tackle the scandal of 15 minute care slots, recruit 5,000 new care workers to help provide care for those with the greatest needs at home, and introduce a new system of safety checks for vulnerable older people
    • Ensure that when changes are proposed to local hospital services, patients and the public have a seat around the table from the very start, helping design and decide on plans for change
    • Repeal the Health and Social Care Act to scrap David Cameron’s privatisation plans and put the right values back at the heart of the NHS

    Restoring the right values

    Labour will ensure that the NHS remains rooted in the values that underpinned its creation.

    Care, compassion and co-operation are as important now as they were when the NHS was founded in 1948. But in recent years we have seen those values slowly eroded by the Health and Social Care Act which has placed the values of the market and competition at the heart of the health service. The Act also removed the Secretary of State’s historic duty to provide a comprehensive health service and allowed hospitals to raise up to half of their income by treating private patients.

    The effects of the Health and Social Care Act have been all too apparent. Service standards are declining. Accountability for problems in the NHS is ducked by ministers. Service improvements and collaboration have been hindered by competition law, and millions have been wasted on competition lawyers.

    To reshape services over the next 10 years, the NHS will need the freedom to collaborate, integrate and merge across organisational divides and will need to be freed from running wasteful tenders that make integration harder to achieve. Labour’s first Queen’s Speech will bring forward a bill to repeal the Health and Social Care Act. This will not be another top-down reorganisation – we will work through the structures we inherit – but it will put the right values back at the heart of the health service.

    Our bill will restore proper democratic accountability for the health service, and will introduce tougher safeguards on hospitals’ ability to raise Private Patient Income – in order to ensure that NHS patients are always put first. It will repeal the market framework, removing the role of Monitor and the Competition and Markets Authority as economic regulators enforcing competition, and scrapping the ‘Section 75’ regulations that have effectively made tendering statutory. This will be replaced with an ‘NHS Preferred Provider’ framework, to ensure that the NHS is not destabilised by market competition, and we will draw a clear distinction between not-for-profit and for-profit providers by giving voluntary sector organisations the benefit of longer and more stable arrangements. Labour’s repeal Bill will legislate to ensure NHS services are fully protected from EU procurement and competition law, and we will ensure the NHS is protected from the TTIP treaty.

    There is a limited role for independent sector organisations in providing services where there are gaps in delivery or where the NHS cannot provide a particular service. But that must be in a role supporting the public NHS – not to replace it and break it up. On those occasions where private companies are involved in providing clinical services, Labour will impose a cap on the profits they can make from the NHS to ensure resources are spent on patient care.

    Labour will:

    • Restore the Secretary of State’s historic duty to provide a comprehensive health service and ensure proper democratic accountability
    • Repeal the market, scrapping the ‘Section 75’ regulations that have effectively made tendering statutory
    • Put in place an ‘NHS Preferred Provider’ framework, to ensure that the NHS is not destabilised by market competition
    • Where private companies are involved in providing NHS-funded clinical services, impose a cap on any profits they can make from the NHS
    • Ensure the NHS is protected from the TTIP Treaty
    • Place tougher controls on hospitals’ ability to raise Private Patient Income, in order to ensure NHS patients always get put first

    Joining up care from home to hospital

    Today, long-term conditions like cancer, heart disease and dementia account for 70 per cent of all NHS spending, and increasing numbers of people are living with more than one condition.

    As the Independent Commission on Whole-Person Care, chaired by Sir John Oldham, set out, this poses challenges for the health and care system and requires services that are joined up around the individual.

    But the current Government’s reforms are holding the NHS back from meeting these challenges. The Health and Social Care Act 2012 distracted the NHS from the vital task of reshaping services and imposed a market framework on the NHS that is making service integration harder. Services that support people to stay healthy outside hospital – such as GP services, mental health services and social care – have been stripped back, in turn pushing up demand on hospitals.

    The next Labour Government will integrate health and care services into a seamless system of ‘whole-person care’. This approach will bring together three fragmented services into a single service coordinating all of a person’s needs – physical, mental and social – with integrated, multi-disciplinary care teams working around the individual. This will enable better coordination of care. It will allow a greater focus on prevention and early intervention. And it will enable more care to be offered in the home rather than the hospital.

    As part of this, we will also ensure better integration between the ambulance service, NHS 111 and GP out-of-hours services.

    To help drive this transformation, Labour will introduce powerful new rights in the NHS Constitution.

    All people with complex needs will be entitled to a personalised care plan, developed with the individual and their family, and tailored to personal circumstances – not restricted by service boundaries. We will give people with complex conditions a single point of contact for all of their care needs, to act as their advocate in the system, and the option of a personal budget where appropriate. We will introduce new rights on care in the home, including giving all women a clear expectation that they can exercise real choice over where to give birth, where clinically appropriate, and giving those who are terminally ill with the greatest care needs the right to be in their own home at the end of their life, with all care provided on the NHS.

    Access to new technology, alongside the provision of information, is a key part of empowering people needing care. It is also key to helping families and friends support each other in their care. We will allow patients and carers to access their records and communicate with services online, making it easier for people to manage their own conditions and stay at home for longer.

    For too long, care for women who have miscarried has not been good enough. Compassionate care and clear information make an important contribution towards minimising the trauma of miscarriage. Labour will commit to improving the quality of miscarriage care, and joining-up the different services responsible for women who experience miscarriage.

    To support integration of services, we will bring budgets, commissioners and providers together at a local level. Health and Wellbeing Boards will be supported to become a vehicle for system leadership. Local areas will be supported to develop NHS integrated care organisations and networks. Providers will be incentivised to focus on prevention through year-of-care budgets, which will cover all of a person’s care costs over a year. Measures in the outcomes frameworks will be integrated to better coordinate performance monitoring across health and care.

    There also needs to be a change of role for Monitor, driving integration by focussing on the viability of whole health economies, rather than just the individual organisations within them.

    Integration cannot be imposed by top-down edict. It must be driven at a local level and designed around local needs. The journey to the end point will be determined locally – what makes sense in inner city Birmingham might not make sense in Cornwall. We will encourage communities to consider the appropriate model for their local health and care service and to move there at the appropriate pace.

    Labour will:

    • Give all people with complex needs a personalised care plan covering all of their care needs, developed with the individual and their family and tailored to personal circumstances
    • Give all people with complex needs a single point of contact for their care
    • Support those who are terminally ill with the greatest care needs to remain at home at the end of their life if they wish, with homecare provided on the NHS
    • Give patients the right to access their records and communicate with services online
    • Ensure anyone diagnosed with a long-term condition is linked up with peer support, so that no-one has to deal with a long-term condition by themselves

    Better access to primary care and diagnostic tests

    Under the Conservative-led Government patients are finding it harder see a GP. One in four people now wait a week or more, or can’t get an appointment at all, and the number of people saying they can regularly see their preferred GP has also declined. This is bad for families, who depend on their local GP service, and is putting huge strain on A&E. Studies have estimated that 5.8 million A&E attendances a year occur because people cannot get a GP appointment.

    The next Labour Government will guarantee the right to a same-day consultation with a doctor or a nurse at your GP surgery, and the right to a GP appointment within 48 hours. We will also ensure patients have the right to book more than 48 hours ahead with the GP of their choice.

    Helping people get quicker access to the help they need will improve health outcomes; for example, one recent study has found that patients able to see their GP within 48 hours are less likely to have their initial cancer diagnosis as an emergency hospital admission. Ensuring the ability to book ahead with the GP of your choice is important for those patients whose priority is not speed but the ability to plan ahead and to see the same doctor; for example, another recent study found that a five per cent increase in patients seeing their preferred GP was associated with a three per cent decrease in emergency admissions. In monitoring performance against these new access standards, we will give equal priority to continuity and the ability to book ahead.

    Labour is committed to recruiting 8,000 more GPs by 2020. This expansion of capacity will play a key part in helping the NHS deliver this access guarantee, and in ensuring more people can see their GP at a time convenient to them, such as evenings and weekends. But we also know that general practice is under enormous pressure, so we will also invest an extra £100 million in GP surgeries to support the delivery of these new access standards, paid for through savings from removing competition bureaucracy from the NHS. We will also work to reduce the paperwork burden on GPs, giving them more time to care for patients.

    Early diagnosis is another major priority for improving health and ensuring the NHS remains sustainable for the future. For example, earlier diagnosis is critical to improving cancer survival, because treatment is more likely to be successful at an earlier stage.

    By 2020, the next Labour Government will guarantee a maximum one-week wait for cancer tests and results, on route to a goal of a one-week maximum wait for all urgent diagnostic tests by 2025. This guarantee will be funded by investing £150 million extra a year in diagnostic capacity, matched by revenue raised through a new levy on tobacco firms. We will start with a focus on those tests for which experts say there could be particularly important benefits, such as abdominal ultrasound for ovarian cancer and endoscopy for bowel cancer, before broadening the guarantee out to a wider set of tests. We will ask clinicians and experts to advise on the specific set of tests and the priorities for implementation.

    Speeding up tests will have several benefits, including helping people get treatment quicker and reducing the anxiety around waiting for a cancer test result. And this extra investment in diagnostic capacity will be part of a broader drive to improve access to testing in primary care and to remove barriers to GPs requesting tests.

    Labour will:

    • Improve access to a GP by guaranteeing appointments within 48 hours, or on the same day for those who need it
    • Help patients plan ahead by giving people the right to book further ahead with the GP of their choice
    • Save £100m from competition red tape to invest in better GP access
    • Ensure that by 2020 no-one waits longer than one week for vital cancer tests
    • Introduce a levy on tobacco companies, to support extra investment of £150m a year in the NHS
    • Create a new Cancer Treatments Fund to improve access not just to the latest drugs but also to the latest forms of radiotherapy and surgery

    Improving Cancer Survival

    Labour’s goal is to match the best in Europe for cancer survival, which would save 10,000 lives a year.

    Our cancer test guarantee is part of a wider plan to improve early cancer diagnosis. Our plans include more public awareness campaigns – including making the Teenage Cancer Trust’s programme of awareness sessions on cancer available to every school in England – and ensuring GPs have access to the training and support they need to diagnose cancer. On cancer screening, we will roll out the Bowel Scope Screening programme to the whole country and we will ask the National Screening Committee to make recommendations within a year on whether we should introduce new lung and ovarian cancer screening programmes.

    Labour will also create a new Cancer Treatments Fund to improve access not just to the latest drugs but also to the latest forms of radiotherapy and surgery. The Tory-led Government’s decision to restrict a fund for extra investment to drugs has led to thousands of patients missing out on cutting-edge radiotherapy and surgery – the two forms of treatment that are responsible for nine in ten cases where cancer is cured. As part of this, Labour will guarantee that any patient in receipt of a drug from the Cancer Drugs Fund, when it comes to an end in March 2016, would continue to be offered that drug in the Cancer Treatments Fund.

    Labour will publish a new cancer strategy within six months of entering government, including a plan to tackle ageism in cancer treatment.

    Investing in staff so the NHS has time to care

    Over the last five years, staff numbers have not kept pace with demand. More than half of nurses say their ward is dangerously understaffed, there are fewer GPs per head compared to 2010 and the Government’s own GP taskforce has concluded that “there is a GP workforce crisis”. Cuts to nurse training – with 8,000 fewer nurse training places during this Parliament than if numbers had been retained at 2010 levels – have added to the shortage of nurses, forcing the NHS to recruit one in four nurses from abroad in the last year and creating a spiralling bill for agency staff too.

    The shortage of staff, and the failure to value the staff we have, is holding the NHS back.

    Labour will raise £2.5 billion a year for a Time to Care Fund, funded through a mansion tax on properties worth over £2 million, cracking down on tax avoidance and a new levy on tobacco firms. This will enable us to deliver, by 2020:

    • 20,000 more nurses, helping ensure safe staffing in hospitals, and providing personalised care outside hospital to families with the greatest needs.
    • 8,000 more GPs, to help people stay healthy outside hospital and to tackle the GP access problems faced by hundreds of thousands of families every week.
    • 3,000 more midwives, to provide safe, one-to-one care to women during labour.
    • 5,000 new care workers to work in integrated care teams – the beginning of a shift towards an NHS focussed on providing joined-up support to help people to stay in their home, particularly at the end of life.

    These new staff will enable us to drive service transformation, supporting new models of care and new ways of working.

    They will also help ensure the NHS has enough staff with the time to care. For example, these extra nurses will help ensure safe staffing in hospitals. The extra GPs will not only help improve access but help address the squeeze on consultation times. And the 3,000 more midwives will, for the first time, allow us to guarantee all women one-to-one care from a midwife during labour. This will mean the midwife is able to give her full commitment to being with the woman whilst she is in labour, and is widely accepted to improve the quality and safety of care for women and their babies.

    Delivering these extra staff numbers will require action on a range of fronts, including increasing the number of training places, developing new targeted apprenticeship routes into training, improving retention of existing staff and encouraging more staff to return to practice.

    Labour will reverse recent cuts to nurse training to reduce the reliance on overseas recruitment and to ensure young people in Britain have better opportunities to enter the nursing profession. As part of our Time to Care Fund, Labour will train 10,000 more British nurses above current training levels so that we achieve an average 21,000 training places a year in the next Parliament.

    On public sector pay, Labour believes in national pay frameworks and the stability and recognition they give to the health and care workforce. Labour will respect the views of independent Pay Review Bodies – rather than irresponsibly brushing them aside or reneging on the agreed processes as the current Government has recently done.

    Staff morale and wellbeing are also essential. Labour will work to foster a more positive culture and a better dialogue with the health and care workforce. And we will create a new NHS staff champion to help improve workplace culture and cut the high rates of work-related stress, bullying and abuse that too many staff face.

    We will work with staff to build a consensus around the expectation on the health and care workforce in providing seven-day services.

    Labour will:

    • Raise £2.5bn a year for a Time to Care Fund, funded by a mansion tax on properties over £2m, tackling tax avoidance and a levy on tobacco firms
    • Recruit 20,000 more nurses, 8,000 more GPs, 3,000 more midwives and 5,000 new care workers by 2020
    • Increase training places to reduce reliance on overseas recruitment and agency staff, including training 10,000 more nurses in the next Parliament above current training levels
    • Recommit to the Pay Review Body process, and respect the views of the independent Pay Review Bodies
    • Create an NHS staff champion to improve staff health and well-being, and help tackle bullying and abuse

    Giving mental health the priority it deserves

    Mental health is the biggest unaddressed health challenge of our age. One in six people across Britain are affected by a mental health problem at any one time and the World Health Organisation estimates that by 2030 depression will overtake heart disease and cancer as the leading global burden of disease.

    The Tory-led Government’s record on mental health has been one of failure and false economies, leading to greater costs and pressure on the NHS. Spending on mental health has fallen for the first time in a decade. We have seen key prevention and early intervention services stripped back, such as Child and Adolescent Mental Health Services (CAMHS) and Early Intervention in Psychosis services.

    It is essential that we give mental health the priority it deserves if we are to thrive as a nation and ensure the NHS remains sustainable for the future. In this Parliament, Labour peers forced the Government to write parity of esteem between physical and mental health into law and our approach starts with a commitment to make this a reality on the ground.

    Our plans to bring together physical health, mental health and social care into a single system of whole-person care will place mental health at the heart of the future system. Central to this will be the key principles of prevention, early intervention and better support set out in the recent report of Sir Stephen O’Brien’s independent Taskforce on Mental Health in Society.

    We will create a new right to talking therapies in the NHS constitution – just as people currently have to drugs and medical treatments. We will also set out a strategy and timetable to deliver a waiting time standard of 28 days for access to talking therapies, for both adults and children, and to ensure that all children have access to school-based counselling or therapy if they need it. To continue the expansion of talking therapies, we will set a specific new ambition for both adult services and CAMHS to extend access to more of those who could benefit from them.

    We will put in place a national programme of ‘social prescribing’ in GP surgeries and primary care, including with a focus on tackling isolation and loneliness to improve mental health. This will empower GPs to support people differently.

    We will ensure that the training of all NHS staff includes mental health, so mental health problems get spotted and addressed. In particular, we want to see a core module focussing on perinatal mental health in the training of all midwives.

    Labour is determined to end the scandal of the neglect of child mental health. It is simply not right that when three quarters of adult mental illness begins in childhood, children’s mental health services get just six per cent of the mental health budget. Despite the Government saying they would protect frontline services, the budget for child and adolescent mental health has been reduced year on year. This decision has led to more young people being placed on adult wards, and many sent hundreds of miles as a result of bed shortages.

    So we will work to reverse the damage suffered by child mental health services in  recent years. We have set an ambition that, over time, the proportion of the mental health budget spent on children will rise as we make smart investments to improve mental health in childhood, in turn, lessening the demand on services when young people become adults. We will also ensure that all teachers have training on child mental health so they are equipped to identify, support and refer children who might need help and support.

    All of these changes must be underpinned by a wider generational shift in attitudes and behaviour towards mental health. Recent years have shown some encouraging signs of improvement, but there is still much further to go. So we will continue to support efforts to fight the stigma and discrimination that too many people living with mental health problems still face.

    The Department of Health’s recent consultation paper found that, although much has been done in recent years to try to improve the lives of people with mental health needs, learning disabilities and autism, we must do more to ensure they enjoy the same rights as anyone else. Labour will prioritise making meaningful progress for these groups.The first autism strategy, introduced by Labour, marked a fundamental change in public services helping adults with autism to live independent lives and find work. Labour will work with local authorities and NHS bodies to ensure that the guidance to support the updated strategy is properly implemented and understood at a local level.

    Labour will:

    • Ensure that the training of all NHS staff includes mental health
    • Create a new right to talking therapies in the NHS Constitution, just as people currently have a right to drugs and medical treatments
    • Introduce a national programme of ‘social prescribing’ in GP surgeries and primary care, including with a focus on tackling isolation and loneliness to improve mental health
    • Set an ambition that, over time, the proportion of the mental health budget spent on children will rise
    • Ensure that teacher training includes child mental health so that all teachers are equipped to identify, support and refer children with mental health problems
    • Set out a strategy and timetable to deliver a waiting-time standard of 28 days for access to talking therapies, for both adults and children, and to ensure that all children have access to school-based counselling or therapy if they need it

    Valuing social care

    Recent years have seen deep cuts to local authority budgets that pay for adult social care, and the system is close to collapse. Tighter eligibility criteria mean that 300,000 fewer older people are getting care compared to 2010. Many more face inadequate, 15-minute visits: a recent survey found that 74 per cent of councils now commission 15-minute visits, up from 69 per cent last year, with one in seven home-care visits in these areas now being just 15 minutes long. And the rising burden of care charges is adding to the cost-of-living crisis.

    Social care workers carry out some of the most important work in society. Yet the current crisis is seeing the work they do being increasingly undervalued. Many are on zero-hours contracts and many are paid less than the National Minimum Wage, often due to the failure to pay workers for time travelled between home-care visits. There are also low levels of training and a lack of high-quality apprenticeships in the care sector.

    The growth in 15-minute visits means care workers are increasingly forced to choose between helping prepare a meal for a frail, older or vulnerable person or taking them to the toilet.

    This doesn’t just make for a worse service for the people who depend on social care; in the long term it makes for a more expensive system too. It means we have more and more people not getting the support they need at home, struggling, falling ill and having to come into hospital, or lying trapped in hospital beds because of the lack of support to help them return home.

    Since 2010, there has been a 49 per cent increase in the number of people aged over 90 being taken to A&E by ambulance. The Care Quality Commission also recently found that one-in-ten over-75s and one-in-five over-90s experienced an avoidable admission that could have been prevented if they had received better support outside hospital.

    We want to ensure that no-one fears their old age or struggles to cope with the care of a loved one. Labour supports measures to cap the costs of care. People need a fairer deal and protection against catastrophic costs of care at the end of their lives.

    We also need to improve the quality of social care. At the moment, the way we pay for care does not incentivise highquality care at home.

    Labour’s plan to integrate services from home to hospital will drive out the culture of 15-minute care slots by introducing new year-of-care budgets, which will mean providers will have a much stronger incentive to invest in preventing problems and improving care outside hospital.

    We will introduce a system of safety checks for vulnerable older people, to identify risks to their health and prevent problems before they occur – for example, cold homes, loneliness and depression, or risks of falling in the home.

    We will work towards making all health and care settings dementia friendly, and we will work with charities, businesses and others to realise the ambition of a dementia-friendly society. To demonstrate leadership we will champion the Alzheimer’s Society Dementia Friends programme across government.

    We will bring in 5,000 new care workers to help support those with the greatest needs at home, including to help those who are terminally ill with the greatest care needs to remain at home at the end of their life if they wish.

    To tackle workforce exploitation in the care sector, we will ban zero-hours contracts that exploit workers, strengthen the enforcement of the National Minimum Wage and incentivise employers to pay the living wage.

    We will also improve training opportunities in social care, by creating new apprenticeships and providing more opportunities for career progression for care workers. This will include our commitment to build a new generation of 5,000 care workers in the NHS, which will provide new opportunities for training and career development.

    Labour will:

    • Support measures to cap the costs of care and reject Tory plans for extreme spending cuts in the next Parliament that could see hundreds of thousands fewer people get social care
    • Introduce new year-of-care budgets to help drive out the culture of care visits limited to just 15 minutes
    • Introduce safety checks for vulnerable older people to identify risks to their health and help prevent problems before they occur
    • Bring in 5,000 new care workers to help support those with the greatest needs at home, particularly at the end of life
    • Tackle workforce exploitation in the care sector to improve care standards and conditions for care workers

    Better Support for Carers

    The next Labour Government will improve support for England’s 5.4 million carers.

    As we live for longer, more and more of us are caring for elderly or disabled relatives. And carers do one of the most important jobs in society. But caring can also be a real struggle and many families feel pushed to breaking point. Too often carers have to battle against the system to try and get the support they need. A recent survey found one in three family carers who are in paid work have had to give up their job or reduce their hours because they can’t get the right support or flexible working hours.

    Many carers don’t have enough time to look after their own health, and many don’t come forward for help or get any breaks. Often people don’t even see themselves as being a carer – they’re just a son, daughter, husband, wife or friend trying to look after the person they love.

    Labour is determined to improve support for carers. Our approach will make sure people get the help and support they need early on, to prevent problems from developing and costs escalating – for carers, their families and the taxpayer.

    Labour will:

    • Ensure carers get the right help and support by placing a new duty on the NHS to identify carers
    • Help carers get health problems identified earlier by giving them a new right to ask their GP practice for an annual health check
    • Give families caring for people with the greatest needs a single point of contact with care services, so they don’t have to battle different parts of the system
    • Ensure funding currently identified for carers’ breaks goes to carers by making sure it is properly ring-fenced
    • Consult with employers, trade unions and carers organisations on how to improve flexible working for carers, which could include measures such as a new period of ‘adjustment leave’ to help families cope with a short-term crisis
    • Recognise the transport costs facing carers by including carers in the groups who can be eligible for hospital car parking concessions
    • Work with hospitals to ensure the valuable role carers play in supporting loved ones with dementia becomes a key part of hospital care, in line with the call of ‘John’s Campaign’
    • Abolish the bedroom tax – which hits 60,000 carers and penalises them for the extra facilities they need

    Better public health

    Better public health policies are needed if we are to live longer, healthier lives. And left unchecked, poor public health will impose substantial costs on the health service and the wider economy. To take one example, unless firm action is taken to halt the rise in diabetes, the proportion of the NHS budget spent on treating the condition and its complications is likely to rise from approximately 10 per cent now to 17 per cent by 2035/36.

    Labour’s approach to public health is borne out the desire to avoid a ‘nannystate’ approach, whilst recognising the failure of the Tory-led Government to show the strong leadership and ambition needed to match the scale of the public health challenge we are facing. This Government has failed to stand up to vested interests and their decision to rely solely on industry self-regulation and voluntary initiatives (the ‘Responsibility Deal’) is widely seen to have been ineffective.

    Labour will take tough action to support parents in protecting their children from commercial pressures and the harm caused by alcohol, sugar and tobacco. To help adults take greater responsibility for their health, we will empower them with better information, and support to get physically active. We will also make use of new technology to help people make healthier decisions and enable individuals to manage conditions, such as diabetes, more effectively.

    Labour will tackle the marketing of unhealthy food to children, including setting limits on the amount of sugar, fat and salt in food marketed substantially to children in major product groups – for example cereals, crisps and soft drinks.

    To better protect children from TV advertising of products high in sugar, fat and salt, we will ask the Committee on Advertising Practice and the Advertising Standards Agency to report on how this can be more effectively done, including the option of lowering the required proportion of children in the audience for a programme to be considered ‘of particular appeal to children’.

    We will crack down on those highstrength, low-cost alcohol products that fuel binge drinking and underage drinking. And we will give local authorities new powers so that local communities can shape their high streets and manage the future number of fast food outlets locally.

    On tobacco, it has been left to Labour to lead the debates and win the fight for a ban on smoking in cars with children and the introduction of standardised tobacco packaging. Labour will set a goal that children born in 2015 will become the first ‘smoke-free generation’.

    Labour will place the promotion of physical activity at the centre of public health policy with new, easily understandable recommended levels of physical activity and a new national ambition to help people get more physically active. We will reinstate the goal of all children doing a minimum of two hours PE a week. We will also look at how we can better support local communities so that they have the opportunity to use sporting facilities in schools outside school hours, including outside term time.

    We will propose a new plan to locate Automated External Defibrillators (AEDs) in major public places – such as shopping centres, airports, rail stations and sports stadia. And by the time they leave school, all young people will have had access to emergency first aid training including Cardiopulmonary Resuscitation (CPR).

    Our historic mission remains the same: to break the link between health and wealth and tackle health inequalities, so that no-one’s health is disadvantaged by where they live or what they earn.

    Labour will:

    • Set limits on the amount of sugar, fat and salt in food marketed substantially to children
    • Crack down on those high-strength, low-cost alcohol products that fuel binge drinking and underage drinking
    • Give local authorities new powers so that local communities can shape their high streets and manage the future number of fast food outlets locally
    • Ensure public health is embedded throughout the licensing system so that measures promoting public health can be included in the licensing statement
    • Ensure that, by the time they leave school, all young people will have had access to emergency first aid training including cardiopulmonary resuscitation
    • Create a new national open register of AEDs (available via digital apps) to give people instant information on where to find the nearest AED in an emergency situation.
    • Reinstate the goal of all children doing a minimum two hours of PE a week
    • Make sex and relationships education compulsory in all English schools and set out a robust, new sexual health strategy
    • Prioritise reducing infant mortality as a key area of improvement for the NHS

    Improving patient safety and care quality

    Labour is proud of our record on the NHS. By the time we left office, waiting lists were at a record low and public satisfaction was at a record high. To improve patient safety, Labour introduced independent regulation and inspection of hospitals and statutory protection for whistleblowers.

    In the last five years, however, care problems have become more likely, not less. A recent survey of NHS staff found that the overwhelming majority think the NHS reorganisation has harmed patient care. Clinical negligence claims are up 80 per cent since 2010, requiring an extra £7 billion to be set aside for potential pay-outs. And twenty hospital trusts have deteriorated to the point where they have had to be put into ‘special measures’.

    When things go wrong everyone must learn the lessons, such as with the terrible failings at Mid-Staffordshire and Morecambe Bay. In recent years, there have also been a number of examples of appallingly poor care being provided in social care settings, and also instances of abuse and neglect, such as at Winterbourne View.

    Labour has ambitious plans for improving patient safety. We want to see a mandatory review of case notes for every death in hospital so that concerns can be identified and acted upon, and lessons learned. We are also committed to implementing a system of independent medical examination to identify patterns of poor care in the community as well as in hospitals.

    Alongside better regulation we also need to prevent problems from happening in the first place.

    The next Labour Government will recruit 20,000 more nurses and 3,000 more midwives to help ensure safe staffing on our wards. We will use service user feedback to improve the quality of care and make services more responsive. We will also make sure NHS staff are supported to deliver the ambition that all patients are treated with the highest levels of dignity and respect.

    Safety and quality will be prioritised in social care services, as well as in the NHS. All NHS and care staff will be expected to receive training in whistleblowing and in listening to and acting on concerns.

    Too often in recent years it has proven impossible to prosecute individuals involved in the running of care homes, whose management was responsible for creating a culture of abuse. To tackle abuse, prevent families being let down by the system and bring those responsible for allowing abuse to justice, Labour will consult on how a new offence of corporate neglect for directors of care homes could be created. This could mean offenders would be liable to a prison sentence or statutory fine if they neglect or are involved in the abuse of people in their care.

    We will also take action to modernise the regulation of healthcare professionals, as recommended by the Law Commission, to ensure regulators can focus on promoting safe, compassionate care.

    Labour will:

    • Recruit 20,000 more nurses and 3,000 more midwives to help ensure safe staffing in hospitals
    • Ensure concerns can be identified and lessons learned, by introducing a system of mandatory case-note reviews for every hospital death
    • Help staff raise concerns and feel confident acting upon them with a clear expectation that all NHS and care staff receive training in whistleblowing
    • Tackle abuse in the care system by consulting on a new offence of corporate neglect for directors of care homes
    • Modernise the regulation of healthcare professionals, as recommended by the Law Commission

    Medical Research and Innovation

    Labour will make sure the importance of research and innovation is understood across the NHS. The next Labour Government will support the work of the Health Research Authority to streamline the process for setting up clinical trials. We will also ensure that the improvements set out in the European Clinical Trials Regulations are realised.

    Labour will commit to maintaining the Pharmaceutical Price Regulation Scheme as it provides certainty on drug prices and enables the NHS to budget effectively for the medicines that it uses.

    The current Government promised to reform how drugs are made available on the NHS but has failed to deliver this. The previous Labour government set up the National Institute of Clinical Excellence to provide high-quality, independent, clinical guidance on what treatments should be available in the NHS. A future Labour government will make sure it is fit for the future, including looking at setting tougher rules on implementing NICE guidance and ensuring there is a clear route into routine commissioning for innovative treatments.

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    In its damning report last month, the King’s Fund health think tank criticised the government’s NHS reforms as “damaging and distracting” for introducing even more markets to the NHS, for making it too complex to govern properly and lacking effective leadership.

    The man behind these reforms, former health secretary Andrew Lansley, dismissed the report, saying that the King’s Fund should have focused on “whether patient care has been improved”.

    We agree: quality of patient care is the most important measure of the success of government health policy. So let’s examine the evidence.

    1. A & E waiting times – WORSE

    The government has a set a target of no more than 5% of patients waiting over 4 hours in A & E for treatment, referral or discharge.Yet in the period October – December 2014, 414,000 patients waited more than 4 hours for – an increase of 47% on the previous quarter and the worst performance in over a decade. 42,000 patients waited on trolleys for more than 4 hours, a 134% increase on the previous year. And the number of Foundation Trust hospitals missing the 4 hour target has doubled to 66 since the summer of last year.

    Below: % of patients waiting longer than 4 hours in A&E

    2. Treatment waiting times – WORSE

    The total number of patients on the waiting list for treatment has increased from around 2.5m in May 2010 to over 3.2m at the end of last year. Below: % of patients waiting longer than 18 weeks for treatment

    The number of patients waiting longer than 18 weeks for treatment at Foundation Trusts has increased by 30 per cent in just over a year. That’s an increase from 87,000 in September 2013 to 113,000 in December 2014.

    In fact, 12.5% of all patients have to wait more than 18 weeks– the highest level since the target was introduced in 2008

    3. Cancer care waiting times – WORSE

    The government has a target of 85% of patients receiving treatment within 62 days of referral from their GP.

    Below: % of patients receiving cancer care within 62 days

    The proportion of cancer patients receiving treatment within the 62 day target has fallen from 86.7 per cent in April 2010 to 83.5 per cent in October 2014, with the target missed now for three consecutive quarters. The number of Foundation Trusts missing the target has almost doubled to 31 since the summer of last year.

    4. Delayed transfers of care – WORSE

    Delayed transfers of care are where patients still occupy a hospital bed, but are ready to return home or transfer to another form of care. This clogs up the entire medical service, and means that patients might not get the kind of care they need.

    Below: Average number of patients delayed in hospital per day each month

    The number of delayed discharges from hospital increased sharply to more than 5,000 per day in November 2014, an increase of almost 20% since the previous January. This reflects a longer-term increase dating back to April 2011

    5. Adult social care – WORSE

    Following cuts over around 12% to care budgets across local authorities in England, there has been a 25% reduction in the numbers of people receiving care through community services, nursing or residential homes, leaving more old people reliant on NHS services.

    Below: The number of people receiving state-funded care

    The government failing patients

    These are five key ways that patient care is on the decline. But there are others too. The number of cancelled operations is up by a third between November and January, compared to the same time in the previous year. Ambulance response times are rapidly deteriorating with all three national standards for response times missed in quarter 3 2014/15, largely because of increased handover times at over-stretched A&E departments.

    What is causing this failure of patient care?

    Clearly the toxic mix of restructuring, complexity, confusion and lack of system leadership referred to by the King’s Fund report is taking its toll. The view from the front line is that services are deteriorating. Over a third of NHS trust finance directors feel that care in their local area has worsened over the past year, a view shared by a similar proportion of CCGs. But the fundamental problem is the massive financial squeeze by the government, at a time of rising demand.We have discussed previously how the finances are in parlous state due to flat-lining government spending on the NHS. More recent evidence shows that 60 out of the 83 acute Foundation Trusts are currently in deficit, over three-quarters of NHS Trust Finance Directors are not confident of achieving financial balance in 2015/16 and over a quarter of CCGs are not confident that they can stick to budget without compromising care quality or access over the next 12 months.

    Below: Percentage of NHS Trusts and Foundation Trusts in year-end deficit (2014/15 – predicted)

    This is leading to staff shortages and capacity constraints, particularly a lack of beds. Monitor, the English NHS regulator, reports that “constrained bed capacity” is contributing to increased A&E waiting times, that 45 per cent of Foundation Trusts cite “inadequate capacity” as a factor behind missed cancer treatment targets and that with staff vacancies for qualified ambulance staff ranging between 10% and 24% has had a “significant impact on performance”.

    There is a very clear message coming through. No matter what David Cameron might argue, the NHS has been starved of investment with a direct impact on patient care.

    Below: Real growth in public expenditure on healthcare

    John Appleby, Chief Economist at the King’s Fund sums it up thus:

    “Services are stretched to the limit. With financial problems also endemic among hospitals, and staff morale a significant cause for concern. The situation is now critical”


    Health Service Journal – CCG Barometer 2014

    Health and Social Care Information Centre – Community Care Statistics: Social Services Activity, England, 2000/01 – 2013/14
    King’s Fund – Quarterly Monitoring Report, January 2015
    Monitor – Performance of the Foundation Trust Sector, February 2015
    King’s Fund – The NHS under the Coalition Government, February 2015
    The Coalition’s Record on Health: Policy, Spending and Outcomes 2010-2015 – CASE / LSE January 2015
    First published on the TUC Touchstone blog

    The minimum practice income guarantee is set to make headlines again this year, as GPs and patients in Wales begin to see the effect of its withdrawal.

    The minimum practice income guarantee (MPIG), which is variously described as a ‘correction factor’ or ‘compensation payment’ for small practices, is being phased out over seven years in Wales from 2015 despite doctors’ lobby for maintaining the MPIG’s protective and stabilising effect on the finances of small practices, including those located in rural areas.

    According to BMA Cymru (Wales), which represents doctors in Wales, around 40% of practices will see reduced income as a result of the MPIG withdrawal – on average by around £5,000 a year per year. As the BMA has accepted in its communications to GPs, “affected practices will have to make some difficult business decisions in order to absorb these losses”. English practices know all too well about these difficult business decisions. The process of removing MPIG from GP funding in England started in 2014, and already it has attracted significant political opposition. In February, 2014, South Lakes MP Tim Farron called for Parliamentary debate about rural GP funding following concern about the risk to smaller local surgeries caused by the MPIG withdrawal, and the effect closures could have on patients.

    Delivering on rural promises

    In its 2012 Rural Statement , the Government restated its commitment to rural England, focusing on three objectives:

    • economic growth – rural businesses can make a contribution to national growth
    • quality of life – people living in rural areas have fair access to public services
    • talking directly to rural communities – political empathy with rural areas.

    NHS Pharmaceutical Services policy in England, Wales and Scotland dictates the framework and, in part, the funding for dispensing GPs, which as a group provide primary medical and pharmaceutical services in Britain’s most rural areas. It is the position of their representative organisation, the Dispensing Doctors’ Association, that the current regulatory and financial  arrangements for rural GPs fail to deliver on the promises made by Government in its 2012 rural statement, for the following reasons:

    1) economic growth: in 2012 the Welsh Assembly concluded that “the cost factors incorporated into funding formulae can be too low, and so fail to accurately account for the costs of rural service provision”. For the rural GP practice these costs may include the increased costs of transportation (home visits) and supplies (low volume surcharges), staffing costs (incentivised recruitment) and provision of a wider range of healthcare services that acknowledges the lack of other local healthcare service providers. In dispensing practices routinely reinvest the profits from the dispensing activity to cross-subsidise the increased costs of providing rural general medical services. In hard to staff areas, dispensing income is also used to incentivise GP recruitment and retention. This phenomenon was only publicly acknowledged for the first time in 2014 and at the time of writing, the principle is yet to be embedded in either rural GMS funding or in the remuneration/reimbursement processes for the GP dispensing activity

    2) rural patient engagement: When patients are eligible to choose to receive dispensing services from their GP the overwhelming majority choose to do so. A 2008 Patient Survey by the Dispensing Doctors’ Association demonstrates patients’ preference for GP dispensing services. However, in England patient eligibility for the GP dispensing service takes no account of patient choice. Only last year (2014), Scotland passed new regulations affecting dispensing practice, which acknowledged prior shortcomings in the dispensing patient engagement process. It is yet to be seen how the new regulations will improve the patient engagement process.

    3) Equitable service provision: Throughout Britain rural patients are denied services that are available to urban patients who access pharmacies. Pharmacy services currently unavailable to rural patients using dispensing practices include: the electronic prescription service, the new medicines service, the medicines use review service, and the chronic medication service. The untapped economic potential of rural areas is said to be worth an extra £347 billion per annum to the national economy, if only more policies supported rural economic development. Defra has made this issue its top priority and has launched a number of schemes aimed at growing the rural economy.

    Rural GPs would urge the NHS to follow Defra’s example, and allow rural medical services to play their full part in the development of Britain’s countryside areas.

    Dr Richard West is chairman of the  Dispensing Doctors’ Association

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    This updated briefing:

    • comments on the decision, announced by the Department of Health in February 2015, to defer proposals to extend the overall NHS charging regime;
    • comments on the introduction of the new Immigration health charge or surcharge;
    • gives detailed consideration to the National Health Service (Charges to Overseas Visitors) Regulations 2015 due to come into force on 6th April 2015;
    • provides an overview of the charging regime for NHS hospital services currently in place and notes some key changes associated with the National Health Service (Charges to Overseas Visitors) Regulations 2015.

    The Department of Health decision to extend the charging regime beyond hospitals on hold

    The Department of Health announced that a decision has been taken to deprioritise extending and amending charging in primary care in order to focus on making the existing charging regime work better and introduce the new immigration health charge. However, we understand that the current Government still intends to look at extending charging beyond the current rules.  If implemented, the extended charging regime, could in due course lead to:

    • the introduction of charges for A&E care, outside EHIC collection in NHS hospital settings (supposedly without compromising rapid access to emergency care for those in immediate or urgent need); and
    • the extension of charges, in NHS services outside NHS hospitals, to the majority of NHS services including community services, dentistry, optics and pharmacy and extending current charges to treatment provided by all commissioned providers of NHS services.

    Subject to the outcome of the general election in May 2015, consultations with various stakeholders and interested parties will take place before a final decision is taken as to whether to extend charging into primary care and A&E; these consultations will not take place before the autumn of 2015. However we should not be complacent and the recent assessment by the Migrants Rights Network strikes an important cautionary note.

    The new Immigration health charge or surcharge

    The Immigration Act 2014 gives the Secretary of State the power to issue an order to require certain migrants (those seeking leave to enter, remain or entry clearance) to pay an immigration health charge. (Regulation 10, The National Health Service (Charges to Overseas Visitors) Regulations 2015)  Whilst previously it had been thought that the rate might be £150 for international students and £200 for other categories, it would now appear that the charge may be considerably higher, possibly £600 per person. However, the actual rate will need to be confirmed in statutory regulations. The statutory regulations containing this order are due to be laid before Parliament and are meant to come into force in April 2015.

    The National Health Service (Charges to Overseas Visitors) Regulations 2015

    According to guidance on the DH’s website on the changes:

    • Overseas visitors who need healthcare while in England will soon be charged differently for using the NHS as part of efforts to recoup £500 million a year by 2017 to 2018.
    • From April [2015], the way the NHS charges these visitors is being changed so that it does not lose out on income from migrants, visitors and former residents of the UK who have left, who should all pay for their care while in the country.
    • Within the UK, free NHS treatment is provided on the basis of someone being ‘ordinarily resident’. It important to note that changes in the Immigration Act 2014 redefine and provide a more restrictive definition of ‘Ordinary residence’. It is not dependent upon nationality, payment of UK taxes, national insurance contributions, being registered with a GP, having an NHS number or owning property in the UK.
    • The changes which come into effect from April 2015 will affect visitors and former UK residents differently, depending on where they now live.
    • Treatment in A&E departments and at GP surgeries will remain free for all.

    The regulations are divided into 5 parts and 4 schedules. 5 of the regulations (3-7) focus on making and recovering charges. NHS bodies are required to recover charges from individuals unless the NHS body has determined that the individual is exempt (regulation 5). The rate of charge will depend on whether the individual comes from a country that is a member of the European Economic Area (EEA). For those who come from outside the EEA the charge will be set at 150% of the NHS national tariff for any care they receive.  ‘People who live outside the EEA, including former UK residents, should now make sure they are covered by personal health insurance, unless an exemption applies to them. Anyone who does not have insurance will be charged at 150% of the NHS national tariff for any care they receive.’

    The National Health Service (Charges to Overseas Visitors) Regulations 2015

    The DH’s Implementation Plan, published in July 2014, stated that where vulnerable groups are not currently exempt, the DH  would consider ‘strengthening exemptions, or other ways of ensuring necessary treatment is provided, for victims of domestic violence, human trafficking and vulnerable children.’ The plan also stated that ‘the Government committed to ensuring that any new system takes into account international law and our humanitarian obligations… vulnerable groups such as asylum seekers, refugees, humanitarian protection cases, victims of human trafficking and children in Local Authority care will continue to have free access to the NHS and will not be subject to the surcharge.’ The exemptions are overviewed in appendix 1 (5). Broadly speaking the scope and range of these exemptions are very welcome. However, it is unclear:

    1. how all those who are exempt will be identified;
    2. how practical or realistic it will be to recover the £500 million a year by 2017 to 2018 planned by the DH;
    3. how any financial shortfalls will affect hospitals and their budgets;
    4. what actions will be taken to ensure that racial profiling will not determine who will be asked for their papers/ documentation to prove their immigration status;
    5. how the complex range of exemptions will be operationalized by NHS staff and made clear to would be service-users.

    This note was first published, with more detail, by the Race Equality Foundation.  If you would like to receive further updates from Leander Neckles, please sign up to the Race Equality Foundation’s monthly e-bulletin.

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